Defensible Documentation

---
name: defensible-documentation
description: "Write and review defensible PT/rehab daily notes and evaluations — establishing medical necessity every visit, documenting skilled care as skilled, tying each note to a plan-of-care goal, and avoiding boilerplate that invites a denial or audit finding."
---

# Defensible Documentation

The cheapest denial is the one the note prevented. Each note must read as **skilled, medically necessary, and tied to the plan of care**.

## The checklist (every visit)

1. **Medical necessity, today.** Why was skilled therapy required this visit? Clinical reasoning, not a modality list.
2. **Skilled care reads as skilled.** Name the clinical decision-making, the progression/regression, the cueing/adjustment that required a licensed therapist. "Tolerated well" is not skilled documentation.
3. **Trace to a POC goal.** Today's note maps to a plan-of-care goal; an orphan note is an audit flag.
4. **Objective + functional.** Measurable change toward a functional outcome, not just "patient feels better."
5. **Signed and dated** per the applicable signature requirement (`[verify-at-use]`).

## Smell test (the advisory hook also flags these)

- Timed treatment minutes recorded but no unit count → loop in billing.
- "Patient tolerated treatment well" with no skilled-care justification.
- A plan of care with no certification / recert review date.

## Verify-at-use

- Signature, timing, and content **requirements vary by payor and by CMS/Medicare rules** and change — cite the standard + retrieval date, or mark `[unverified — training knowledge]`. Never paste patient PII; work from de-identified examples.

See the medical-necessity / defensibility tree in [`../../knowledge/pt-clinic-decision-trees.md`](../../knowledge/pt-clinic-decision-trees.md) and the [`../../templates/daily-note-skeleton.md`](../../templates/daily-note-skeleton.md).