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Common Findings and How to Avoid Them

Module 12: Documentation, Notes, and Billing Integrity · Lesson 2 of 3

12 min Back to module

Story opener

It is 6:15 p.m. and you have nine notes left. Everything you write from here will be read by someone who was not in the room — a reviewer, a supervisor, maybe a court. Speed and defensibility are not opposites; they are the same skill.

Learning objectives

  • Be able to same-day documentation is a non-negotiable habit
  • Be able to content must justify the time billed

Lesson

Auditors see the same six problems everywhere.

Late notes, cloned notes, time not supported by content, services outside the plan, missing signatures, and activity-only descriptions. Every one is preventable with a routine.

Document in the field between visits. A note written three days later is both less accurate and less defensible.

Maryland guidance & authority labels

Every statement below is labeled so you know what is binding regulation, what is only proposed, what is professional guidance, and what is our house standard.

  • COMAR — current

    Notes must be contemporaneous, signed and dated with credentials, and linked to an authorized objective in the current plan.

  • COMAR — proposed

    Telehealth-delivered PRP documentation expectations have been an active area of proposed revision; record modality and participant location until the final language settles.

  • Internal best practice

    Objective / Intervention / Response / Plan. Eight minutes. Same day.

Common mistakes

  • Describing what you did without describing what the participant did.

    Do this instead — Record the intervention and the participant's observable response to it.

  • Treating regulation as a filing chore separate from practice.

    Do this instead — Let the required elements shape the session itself, so documentation writes itself.

Practical examples

Practical example

Instead of 'met with participant to discuss goals,' write: 'Reviewed the transportation objective; participant identified the #22 route unassisted and named one back-up plan. Verbal prompt needed once. Next session: practice the transfer at Mondawmin.'

Key takeaways

  • Same-day documentation is a non-negotiable habit
  • Content must justify the time billed

Reflection prompts

  1. 1Which part of this lesson describes something you are already doing differently in practice?
  2. 2What would an auditor see in your last five notes that contradicts this standard?

Bring your answers to supervision — the case-study workspace in this module saves written notes to your account.

Knowledge check

4 questions drawn from a bank of 7 · 75% to pass · instant feedback on every answer

1. Which note element most often fails to support billed time?

2. Which additional point does "Common Findings and How to Avoid Them" emphasize?

3. A colleague does this: Describing what you did without describing what the participant did. What should they do instead?

4. A colleague does this: Treating regulation as a filing chore separate from practice. What should they do instead?

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