Industry Standard Documentation in Physical Therapy—- that is wrong.
By Robert Wallace, PT, DPT
After thirty years of seeing physical therapy documentation, I’ve noticed that there are several things that we document that are simply incorrect. It seems that therapists tend to see someone write something and then simply repeat it, without thinking about what it really means. We document to get paid, really, but what you are trying to do is let a therapist that may be treating after you know the assistance needed for that patient. We do it while documenting gait, muscle testing and transfers. Here are several examples:
1) Gait- “The patient ambulated 40’ with handheld assist.” Handheld assistance does not exist. If you are holding the patient’s hand during ambulation because they need some amount of assistance to complete the task then they require that amount of assistance. Just because they don’t use a walker and you are guiding them while holding their hand, does not change the amount of assistance that is required. If they need guidance than that is contact guard assistance. How functional is that gait, by the way?
2) Manual muscle testing- “ Increase the patient’s strength by ½ a grade.” Our manual muscle testing scale has 2 segments between each level, as in 3, 3+, 4-, 4. This makes each segment ⅓ of a grade. Half a grade would put the number somewhere between 3+ and 4-, that is not necessarily the most accurate description and seems a bit too complicated.
3) Transfers- “The patient required max assist x 2.” During transfers we should be indicating the amount of assistance the patient provides, not the therapist. Do we document the same if a 300 pound linebacker type is able to perform the transfer by him–or herself or if it takes three 100 pound therapists to perform the same transfer? (Is this max assist x 3, by the way?) If the patient is only able to assist with the transfer 10% then it should be maximum assistance no matter the strength of the therapist.
We use goniometers, muscle strength scales and standardized tests in order to try and make our profession scientifically based, yet we don’t document properly on some of our most basic tasks. Documentation is not only used for payment but also to describe the functional levels to therapist assistants and others who treat the patient. Most therapists use these terms and many have documented these terms but technically, they are wrong.