Are Your Therapy Notes as Clear as They Should Be?
Regardless of who your patients are the documentation created by yourself and your therapists in each session must support the primary focus of the patient’s treatment.
In particular, it is not recommended that the diagnosis be changed or altered so that the cost is covered by the patient’s insurance.
The Importance of Clear Documentation
If your documentation doesn’t match what the patient is being treated for you are either failing to document the information properly or you’re not being as clear about what’s going on in the therapy session.
Guidelines and policies in the long term will benefit your clients, and of course, your staff. Ensuring that your therapists are following your set procedures will develop feelings of trust, and build the integrity of your business.
In other words, your words must match the actions of your clinic. This will remove any confusion and avoid misrepresentations which could land you in hot water.
You don’t want your clients going claiming sessions with their insurance companies only to be told they are asking for one thing, but the documentation is covering another.
Creating Clear Policy
If you haven’t already, ensure that you have created clear polices about what services you are providing, and how sessions should be documented. This might take time, but it may save you a lot of issues later on.
You and your therapists should also communicated this information to clients to avoid any misunderstandings when they approach their insurance companies.
Structuring documentation clearly for clients, insurance companies, and your business is imperative. As a therapist you should create clear policies based on best-practice procedures which will lead to an open practice which offers value for its clients.
Let Therasoft help your clinic develop clear documentation practices.
