When it comes to being a great therapist, the treatment that you provide is only half of the equation. The other, just as important half, is accurate and timely documentation. We’ve all heard the saying “if it’s not documented, it never happened.” And this is true in so many ways. Think of it this way. A truck driver is supposed to deliver merchandise to a store 200 miles from the warehouse where he works. He leaves the warehouse without loading his truck with the merchandise and then drives 200 miles to the store where it is supposed to be delivered. What good does it do to drive the 200 miles without delivering the merchandise? The truck driver followed through with half of his job duties, but neglected the other, just as important half.
Why is documentation so important? The obvious reason, the reason every therapy company stresses, is to protect you as a therapist and the company you work for from the Center of Medicare Services audits. CMS can conduct audits at nursing homes 24 hours a day seven days a week without warning. They can audit any services provided in the building from previous patients in medical records to current patients residing in the nursing home. Another reason for documentation is to provide guidance to other therapist or healthcare providers that may be directly involved in giving quality patient care. Finally, documentation gives the therapist a way of tracking the plan of care and the progress, or lack of progress, their patient may be making.
Most of us have been guilty of letting documentation get behind without realizing the consequences. And those consequences can be as serious as losing your license as a therapist or making your therapy company reimburse large amounts of money back to Medicare. From the time the documentation is due you have 24 hours to get it filed in the patients chart. So make sure that documentation it is filed timely and accurately. To assure accuracy when documenting make sure you include the quality of performance, carryover, response level, tolerance level, and safety the patient may or may not be demonstrating. We owe it to ourselves, as well as the patients we treat, to be accurate with what we document.
The next time you’re putting off that paperwork think of yourself as the truck driver who delivered an empty load. We’ve heard it once, we’ve heard it a thousand times, “if it’s not documented, it never happened.”