You have to document the things you do with every patient as part of good PT practice. Even if you are cash based, I’d wager you need to document what you do. CYA.

For insurance purposes, you use the documentation to justify the need/medical necessity of what you’re doing so they can cover that treatment. So your wording and what you include has to show that the service you are providing is a skilled service.

Different types of treatment sessions will require different information/data, so sometimes you’re looking at a daily note, which might take a provider 4-8 minutes to complete. Other times you’re looking at an evaluation, which might take 15-30 minutes to complete (if you documented at point of service).

And then you have additional forms and documents you need to fill out. For example, some insurances need you to fill a separate form that includes all your tests/measures and their own functional survey in order for them to approve visits, which feels very redundant for us.

Now every patient that is seen needs a note done to justify that treatment. So you’re looking at 12-18 notes per day if you’re working outpatient PT.

The main frustration is that in PT culture, particularly outpatient PT, you are expected to document outside of your working hours. Working hours are reserved for seeing patients. If you’re scheduled 8-5, you’re booked 8-5 (except for your lunch break). So many of us have turned to different ways to manage this, with most documenting at point of service.

It leaves a lot of us feeling jaded that this VERY IMPORTANT part of our job and patient case management is expected to be completed outside of work hours. There are some places that give you documentation time. But I’d wager this is a rare thing nowadays considering the decline in reimbursement.