How to Meet the Challenges of Good Patient Documentation

documentation is an integral component of providing patient
care. Concise and accurate patient documentation not only helps to deliver
quality patient care, it also can help ensure timely and complete
reimbursement. Conversely, incomplete or inaccurate patient
documentation can be considered as poor patient care, and can delay
reimbursement or even ultimately result in complete denial of a claim or a
demand from the payer to return payment.

In addition, as the O&P industry continues to move away from being
considered a craft or trade to being a professional health care discipline with
master’s level requirements and higher levels of
accreditation, satisfactory patient documentation becomes
important in aiding outcomes research and achieving evidence-based practice.
How can O&P practitioners ensure their patient documentation supports this
level of accreditation and credentials for the profession?

Crucial aspects

  © 2010

The most crucial aspect of patient documentation that O&P
practitioners need to embrace is that documentation is patient care,Brian
Gustin, CP, president of Forensic Prosthetics and Orthotics, explained. Even
though practitioners may not be laying hands on a patient or they may not have
a patient directly in front of them, having the ability to accurately document
their case and their progress and the ability to write and convey an idea is,
first and foremost, patient care.

There are two critical components of patient documentation. The first is
documenting what happens during a clinical visit with patients, and the second
is documenting why a particular procedure or service is being performed or why
a particular device is being used.

“As a profession, we do a pretty good job of documenting the
‘what’ we do. For instance, ‘Fit patient with 12-ply sock,’
but we are not as strong in documenting the ‘why’ we are doing what
we are doing,” Mitchell Dobson, CPO, FAAOP, director of compliance for
Hanger Prosthetics & Orthotics, said. “By explaining the why component
within our clinical documentation, we can communicate better to those who are
not educated in orthotics and prosthetics, specifically payers and other
entities outside of the O&P industry who do not understand that an increase
in sock ply is going to lift the patient up out of the prosthesis a little bit.
They do not understand the cause and effect.”

Jonathan Naft, CPO, president of Geauga Rehabilitation Engineering and
O&P Business News Practitioner Advisory Council member, also
believes that O&P practitioners are good at documenting what they did
clinically but not why they did it.

“We are very good at documenting what we did. For instance, we
document that we fit a high-tech foot including complex components, but what we
need to do better is document why we used that particular foot and why that
particular foot is best for that particular patient,” Naft explained.

In addition, as both the level and cost of the technology being used in
O&P devices continues to increase over time, it is becoming even more
important for practitioners to adequately explain exactly why the technology is
necessary and why their patients need a specific device or component from a
medical standpoint.

Gustin explained that keeping the focus of the why explanation on the
specific medical condition, as well as offering evidence to support that claim,
is vitally important for reimbursement. He offers the following example: If a
practitioner requests reimbursement for a microprocessor knee claiming that it
will reduce stumbles and falls, the practitioner needs to support that claim
with evidence that the patient received treatment for a stumble or fall.

“Documentation needs to be truthful, believable and legitimate
relative to the patient’s condition and not geared toward getting
reimbursement for the practitioner,” Gustin said.

By communicating why patients need something within clinical
documentation, practitioners often can answer questions payers may have before
they can even be formulated.

Consistent format

Practitioners also should strive to be consistent, pertinent, factual
and timely in their patient documentation. Gustin recommends that practitioners
understand who they are writing to and address their points accordingly. He
suggests practitioners should learn to think of themselves as an attorney and
approach documentation as if they are writing an O&P medical, rather than
legal, brief.

  Brian Gustin
  Brian Gustin

“Practitioners are advocating for a position, and the position is a
need that their patient has, and they have to be able to convey that in terms
the reader can understand,” Gustin told O&P Business
. “Many times a practitioner is asked to provide a letter of
medical necessity to gain an approval for their proposed service. All too often
this is passed off to an administrative person or the practitioner writes a
poorly constructed letter, which often times is condescending in nature. Think
of the letter of medical necessity being the same as a lawyer who writes a
legal brief to the court advocating a position he or she wishes the court to

  Mitchell Dobson
  Mitchell Dobson

Ted Markgren, CO, chief surveyor for the American Board for
Certification in Orthotics, Prosthetics and Pedorthics’ (ABC) facility
accreditation programs, noted practitioners often tend to write casually and in
a manner similar to the way they talk in a social setting. Instead, he
recommends practitioners write with a medical mindset and use the time-honored
SOAP format:

  • Subjective: What did the patient say?
  • Objective: What did I observe?
  • Assessment: What is my assessment?
  • Plan: What is my plan for treatment?

In addition, the content of clinical notes should be professional and
use approved and accepted terminology rather than jargon, which reviewers do
not understand. Phrases such as “a little bit,” “a tweak here
and a tweak there” and “big time” are out of place in a
patient’s clinical record, Markgren said.

  Jonathan Naft
  Jonathan Naft

Practitioners also should work on improving their writing skills. Being
able to write effectively, accurately and concisely should be viewed as just
another aspect of providing good patient care.

