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Documentation of the services you provide serves many purposes, and it's
important to maintain high standards for this essential element of practice.
Both state and federal law requires health care providers to maintain records on the patients/clients to whom they provide services. Documentation is defined as any entry into the patient/client record, including a consultation report, an initial examination report, a progress note, a flow sheet or checklist that identifies the care or service provided, re-examination reports, or a summation of care. Mere notations or flow charts are considered a component of the documented record, but they do not meet the requirements of documentation in and of themselves.1
A Legal Document
The patient/client record is a legal document subject to state and federal laws, including Medicare and Medicaid law, medical record and privacy laws, and state licensure laws. Physical therapists should become familiar with the laws that affect their practice to ensure that their documentation meets all applicable requirements.
The record may be used as evidence in litigation such as automobile accident or workrelated injury or malpractice claims; therefore, physical therapist documentation should be complete, accurate, legible, and truthful. For maximum liability protection, the documentation should present a clear, chronological record of the patient/client condition, the physical therapy care provided, and the resultant outcome.2
All elements of patient/client management, including the physical therapy examination, evaluation, diagnosis, prognosis, and intervention, should be documented, dated, and authenticated by the PT who performs the service. Interventions provided by either the PT or the PTA should be documented, dated, and authenticated by the PT, or, when permissible by law, by the PTA, or by both.
Authentication, which may include handwritten or electronic signatures, provides assurance regarding the identity of the author or source of the information.3 A handwritten signature serves to identify the person who made the entry, indicates that a review of an entry has been made, and designates the approval of the entry. Handwritten signatures should include the signer's full name and physical therapy regulatory designation (PT or PTA), followed by other letter credentials such as MBA, PhD, or OCS.' Electronic signature is the legally binding equivalent of the handwritten signature.4
A Means of Communication
Documentation is a...