5 Documentation Errors You Need to Avoid

Documentation quality in physical and occupational therapy continues to be increasingly important to justify treatment.  With the never-ending quest for greater productivity, bad documentation habits can be easy to form.  Gaining efficiency through quick, minimalistic documentation can end up costing a great deal in the long run.  The RAC hounds are out and looking to collect as much as possible on past claims.  Don’t let your hard work go to waste by having to pay back reimbursement due to poor documentation. 

Here is a small collection of common mistakes frequently seen when writing daily treatment notes:

“S:  No significant change in symptoms”

“O: Rx with therex per flowsheet”

“A: All treatment Tolerated Well”

“A: Patient progressing”

“P:  Continue with plan of care”

Some additional guidance on improving documentation can be found here:

The APTA's defensible documentation publication (membership required)

Medicare guidelines on documentation

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