“All too often, practitioners will go into lengthy detail about how
a device or component works, which is immaterial to the reviewer,” Gustin
explained. “What the reviewer wants to see is how this service benefits
the patient from a medical standpoint, and if this is a covered benefit under
the patient’s plan, period.”


Documentation is necessary for reimbursement and provides justification
for the device by clarifying and supporting the medical necessity. Naft cited
three reasons practitioners document for reimbursement:

  1. It is required by policy for reimbursement;
  2. It allows communication among the different areas within a practice;
  3. It provides additional protection from liability.

In fact, many of the documentation requirements for the clinical record
are mandated by Medicare quality standards as well as by all other payers. If a
practitioner’s clinical notes do not accurately and completely reflect not
only what was done but also why it was done, payers can demand that monies made
as payment be returned. In such a situation, clinical notes can become a
defense tool against billing records.

“It is not just good enough that you have a prescription anymore.
Your prescription has to include your evaluation to confirm that the script is
not only appropriate but meets the patient’s functional requirement,”
Markgren said. “There is a standard that we have in the ABC accreditation
program, and it is also a Medicare quality standard, that the practice will
conduct a diagnosis-specific patient evaluation.”

Accreditation and Documentation: How Does Your Facility

All of the accrediting bodies, such as the American Board
for Certification in Orthotics Prosthetics and Pedorthics (ABC), the Board for
Orthotist/Prosthetist Certification (BOC) and the Joint Commission on the
Accreditation of Healthcare Organizations, to name a few, review patient
records during site surveys before granting accreditation. As such, it is
incumbent on O&P facilities to routinely examine clinicians’ chart
notes to ensure that they are meeting the expectations of the facility’s
policies and procedures as they relate to accreditation standards or other
provider requirements.


What the accrediting organizations often find, however, is
that documentation is not always detailed well, Ted Markgren, CO, chief
surveyor for ABC’s facility accreditation programs, said. Practitioners
are good at indicating what went into a device but often are not specific about
detailing what the component is going to provide for the patient.

“All of the accrediting organizations have some
standards that relate to patient clinical record keeping, and most of those are
driven by the Medicare quality standards,” Markgren said. “If you
look at the Medicare quality standards, you will find that they are expecting
us to put a lot more information in our records about the whys and the expected
outcomes, and justifying each component than we have historically been doing in
our profession.”


In his position, Markgren noted that he has reviewed a lot
of patient charts. In fact, he estimates that he has seen approximately 80,000
in a couple of thousand facilities, and he has seen charts that range from
“absolutely abysmal to stellar,” as well as everything in between.

“I would say about 10% to 15% of the companies that we
survey are doing an outstanding or excellent job of this, probably better than
70% are doing an adequate job, but there are about 20% to 30% that really are
failing to properly document everything they are doing, and those people are
going to be at risk if they are ever audited,” Markgren said.

Although Markgren notes that he cannot prove any
relationship between the following findings, many of the practices that boast
fewer adjustments and repairs often are the ones that do a better job at
documenting all of the things at the front end.

“The really well-done clinical records seem to be found
in organizations where there are not as many returns for adjustments, there are
not as many failures or repairs, there are not as many problems with skin
breakdown or pressure because the practice is tuned into that and paying
attention to it, documenting all of those steps as they go along and trying to
eliminate them,” Markgren said.


Clinical documentation must include the goals and functional outcomes
that patients are expected to achieve with the orthosis or prosthesis. The
record needs to indicate that the device will allow patients to achieve some
benefit or functional improvement that will enhance their life by increasing
their stability or safety, reducing their risk of falls, enhancing their gait
or improving their activities of daily living.

“What we are seeing and what we are hearing in the field from
everybody is that when requests for additional information are coming in, they
are looking at those clinical records to see that every add-on component, every
feature is documented in a way that shows the clinical purpose for that
particular design or device,” Markgren said. “Why did you do a $1,200
item when a $100 item could do? Why did you do this when you could have done
that? Why did you do it all?”

Typically, clinical documentation is the first point of review by
payers. It is easy for payers to request, and it is easy for providers to
supply. As such, it is often the first impression that a payer has of a
practice, and as Dobson noted, “You do not get a second chance to make a
first impression.”

Good quality documentation that includes both what and why can set the
stage for reimbursement and give practitioners the best opportunity to gain
reasonable and fair reimbursement in a more timely fashion. Conversely, if
documentation is insufficient, reimbursement can be delayed by having to engage
the appeals process or reimbursement can even be denied entirely.


A practice’s procedures and processes also can have an impact on
the quality of patient documentation as well as on reimbursement.

“Practitioners should establish definable and repeatable process
measures to ensure consistent documentation for each and every patient by each
and every practitioner,” Gustin said. “Additionally, they should
establish an internal auditing process to ensure compliance with their own
standards. Failure to do so could result in future recoupment of reimbursements
at a minimum or more onerous fraud and abuse allegations at a maximum.”

