defensible-documentation

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)

1. Medical necessity, today. Why was skilled therapy required this visit? Clinical reasoning, not a modality list.
2. 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.
3. Trace to a POC goal. Today's note maps to a plan-of-care goal; an orphan note is an audit flag.
4. Objective + functional. Measurable change toward a functional outcome, not just "patient feels better."
5. 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.