HPSO Risk Advisor 2011-2012 1

Healthcare Providers Service Organization

Risk Advisorfor Physical Therapists

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Making the leap to electronic health recordsIf you don’t use electronic health records (EHRs) in your practice now, it’s likely they’re coming soon. The Federal government has established a Medicare and Medicaid incentive payment program for facilities to implement or upgrade EHR technology.

Benefits of EHRs for physical therapists include improved reporting and efficiency, better interdepartmental communica-tion, and more accurate data. EHRs also make it easier to report on quality standards, an increasing focus of the government and third-party insurers. But reaping the benefits of EHRs depends on using them properly.

Know your facility’s EHR policiesMake sure you know how to properly input complete entries in each patient’s EHR and how to correct er-rors if you make them. Deviating from your facility’s standards can lead to mistakes and misconceptions in the EHR and create liability exposure when none is warranted. A mistake in the EHR can make it look like you did something wrong when in reality it was just an inputting error. Your facility will have a written policy that will not only cover documentation style (such as documentation by exception, charting, and so on), but also establish policies regarding the documentation of late entries and correcting entries. For example, when a late entry is made, include a rationale for the delay and label it as a “late entry.”

Stay current with all policies that affect your docu-mentation of patient care to ensure that the documen-tation reflects the care you provided. If you are unsure of how to document something in a patient’s EHR, contact your supervisor immediately so you don’t make any inputting mistakes. Ask for additional train-ing if you feel it’s necessary.

When things go wrong … Every physical therapist strives to provide safe patient care without incident, but unfortunately adverse events can happen. Should one of your patients experience an adverse event, follow your facility’s poli-cies and procedures for documenting them properly. Whether using EHR or traditional paper files, docu-ment all relevant facts related to the adverse event. Include your assessment of the patient’s condition, prescribed therapy, what went wrong, any interven-

In this issue Electronic health records 1

Effective reevaluations 2Caution: Telephone advice 4

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tions, and the patient’s response. Make sure you follow your facility’s policy on documenting an adverse event. Additional in-depth investigation and documen-tation may be required by your facility. You may need to complete an event report. Event reports document

the findings of the investigation: what happened, why it happened, what harm was done, what responses were made, and what changes are required to prevent a similar event in the future. Check with your risk man-ager for your facility’s policies for documenting events.

Keep it privateRemember that the Health Insurance Portability and Accountability Act of 1996 applies to information whether it’s on paper or in the computer. Take steps to ensure each patient’s privacy, such as when printing an EHR. Never share access or passwords with other therapists.

Once you’re using an EHR system, report any prob-lems or glitches you see in the system to your supervi-sor so they can be addressed. Keeping a close eye on what works and what doesn’t will help protect you from making mistakes in the record and putting your reputation at risk.

Making the leap continued

Reevaluating a patient’s status at appropriate points in an episode of care is a physical therapist’s professional responsibility. Reevalu-ation is important to determine a patient’s progress or lack of prog-ress toward established goals and determines whether the plan of care needs to be updated or changed or, in some cases, whether care needs to be discontinued. Good outcomes often depend upon a careful reevaluation.

Conducting a reevaluationThe American Physical Therapy Association (APTA) includes reexamination as a part of the patient/client management model in its Standards of Practice. This document states: “The physical therapist reexamines the patient/client as necessary during an episode of care to evaluate progress or change in patient/cli-ent status and modifies the plan of care accordingly

or discontinues physical therapy services.”

A reevaluation isn’t the same as a reassessment. Assessments are a routine, expected part of the provided service and are not typically covered by most health insurance plans, including Medicare.

In general, a billable reevaluation should oc-cur whenever there is an unanticipated change in

the patient’s status, a failure to respond to physical therapy intervention as expected, the need for a new plan of care, and/or requirements based on state prac-tice acts. Medicare considers a secondary condition that requires physical therapy and develops during an existing episode of care to be within the same “epi-sode” of care.

Some insurance providers and state regulations have specific requirements for how often a reevaluation must be completed. To obtain payment from Medicare, reevaluations have to meet Medicare guidelines.

Make your reevaluations effective

Using EHRs correctlyEHRs can provide many benefits, but they must be properly used to be effective.● Use a complex password (a sequence of

unrelated numbers and letters) as opposed to one that could be easily guessed such as your birthday or your child’s name. Change your password frequently.

● Be aware of defaults that appear in an electronic template. It’s easy to skip over this information without verifying it’s correct.

● If you make additions or changes after an entry is completed, include the reason for the late entry and an electronic signature.

HPSO Risk Advisor 2011-2012 3

The reevaluation compares similar data at two points in time and determines whether or not the plan of care needs to be updated or changed. It also covers how these changes will affect the expected outcomes and timeframe of care.

