Documentation & Audit Preparedness

Core practices

• Write to function and goals; tie interventions to outcomes.
• Use inclusion cues and stop criteria; document risks addressed.
• Apply time rules consistently (e.g., 8‑Minute Rule where applicable).
• Use modifiers correctly and avoid duplicate coding.

Quick audit checklist

• Signed plan of care and updates
• Clear visit counts and authorizations
• Objective measures with progression
• Billing aligns with documentation