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The Ethical Imperative of Comprehensive Documentation in Physical Therapy Practice

Trisha Salome, PT, DPT

May 15, 2024

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Question

How does documentation relate to the ethical principles guiding physical therapists?

Answer

Comprehensive documentation is essential for upholding several core ethical principles in physical therapy practice. Principles like providing truthful and accurate information (4A), ensuring appropriate reimbursement (7B), and accurately reflecting services provided (7E) are directly tied to thorough, defensible documentation. Ethical documentation demonstrates medical necessity, justifies skilled care needs, and facilitates appropriate billing - ultimately advocating for patients to receive the required care.

 

 

This ask the expert is an edited excerpt from, Documentation: An Opportunity to Advocate for Your Patient, presented by Trisha Salome, PT, DPT.


trisha salome

Trisha Salome, PT, DPT

Trisha Salome, PT, DPT, is currently a Service Line Director for Penn Highlands Healthcare in Pennsylvania.  Dr. Salome earned her doctorate in physical therapy from Saint Francis University, where she also received her Bachelor of Science in health sciences.  She has spent her entire career working for nonprofits with notable works in pediatrics, home health, hospice, leadership development, clinical documentation, community programs, and operational efficiency. Previously she has represented her profession in elected and appointed positions in the APTA and has presented Hospice education nationally at CSM and with PhysicalTherapy.com.   


Related Courses

Documentation: An Opportunity to Advocate for Your Patient
Presented by Trisha Salome, PT, DPT
Recorded Webinar

Presenter

Trisha Salome, PT, DPT
Course: #4858Level: Intermediate2 Hours
  'Examples of SMAR goals vs not SMART goals'   Read Reviews
This course addresses the rationale behind having top-notch documentation and provides education on making your documentation a tool to advocate for your patients. The course covers ethics of documentation, goal writing, and measuring progress in difficult situations such as palliative care or maintenance therapy.

Hospice 101
Presented by Emily Henneman, PT, DPT, Trisha Salome, PT, DPT
Recorded Webinar

Presenters

Emily Henneman, PT, DPTTrisha Salome, PT, DPT
Course: #4731Level: Introductory2 Hours
  'great info that isn't widely discussed in most PT realms'   Read Reviews
This introduction to hospice and end of life care for physical therapists covers the hospice benefit. Emphasis is placed on the role of physical therapists in hospice and how physical therapy can obtain a "seat at the table" with patients on hospice care.

Mindfulness: Beyond Guided Meditation
Presented by Jennifer Stone, PT, DPT, OCS, PHC, TPS, HLC
Recorded Webinar

Presenter

Jennifer Stone, PT, DPT, OCS, PHC, TPS, HLC
Course: #3902Level: Intermediate2 Hours
  'I enjoyed the experiential activities during the course'   Read Reviews
Mindfulness can be a really powerful cognitive-behavioral tool and has many relevant applications when treating patients with pain, especially chronic pain. Many courses for rehabilitation professionals teach guided meditation, which is an amazing tool. However, mindfulness has many other applications and opportunities for use in the treatment of patients with pain. This session discusses the history and science behind mindfulness, as well as provides a variety of practical mindfulness tools for the everyday practitioner. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Diabetes in Adults: Current Guidelines and Evidence
Presented by Sally Stillings, MA, PT, MPT, CHT
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Sally Stillings, MA, PT, MPT, CHT
Course: #3958Level: Intermediate2 Hours
  'Very good course'   Read Reviews
This course gives us an overview of diabetes in adults, discusses current perspectives and guidelines, and addresses its significance in PT practice. It also looks at some of the current literature that addresses the evidence for risk factors and interventions and to see how they may apply to our practices. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Maximizing Patient Engagement Through the Science of Behavioral Economics
Presented by Mike Studer, PT, DPT, MHS, NCS, CEEAA, CWT, CSST, BFPCE, FAPTA
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Course: #4595Level: Intermediate3 Hours
  'Excellent presentation overall, loved all the examples'   Read Reviews
Learn the evidence and the application of mastering your soft skills to optimize the patient experience and patient engagement. Be ready to improve in every aspect of patient care from the interview, diagnosis, education, intervention, and home exercise prescription.

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