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Case Study: Documentation errors lead to two separate licensing board actions

Physical Therapist and License Protection
Case Study with Risk Management Strategies
Presented by HPSO and CNA

Total Incurred: Greater than $15,800
(Monetary amounts represent only the expense payments made on behalf of the insured physical therapist.)


This case involves a physical therapist who co-owned a physical therapy and chiropractic center with a Doctor of Chiropractic (DC). Over a period of two years, the PT treated four patients who were involved in motor vehicle accidents. Initially these patients were treated by the DC and then referred to the PT for physical therapy. However, occasionally, when the PT was busy, the DC would provide modalities for these patients.

After submitting claims for the physical therapy services to the patients’ insurance company, the insurance company found deficiencies in the claims that were submitted. For the four patients’ records that were reviewed in this case, the charts and insurance claims filed by the PT failed to include his name and license number, and he failed to sign the patient notes. The insurance company filed a complaint against the PT with the State Board of Physical Therapy.

Risk Management Comments

During the Board investigation, the PT admitted that his record keeping skills were “deficient”. The PT advised that the computer program the practice used for patient records was a shared word processing program which contained only one patient record for each patient. The PT and the DC shared the same patient records and the program was not capable of accepting an electronic signature, nor was it write-protected.

The Board found that the PT failed to sign or maintain contemporaneous patient records, and failed to include the following information in the patient records:
  • The name and license number of the provider who provided the patients with physical therapy services;
  • a plan of care, including the type of intervention, measurable goals of the intervention, and the frequency and expected duration of the intervention;
  • treatment plans and progress reports;
  • discharge summaries which include the reason for discharge and outcome of the physical therapy intervention relative to the established goal(s); and
  • documentation of communication with the patients’ other treating practitioners.


In light of these findings, the Board concluded that the PT repeatedly violated state patient record regulations, as well as Principle 7E of the American Physical Therapy Association’s (APTA) Code of Ethics for the Physical Therapist, which states that: “Physical therapists shall… ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided.” The PT was publicly reprimanded by the Board, ordered to submit documentation that he completed the APTA Defensible Documentation course, required to submit to the monitoring of his patient records by a Board-approved monitor for one year, and ordered to pay a civil fine of $10,000, in addition to $1,150 in administrative costs.

Furthermore, subsequent to the first Board investigation and disciplinary action, a neighboring state where the PT also maintained a license opened its own investigation. In finding that the PT had a disciplinary action against his license in another state, the Board in the second state also publicly reprimanded the PT’s license and issued a civil fine of $1,500.

The total incurred costs to represent and defend the PT in these two licensing board investigations was greater than $15,800, and the cases took over 6 years to resolve. 

Risk Control Recommendations

For Physical Therapists:
  • Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, appropriate and legible manner. Documentation should support the treatment plan and satisfy board regulatory and third-party billing requirements. When more than one requirement applies, adhere to the most stringent policy.
  • Accurately and contemporaneously document care given in the patient health record. Refrain from using subjective opinions or conclusions.
  • At minimum the record should include:
    • Patient’s chief complaint and review of current problems or symptoms.
    • Review of clinical history, including relevant social and family history.
    • Patients’ acknowledgment that they agree to the treatment to be provided and are aware of the expected treatment outcome.
    • Documentation of each visit or encounter, documenting the date and time, implementation of the plan of care, changes in patient status, and progressions of specific interventions used.
    • Evaluation of the patient’s wound condition, skin integrity, neurological status, and ability to perceive pain or discomfort, if applicable.
    • Educational materials, resources, or references provided to the patient.
    • Encounters with healthcare providers, including those via telephone, facsimile, and email, with a summary of the discussion and any subsequent actions taken.
    • Documentation of reexaminations, including data from repeated or new examination elements. When indicated, document revision of goals and plan of care.
For Physical Therapy Business Owners:
  • Every practice needs a written policy governing documentation issues, and all staff members should be trained in proper documentation practices. The policy should address, among other issues, healthcare information record contents, patient confidentiality and the release and retention of patient healthcare information records.
  • Perform at least annual performance reviews for each employee, including a review of documentation requirements compliance, existing skills and directly observed competencies. Provide physical therapy staff with coaching, mentoring, and clinical and system education as needed to ensure that patient safety requirements are satisfied.
  • Implement appropriate administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and security of all patients’ personal health information.
  • Retain all types of healthcare records for at least the minimum time established by state and federal laws, licensure laws and policies, and third-party contracts; whichever guideline is most stringent. Contact the licensure board in the state(s) where you practice for record retention guidelines. 
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

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