In a typical therapy session, I attempt to fit in the most important tasks I feel the patient needs to focus on for that day. Therapeutic exercise, gait training and pain management modality -- it can be challenging to fit the session goals into the allotted 45 minutes to an hour. Then there are times when the patient is so weak and ill, bed-level exercises and bed mobility are the only options for therapy. In these cases, extensive rest breaks due to increased fatigue and education regarding importance of movement with healing can be filled during the treatment time -- which is duly documented.
One documentation "gray area" I find when working with a patient, particularly one who is new to my schedule, is billing for the time where I'm "building rapport." There are many instances where, after introducing myself to a patient, I'll attempt to engage the person in a topic of interest. Any discussion of family/job/dog/sports/music (etc.) can and usually help relax the patient and begins to build our therapist-patient relationship. These "chats" can last up to 10 minutes or more before any skilled therapy begins.
Throughout the session, I find having irrelevant conversations off topic of the patient's medical condition can lead to an overall more productive treatment. In some cases, the amount of activity is lower but the quality and effort are increased because the patient is less stressed. When I finally sit down to document for that session, I'll chart that extensive rest breaks were taken and encouragement was provided. Personally, I don't actually state that a portion of the treatment time was dedicated to "building rapport," but I've read notes where those exact words were used by other clinicians.
I'm not about to stop engaging my patients in discussions that bring them comfort and some enjoyment, but it definitely can be a balancing act. Keeping a person focused on the therapy session just as much as the talk of his favorite NFL team, it can be challenging but necessary. As well, appropriately billing for therapy treatment is my responsibility as the patient's PTA.