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Components of Good Documentation

Components of Good Documentation

To support billed claims and avoid payment denials, rehabilitation therapists must document both the patient's medical necessity and the skilled services provided by the therapist throughout a treatment session.  This is true for gait training, therapeutic activities, therapeutic exercise, or the provision of biophysical agents.  Components of good documentation are summarized in this table which uses NMES as an intervention example:

Dec2016 graph2.png 

In this example, the narrative noted in the second column would become the basis for capturing medical necessity and skilled intervention in the treatment note.  

For more information about skilled documentation or to request training, please contact your facility's assigned Clinical Program Consultant.

Or call our customer support @ 800.350.1100.

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