| name | defensible-documentation |
| description | Write and review defensible PT/rehab daily notes and evaluations — establishing medical necessity every visit, documenting skilled care as skilled, tying each note to a plan-of-care goal, and avoiding boilerplate that invites a denial or audit finding. |
Defensible Documentation
The cheapest denial is the one the note prevented. Each note must read as skilled, medically necessary, and tied to the plan of care.
The checklist (every visit)
- Medical necessity, today. Why was skilled therapy required this visit? Clinical reasoning, not a modality list.
- Skilled care reads as skilled. Name the clinical decision-making, the progression/regression, the cueing/adjustment that required a licensed therapist. "Tolerated well" is not skilled documentation.
- Trace to a POC goal. Today's note maps to a plan-of-care goal; an orphan note is an audit flag.
- Objective + functional. Measurable change toward a functional outcome, not just "patient feels better."
- Signed and dated per the applicable signature requirement (
[verify-at-use]).
Smell test (the advisory hook also flags these)
- Timed treatment minutes recorded but no unit count → loop in billing.
- "Patient tolerated treatment well" with no skilled-care justification.
- A plan of care with no certification / recert review date.
Verify-at-use
- Signature, timing, and content requirements vary by payor and by CMS/Medicare rules and change — cite the standard + retrieval date, or mark
[unverified — training knowledge]. Never paste patient PII; work from de-identified examples.
See the medical-necessity / defensibility tree in ../../knowledge/pt-clinic-decision-trees.md and the ../../templates/daily-note-skeleton.md.
