Physical Therapy Software: Protect Your Clinic From Lawsuits With Proper Documentation

Medical malpractice, improper care, and even medical billing and Medicare fraud issues seem to be springing up overnight in all kinds of clinics and private practices, including those that provide professional therapy for their clients. Although having medical malpractice insurance is one way to protect yourself and your employees, your efforts shouldn't stop there. Professionally designed physical therapy documentation is another avenue every clinic needs to pursue so that they will be able to produce clear, detailed documents pertaining to all treatment protocols and patient outcomes if they are ever audited or investigated in relation to a lawsuit.

Malpractice Protection

Nothing is as devastating as being slapped with a malpractice claim, whether it is against you personally, your employees, or your practice or clinic as a whole. Lawyers will request detailed records for everything from the initial evaluation of the individual being treated to how often and using what techniques your therapists worked with the person in question.

Sadly, you can take every precaution, be a dedicated and caring PT professional and follow all approved treatment protocols and still be put under a microscope in a malpractice suit. Before a verdict is ever reached, the stigma of malpractice errors can jeopardize your career, your clinic and your employees. The more quickly you can produce requested documents, the more quickly you can get to the end of the tunnel and clear your practice's reputation. Complete physical therapy documentation using an award winning PT software package is a pro-active way to assist your attorney while confounding those who are suing you.

What Thorough Physical Therapy Documentation Looks Like

If you've been working with an old filing system or outdated forms that you continually have to amend as restrictions and guidelines change over time, you could run into legal issues. If, however, your clinic has installed physical therapy software that comes pre-loaded with the latest PT forms for everything from Medicare and insurance submissions to appropriate patient questionnaires and detailed pain diagrams, you'll be a step ahead.

To protect yourself with complete physical therapy documentation, use a PT software program that provides you with:

Treatment tracking forms Client records, including daily notes, progress notes and discharge notes Detailed patient instruction sheets Records of results over time Scheduling protocols and recording of no-shows and non-compliance by the patient

Proving Medical Necessity And Medical Appropriateness

Your PT software should also document details of each and every session any one of your therapists have with each client. Careful records should include notes on treatment progression, measurable outcomes and any home exercise recommendations as well as specific task reminders for your therapists and alerts regarding any special care needs for individual patients.

It's almost impossible to keep track of such a voluminous amount of information for every individual, but a well-designed physical therapy documentation program can make it easy for each therapist to update patient records and draw up detailed progress notes. The fact is, the more detailed your records are and the clearer they are, the less likely it is that a malpractice or fraud investigation can have a negative impact on your PT clinic. If you haven't invested in the latest physical therapy software for your practice, now is the time to do so; before a lawsuit wreaks havoc on your career and your family.