Inaba M, Jones S L
Phys Ther. 1977 Jul;57(7):791-4. doi: 10.1093/ptj/57.7.791.
Medical documentation of patient care by physical therapy has become a requirement for reimbursement of health services paid by federal and state programs or by other third-party payers. The medical record of physical therapy must satisfy several specific requirements of third-party payers before health services can be reimbursed. The fiscal intermediaries require a precise, written statement of the patient's physical problems, treatment goals and plan, and objective information on the patient's response to treatment. The criteria reflected for third-party payment must be satisfied and evident in succinct and accurate documentation in the medical record. Medical documentation must show evidence of a prescription, medical reason for treatment, a viable discharge plan, outcome of treatment, coordination of medical services, patient instruction, and discontinuance or adaptation of services when necessary. The requirements for third-party payment based on medical documentation are discussed.
物理治疗对患者护理的医疗记录已成为联邦和州计划或其他第三方付款人支付健康服务费用报销的一项要求。在健康服务能够得到报销之前，物理治疗的医疗记录必须满足第三方付款人的若干特定要求。财务中介机构要求有一份关于患者身体问题、治疗目标和计划的精确书面陈述，以及关于患者对治疗反应的客观信息。第三方付款所反映的标准必须在病历简洁准确的记录中得到满足且显而易见。医疗记录必须显示有处方证据、治疗的医学理由、可行的出院计划、治疗结果、医疗服务的协调、患者指导以及必要时服务的终止或调整。本文讨论了基于医疗记录的第三方付款要求。
