Physical therapy documentation: Is it all a lie?

physical therapy documentation

When you decided to become a physical therapist, you didn’t think you were signing up for shady deception and unethical practices. Yet, many PTs discover early in their career that the world of physical therapy is fraught with ethical dilemmas, leaving PTs to manipulate billing codes or lie on their physical therapy documentation.

Why is this? Physical therapists are in the crosshairs of decreased reimbursement and unrelenting patient need. In an effort to curb losses, clinics make weighty demands of their PTs, such as seeing multiple patients at once or taking documentation home after work because there’s no time for it in the clinic

Productivity standards continue to tighten as insurance payers such as Medicare reduce reimbursement rates. On top of this, inflation is eating away at the stagnant rates paid by private insurance companies, leaving therapy clinics with a growing deficit in reimbursement each year. 

Declining reimbursement is a fact that, frankly, PTs have no control over. Yet, the effects of horrible reimbursement rates trickle down into a PT’s workload.

When the clinic is a slave to insurance companies, its natural response is to tighten productivity standards and increase patient volume. For a PT, these demands make the job time-consuming, overwhelming, and at times, ethically dubious. 

A Decline in Patient Care

As a result of increased clinic demand, many therapists are required to see multiple patients at once. Instead of giving one-on-one skilled treatment, the PT is forced to rely on techs or, even worse, set up patients like an assembly line. 

No patient wants to be merely assigned a therapeutic exercise without receiving direct attention from their PT, and PTs know that one-on-one attention is what makes a treatment skilled.

Besides a less-than-optimal clinical experience, what are the other trickle-down effects of increased clinic demand? Lower-quality documentation! 

Think about it: if you’re seeing twice as many patients per hour, you’ll finish with double the amount of paperwork. 

A Rise in Physical Therapy Documentation Lies

Every therapist wants to progress patients appropriately and provide higher-level treatments like therapeutic activity and neuro re-ed. But these treatments warrant one-on-one attention, which many therapists are unable to fully provide.

Many PTs are pushed by their clinics to code for these treatments because they are reimbursed at a higher rate. So when therapists say their employers made them lie on their documentation, I assume it’s because of too-tight productivity standards. 

Charging for higher-reimbursed CPT codes requires more from the therapist than simply checking a box. Physical therapy documentation needs to reflect the skill the PT demonstrated in the treatment. For many PTs, it’s ethically dubious to call squats a therapeutic activity if their attention was divided among other patients. With a divided attention, PTs are unable to provide feedback in real time. 

Mounting Paperwork for Physical Therapy Documentation 

Not only are therapists receiving less time with their patients one-on-one, they’re ending up with more paperwork. If you’re like me, you didn’t become a physical therapist to push papers all day. Yet, as working conditions change under increased patient volume, PTs are spending more time typing at a computer.

By my calculations, PTs and OTs easily spend 1-2 hours a day on documentation, usually outside of time spent with patients. 

To make matters worse, many PTs end up completing documentation on their lunch hour or during downtime and patient cancellations. It’s not uncommon for therapists to bring documentation home after a long day in the clinic and spend an hour or more typing notes off the clock.

What’s the Solution?

Now for the looming question: What can a PT do about this?

First off, some issues a PT can’t do anything about, such as declining reimbursement rates and increasing clinic demand. However, if you focus on things you can’t control, you’ll inadvertently ignore variables you can. Therefore, I believe that the best thing therapists can do to resolve this dilemma is improve their documentation, in three main ways.

1. Improve the Efficiency of your Documentation

If you’re a therapist, you probably want to spend less time on notes and more time with patients or family at home.

From my experience, there are ways to become more efficient with your physical therapy documentation, resulting in less time spent on notes and better overall documentation. 

Saving time on paperwork is not so that you can see more people! Rather, improving the efficiency of your documentation will help you produce better notes that better reflect the skill you provided in the clinic. 

2. Improve the Quality of Your Notes

Fun fact: not all PTs are creative writers. Rehab is a hands-on field, and for most therapists, interacting with patients in the gym is the best part of the job.

As PTs, we value staying active and being on our feet. But these perks of the job can become quickly overshadowed by a mountain of paperwork, leaving PTs feeling discouraged and burnt-out.  

It’s okay to feel that way! PTs aren’t supposed to be good at writing; that’s not why we went to PT school! It’s unrealistic to expect a PT to give 100% on the clinic floor and then, at the end of the day, don a writer’s hat. 

Even seasoned therapists experience “writer’s block.” For many of us, creative writing is not a flip we can switch after seeing 15 patients or more for 30 to 60 minutes each. 

As PTs, we can’t always control patient volume. But in terms of the elements we are able to control, the ability to write skillfully is one of the most underutilized tools we have for keeping our sanity in the clinic. 

3. Improve the Accuracy of Your Notes

No judgment here, but I think as PTs, it’s easy to get in a rut, writing the same things over and over again. What’s more, you may be tempted to document on “default,” billing for lower-level therapeutic exercise simply because it’s easier to document. 

Taking these shortcuts is understandable, but dumbing down your documentation isn’t the only way to get through an overwhelming pile of documentation faster. The pressure to see more people doesn’t have to result in lower-quality care or dumbed-down documentation.

Early on in my career as a PT, I struggled to efficiently write an assessment that explained why my treatment justified therapeutic exercise as opposed to neuromuscular re-education.  

Instead of defaulting to an easier billing code, I stepped back and figured out a way to improve my efficiency as well as my writing. As a result, it actually became much easier to keep up with documentation.

Instead of writing similar phrases over and over, I learned how to write in a way that clearly supported my rationale for higher-level treatment.

How I Improved My Physical Therapy Documentation 

I improved my documentation by compiling phrases and creating templates. These pre-made documentation techniques helped me push through writer’s block and stay on top of paperwork so that I could be fully present to the patients I had. 

The documentation templates I made saved me 30 to 60 minutes a day. I have these templates available for download here so that you, too, can benefit from time and energy saved. And every little bit helps when you’re an overworked PT in a double-booked clinic. 

This isn’t efficiency for productivity’s sake; the clinics are already pushing for increased productivity. Rather, improving your documentation will help you reverse the damage wreaked by overbooked therapy sessions.

Tightening up your writing will free you to provide skilled treatment that you can truthfully reflect in your documentation. You win, your patient wins, and your clinic wins.

Physical Therapy Documentation Lies: Is it so?

So is physical therapy documentation full of lies? It doesn’t have to be. The more efficient, more accurate, and more professional your writing becomes, the more truthful your documentation will be.

I’m not saying that improving your clinical writing skills is the foolproof answer; the bigger problem of unethical clinical practices still looms large. Every day, therapists are put in tough situations as clinics demand higher reimbursement billing but decrease one-on-one time for each patient. 

However, unless you flat-out refuse to see multiple patients at once, your best way to cope in these situations is to improve the efficiency, quality, and accuracy in your physical therapy documentation.

My documentation templates will help get you there, saving you 30 to 60 minutes a day. You can check out these templates and my entire system for documentation efficiency here.

Tim Fraticelli DPT, MBA, CFP®

Tim Fraticelli is a Physical Therapist, Certified Financial Planner™ and founder of PTProgress.com. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your financial health.