Documentation Requirements for PM&R

Tags: compliance documentation audit

The “Gold Standard” Note

1. Subjective: Patient’s report of function/pain (VAS scale).
2. Objective: ROM, Strength (5/5 scale), Gait analysis, Special tests.
3. Assessment: Diagnosis + Functional Limitation.
4. Plan: Specific interventions + Frequency/Duration.

Medical Necessity

• Why does this patient need this treatment?
• Must show Functional Progress. If plateaued, why continue?
• Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound).

Red Flags

• Cloned notes (copy/paste).
• Lack of signature/date.
• Treatment without a signed Plan of Care (POC).
• Billing timed codes without time logs.

00 PM&R Coding MOC