As a compliance officer, I am often asked if point of service documentation is ethical or not. As therapists and assistants, our state practice acts outline our responsibilities to ensure documentation of therapy services is appropriate, justifies the course of treatment of the patient, and accurately documented in the medical record.

For example, the Ohio Board of Physical Therapy  states, “Appropriate documentation is integral to all facets of physical therapy care.”

The Florida Board of Occupational Therapy states, “Failure to keep written medical records, justifying the course of treatment of the patient, including but not limited to patient history, examination results and test results” is a violation of the practice of occupational therapy.

The Massachusetts board of Speech Language Pathology states that “Grounds for Imposition of Disciplinary Sanctions” for “failing to establish and maintain an adequate, confidential, legible, secure, and accurate written case record for each patient…”.

From a Federal level, the Medicare Benefit Policy Manual Chapter 8 and Chapter 15 discuss the requirements for nursing and therapy documentation. In the Medicare Program Integrity Manual Chapter 3 Section states, “All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered.” This section is referring to amendments, corrections, and delayed entries in the medical record. This section of the manual also states, “Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service.

Medicare expects documentation in the medical record to be accurate, timely, and an accurate reflection of the services provided to justify why a skilled nurse and/or therapist is required to treat the patient’s condition. My question to you is this: if you provide treatment to eight patients and wait until the end of the day to document each patient, how accurate and detailed do you think your documentation will be? Will you remember the details from the treatment provided to your first patient of the day versus your last? Is there a chance for medical errors being documented?

Human error is the main reason Medical Errors occur. Perhaps those errors are because we are pulled in so many directions during the course of our workday, provider burnout, or maybe it’s something as simple as documenting timely?

I believe it is a combination of multiple reasons. But if you can control one of the contributing factors, wouldn’t you want to for your patients’ wellbeing?

A scenario to consider: Perhaps your first patient of the day has new precautions, and because you waited until the end of the day to document, you forgot to document those precautions. The therapist or nurse who is assigned to the patient the next day is not aware of those precautions and, therefore, didn’t follow them. This, in turn, resulted in a patient injury, or maybe even death in some extreme cases.

Benefits of Point of Service Documentation

  • Improves detail of the entry because the information is still fresh in your mind.
  • Provides an opportunity for the therapist to educate the resident and reinforce the tasks, activities, exercises, etc., while ensuring all the important data is captured accurately.
  • Improves patient involvement in their care. Provides a collaborative process with the patient engaged in what you’re writing, discussing, and documenting.
  • When the therapist/assistant includes the patient in the documentation process, therapists/assistants can better integrate patient feedback & their response to treatment.
  • Provides an opportunity for patient education & training by the therapist/assistant.
  • Promotes resident safety and quality of care.
  • Improves continuity of care; Improves communication between disciplines.
  • Decreases errors. If you document point of service immediately following the session, you will significantly decrease the likelihood of forgetting important information, decrease the likelihood of documenting the wrong information, and improve recall of the session.
  • Improves quality of documentation. Delayed documentation lacks the specific details necessary to support the therapy services provided.
  • Clear and concise therapy documentation ensures residents receive the right care at the right time.
  • Assists in ensuring timely & accurate payment.
  • Ensures meeting state practice act documentation requirements.
  • Decreases risk of lawsuits.

One extremely important point to mention, and this one is extremely important: patient safety always comes first! If it is not safe to document at the time the services is provided, don’t! Your clinical and professional decision-making is imperative to identify whether or not point of service documentation is safe to do.

Not every patient will be appropriate for you to document at the time of service is provided, and that is okay. Be open and recognize that with some patients, it is safe to document at the time of service; with other patients, it may not be. In that case, complete the documentation immediately following the conclusion of your treatment with the patient, and prior to working with your next patient.

Thinking back to the question, “Is point of service documentation ethical?” Considering everything discussed above, my question back is you is this: “When appropriate, is it ethical not to?”