Physical Therapy Documentation: The Essential Components of Compliance

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What makes a physical therapy and medical documentation system compliant? In this revealing article, Nitin Chhoda explains the  key components to look for in any EMR system.

The issues associated with remaining compliant are many, varied and can be tricky to navigate. Federal regulations and payer requirements constantly change and therapists must remain vigilant to avoid stiff civil and criminal penalties.

Remaining in compliance is a challenge that faces any practice owner and there are key components therapists should seek in any EMR physical therapy documentation system they decide to use.

A Very Important Matter

The primary concern of any EMR is the protection, privacy and security of patient information. Any physical therapy documentation system must contain sufficient safeguards to ensure individually identifiable health information is secure, and that appropriate efforts have been taken in that direction.

That includes electronically submitted claims, referral authorizations, and eligibility inquiries to insurance providers, clearinghouses and medical professionals.

The Heath Insurance Portability and Accountability Act (HIPPA) spells out in detail the security and safeguards necessary to remain in compliance and establishes the policies, procedures and conditions under which medical information can be disclosed without specific authorization from patients.

Administrative safeguards and controls must be in place that limits access to patient information to authorized physical therapy documentation personnel only.

EMR As A Tool

An EMR is an important tool for therapists, enabling them to remain current on laws and maintain compliance. Individual login capabilities and the ability to validate the credentials of those accessing information are an essential element of any EMR.

Physical therapy documentation staff must also be trained in the rules and guidelines governing the management of medical records and an EMR can be utilized to accomplish that. EMRs encompass the ability to provide powerful security at all levels of access to maintain the confidentiality of patient records, reimbursement submissions and administration of the practice.

Date and time stamps are especially helpful in a physical therapy documentation system, providing detailed reports of when patient records were accessed and by whom. If another healthcare provider discovers a breach in the system, the medical professional can quickly notify the therapist through a variety of means with an EMR.

Adopting EMR System

The adoption of an EMR allows for almost instantaneous interaction among physical therapy documentation healthcare providers.

This ability ensures the highest level of treatment possible through extreme accuracy, while addressing privacy concerns.

Patients who believe that their medical data is safe with their therapist are more likely to provide complete health information that could mean the difference in a life and death situation.

The adoption of an EMR is part of the American Recovery and Reinvestment Act and requires any EMR to meet Meaningful Use standards and certification. An EMR helps physical therapy documentation therapists in all areas of their practice, from ensuring secure access of medical records to the submission of reimbursement requests.

An EMR significantly reduces the possibility of errors.

Security is the primary component of any EMR. Physical therapy documentation software helps therapists maintain the integrity and privacy of patient medical information, and healthcare providers can easily report the instance of a breach should a situation occur.

Therapists seeking an EMR should also ensure their chosen software includes sufficient flexibility in the documentation process to protect the patient and the practice in the event of a lawsuit or audit.

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