As I mentioned in my last post on point-of-care documentation, documentation during treatment is widely recommended. But when it comes to billing, the RAI User’s Manual says that only skilled therapy time is billable and “[t]he therapist’s time spent on documentation or on initial evaluation is not included.”
Based on my interpretation of the rules, I would never do any documentation during sessions when I was starting out. I’d wait until later in the day (hopefully) or week (yikes!) to flip through my notes and start documenting the session.
This meant I’d end up with a growing pile of notes (not always legible, unfortunately). And as the top of the stack got higher and higher, so did my blood pressure!