Physical therapy goals should be addressed by noting where progress has (or has not) been demon-strated. If necessary, new goals should be developed. Changes in prognosis, diagnosis, and discharge recommendations should be noted.

Reevaluation requires the professional skill needed to make clinical judgments based on objective data and subjective information from the patient. The physi-cal therapist is responsible for conducting the reevalu-ation directly with the patient. The role of the physical therapist assistant is to provide select interventions under the direction and supervision of the physical

therapist. It’s not appropriate for a physical therapist assistant to either directly or indirectly conduct a re-evaluation of a patient.

When conducting a reevaluation of a patient who was initially evaluated by another physical therapist, the physical therapist should properly familiarize him or herself with the patient and take time to establish a rapport before proceeding with the reevaluation. Listen carefully for what the patient says—and doesn’t say. Patients may intentionally or unintentionally over- or under-estimate their progress. It may be helpful to obtain input from family members.

Carefully analyze the data collected from the reevalu-ation and compare this to the data collected during the initial evaluation. This data, along with the patient’s assessment of progress, should be used to determine whether changes need to be made in the plan of care.

DocumentationDocumenting the reevaluation properly is critical to ensuring that the care the patient received is appropri-ate for his or her condition and is modified to reflect changes in status. A standard template that includes required information and a place for the signature and date can be helpful to make certain that all necessary information is included. Be sure to use the correct billing code. The CPT code for reevaluation is 97002 (compared to 97001 for an initial evaluation).

It’s up to youBy appropriately conducting and documenting re-evaluations, you can ensure patients receive the most benefit possible from physical therapy.

Medical malpractice claims can be asserted against any healthcare provider, including physical therapists. Although there may be a perception that physicians are held responsible for the majority of lawsuits, the reality is that physical therapists are more frequently finding themselves defending the care they provide.

In this case, the patient was a 5’2”, 156-lb, 54-year-old woman who underwent a hysterectomy and

afterward began to experience lower back pain. Five months after surgery, the patient sought treatment for her back pain with an orthopedic surgeon who be-lieved she was suffering from degenerative problems and prescribed physical therapy...

To read the full case with risk management recom-mendations, go to: www.hpso.com/case-studies/casestudy-article/341.jsp.

Reevaluation documentationDocumentation of the reevaluation should include:● physical findings of functional status● patient subjective reports of functional status● progress toward existing goals● new or modified short-term and long-term

goals● plan of care (gait training, transfer training,

therapeutic exercise, etc.)● patient instructions● recommended frequency and duration (give

specific numbers, not a range)● signature and credentials of the physical

therapist and the date

Physical therapists and medical malpractice: A case study with risk management strategies

4 HPSO Risk Advisor 2011-2012

Physical therapists give telephone advice in a variety of settings. The therapist who responds to a patient’s question about exercises to do at home or takes a patient’s concerned call about a fall is in a position to provide valuable information and make important assessments. But in their eagerness to help patients, physical therapists must be careful not to expose themselves to legal risks. Here are some tips to protect yourself while providing patients with quality information.

Consistency countsConsistency helps ensure that questions are answered completely and effectively. Algorithms, protocols, and responses to frequently asked questions are useful tools that also reduce legal risk. Tools should be predicated on current standards and evidence, so be sure to review them on a regular basis and update as needed. Physical therapists

who will be responding to questions should receive special training in how to conduct an assessment over the phone.

If it isn’t written…In the hectic rush of the day, it’s easy to neglect documenting telephone calls. Treat each clinically related telephone call the same way you would a face-to-face visit: Document the assessment, the advice given, and any follow-up instructions given to the patient. Regular review of documentation will help maintain quality and identify areas of improvement.

Therapist-patient relationshipRemember that giving advice over the phone es-tablishes a therapist-patient relationship. Keep your clinical skills—and telephone skills—sharp so the relationship yields positive results.

Caution: Telephone advice

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HPSO Risk Advisor is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO Risk Advisor, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. The professional liability insurance policy is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Coverages, rates and limits may differ or may not be available in all States. All products and services are subject to change without notice. This material is for illustrative purposes only and is not a contract. It is intended to provide a general overview of the products and services offered. Only the policy can provide the actual terms, coverages, amounts, conditions and exclusions. CNA is a service mark and trade name registered with the U.S.Patent and Trademark Office. Healthcare Providers Service Organization is a division of Affinity Insurance Services, Inc.; in CA (License #0795465), MN and OK, AIS Affinity Insurance Agency, Inc.; and in NY, AIS Affinity Insurance Agency. HPSO Risk Advisor is published by Affinity Insurance Services, Inc., with headquarters at 159 East County Line Road, Hatboro, PA 19040-1218. Phone: (215) 773-4600. ©2011 Affinity Insurance Services, Inc. All world rights reserved. Reproduction without permission is prohibited.

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