Legality Doesn't Make It Right
Last week I ran across something I'd never seen or heard of before -- a therapist who doesn't write notes. I had 12 of his patients. All 12 were lacking daily notes. The papers were there where the notes would have been written. Times in and out were documented. There just wasn't anything else written down. All of the charts had evaluations and a few had monthly progress notes. None of these were current.
This is wrong in so many ways. The PT had to know notes were required. Hours and hours of PT education is devoted to note-writing. I thought it was universally understood that for every treatment or evaluation, a note had to be written. I guess this PT didn't want to. The other employees weren't surprised. They told me the PT was bad about writing notes. They were very surprised at my refusal to treat the patients because there were no notes.
I didn't actually refuse. I told them I would re-evaluate everyone and charge appropriately. I would provide treatment in whatever time was remaining. I was told not to do that. Instead I was to ask the technician who usually does the treatments. He would know what everyone did.
Later in the day I learned not writing a note wasn't illegal. I can't say that I ever saw or heard of a law that specifically requires a note to be written. There are several laws governing reimbursement that require PT documentation to justify charges. I have no idea how they were getting reimbursement for the PT's charges. How can a bill be submitted without appropriate documentation? Not being illegal doesn't make this right.
I am dumbfounded by how little anyone reacted to the situation. My company said not to worry about it because the PT was available by phone. The man was on vacation in a place nine hours away by plane. I think that is stretching the definition of available by phone a wee bit. I don't even want to think about how many time zones were crossed. Obviously the clinic wasn't upset, based on their reaction to me. I think the only other person upset was the PT when I said I was reporting this to the PT Board.
I still can't believe something like this is possible. I've worked with several therapists who came in on days off to complete documentation. The first thing I was taught was never leave until you finish writing your notes. One chart had 20 blank pages. How can that not be a problem? Since then I've talked to several other therapists about this. They share my reaction. I don't know what else to say.