Electronic Medical Records and Patient Documentation

The depth and scope of how electronic medical records (EMR)
could impact O&P facilities is still being determined, as it has not been
adopted across-the-board. Practitioners seem to agree that both pros and cons
exist and that the implementation of such a process should be fully considered
ahead of time.

“I think that most offices are electronic with regard
to their billing operations, but I don’t believe that they’re
automated with regard to their [patient] documentation,” Jonathan Naft
said adding that he does see progress towards more offices using EMR systems.

Brian Gustin reminds practitioners, however, that these
systems should not fundamentally change what is being documented. Mitchell
Dobson agrees.

“Electronic patient records can be a very good platform
or it can be a very bad platform, and … the quality of the platform has a
direct affect on the patient documentation and the quality of the patient
documentation,” he said. “For instance if you have a pen that
doesn’t work, it’s just a tool. Electronic patient records platforms
are simply a tool in the hands of an expert.”

Easy access or hidden files

Jonathan Naft finds that one of the perks of EMRs is that
information is more readily available.

“When they were paper, it was often difficult to find
the paper. It could be shipped off to another office. It could be on
somebody’s desk in the office. It could be back in the lab,” he said.
“In the worst case scenario, it could have been lost. So now with
electronic formatting, everything is really a click away at the nearest
internet access port.”

Gustin agrees with Naft and asserts that internal protocols
need to be adopted to make an effective switch over to an EMR system.

“The problem with EMR is that data becomes hidden. Once
you enter something into a software program, it gets buried in the digital
file,” he said. “Because of that, certain pieces of documentation can
be forgotten because you don’t have a chart sitting on your desk. The
invisibility of EMR can be a problem, so people need to have good internal

Consistency and completeness

EMR systems, when used effectievly and appropriately, can
also achieve a new level of consistency and completeness within patient
documentation that traditional paper and pen can lack.

“Let’s say you have three clinicians. Are all
three documenting the same clinical information? Does one document range of
motion and the other two do not?,” Naft said. “By moving into an
electronic format, everyone is documenting in the same way, … everyone is
using the same software, which means everyone is documenting the same

Additionally, a good system will provide a set of checks and
balances to make sure that all fields have been completed.

“If there’s required documentation specifically
toward policy and you forget to document that certain policy requirement, the
software is not going to let you do that. It’s going to send you a flag or
it won’t let you save the file until you fill it in,” Naft explained.


Document policies that you want practitioners to follow when
they use an EMR system, Ted Markgren said.

“I think that there has to be procedures and policies
in place – strict policies in place – that those notes are actually
entered by the person who claims to be signing the note,” he said. “
We can’t have [an office employee] typing in notes off of a glossary text
somewhere. It still has to be your note. You’re the clinician of record.
You’re the owner of that note and you better be able to testify that, yes
that is exactly what you intended to say.”

In addition to personal ownership Gustin urges practitioners
to protect their digital files in the same way they would protect hard files.

“You have to protect those digital files the same way
that you would have to protect a hard copy file to ensure its integrity and be
organized that we really do not need to bug each other to ask what
is going on,” Naft said. “A technician should not have to go find a
practitioner to say ‘was that a left or a right?’ A billing person
should not have to chase down the intake person to say ‘where is the
documentation supporting that prescription?’ Everything should be done in
a systematic, organized and uniform approach so that it flows.”


Although the development of such a free-flowing process might sound
complicated, Naft noted that it can be easier to accomplish than one might
expect. It requires that all personnel within a practice meet and discuss the
information that each discipline needs to have in patients’ files. This
exercise often reveals simple changes that can allow all of the staff in a
practice to work more efficiently.

“For example, our intake people said that we needed to modify our
forms to make sure that we have cell phones and e-mail addresses,” Naft
said. “Our technical staff wanted to know some things about the
patient’s activities, hobbies and work noted during intake so that it may
trigger something when they are fabricating the brace that helps to protect the

All of the items that are being billed must be documented, and the
documentation should include as much detail as possible. For instance, any
changes that were made during fabrication should be documented, as well as
sufficient explanation about why the changes were made.

“If you are in an audit and your clinical notes are poor and cannot
back up what you did, you are going to have a hard time on appeal recovering
your money,” Markgren said. “If your notes are well done, even if
sometimes you did not dot all the i’s and cross all the t’s but your
clinical notes substantiate and support why, you have a better chance of
winning those appeals.”

Another aspect of documentation that can impact reimbursement is that at
some point, clinical notes should indicate that the device has indeed enabled
the patient to function as expected. Several months or even a year after
delivery of the device, practitioners should follow-up with patients and
document the outcome in the patient’s chart.

“Ideally at some point in the future, our clinical documentation is
also going to indicate that 12 months ago I fit you with this device and look,
you are in fact performing as we would expect you to perform. You have achieved
those goals and outcomes for which we designed this thing and we can now
substantiate the quality of the service we provided so that if we are ever
called to prove that we are doing a good job, we can” Markgren explained.
“These things are not typically found in the clinical record today.”
by Mary L. Jerrell, ELS

Leave a Reply

Your email address will not be published.