Documentation. It's All About the Skill.

You do great work, your patients respond and improve and you make a positive difference. We know that to be true, but.... can you prove it? Documentation is the only proof of the services that you provided. It ensures that you were "worth the cost" and helps protect you in the event of any future claim. For some, documentation is easy and others struggle. This is a simple strategy to help ensure your documentation can meet medical necessity requirements. Here is the formula:

What + Why + How = Skill

What: Justifies the billing codes

Why: The treatment goals you are trying to reach or the impairment being addressed

How: Demonstrates your skill. (the most important part of the note)

WHAT	WHAT, WHY & HOW = SKILL
THERAPEUTIC EXERCISE AROM for BUE all joints and ranges followed by BUE strengthening using 2 lb weights 3x10 for shoulder flexion/extension, 3x15 for elbow flexion/extension, red theraband 3x10 for horizontal abduction and elbow extension.	Selected [judgement] AROM for BUE all joints and ranges followed by BUE strengthening using 2 lb weights 3x10. Monitored [skill] patient performance and provided verbal/manual cues [education] to ensure correct technique [why]. Determined [judgement] that program could be advanced and added 5 additional reps for elbow flexion/extension exercises. Introduced [judgement and skill] red theraband 3 x 10 for horizontal abduction and elbow extension.
THERAPEUTIC ACTIVITY Dynamic standing balance activities including reach into cabinets performed in kitchen with cues for midline posture.	Dynamic standing balance activities [what] performed in kitchen to improve balance [why] eliciting ankle strategies [skill] with verbal cues for midline posture [education] to reduce fall risk [why]. Added [judgement] reach above shoulder level activities to simulate unloading groceries [functional outcome].
GAIT TRAINING Gait training 2 x 50 feet without AD inside and outside of home with verbal/manual cues	Gait training performed without AD with therapist supervision and guard [how] to challenge [why] balance. Ambulated 2 x 50 feet with verbal/manual cues [skill] to improve postural awareness and maintain step length and height to reduce fall risk. [functional outcome]

For every procedure code that you use, answer the "What, Why, How", mix in some clinical thoughts on the assessment and adjust your plan accordingly. Voila! :-) That, folks, is how and why you get paid for the great work that you do!