Physical therapists likely didn't slog through countless hours of college to become professional notetakers—but it's a necessary part of the process that isn't going away anytime soon. Documentation is a hot-button topic for many PTs because it can cut into getting other things done. And with many practices demanding more productivity out of PTs, there's no room for playing catchup. So, how can PTs be more efficient and streamline their physical therapy documentation? In this article, you'll learn 9 tips and tricks that can help PTs get ahead of their notes before, during, and after the notetaking process to spend more time with patients and less time behind the computer.
Getting to know the technology you're using to chart can speed up the process of physical therapy documentation. Better yet, task a staff member to learn the entire system (or tackle it yourself) and host a meeting. During the session, you can go through each nook and cranny to get comfortable using the tech and customize it to fit the needs of your practice.
Many PT software solutions come preloaded with standard reports, but these can feel clunky depending on the type of therapy provided. Use PT software that enables customizable templates tailored to the needs of your practice, such as:
Update these templates as the needs of the practice shift and ask staff for feedback.
Small documentation mistakes cost time and money. And sometimes, these don't even happen during notetaking. Knowing the most common mistakes PTs make can accelerate the speed of patient documentation (especially when it comes to Medicare).Watch out for:
1. Missing plan of care certifications from the primary care provider
2. Lacking medical necessity (APTA explains defensible documentation here)
3. Failing to notate how a patient is progressing through their plan of care and while there are other ways PTs can make errors, it's easy to remember the basics and write notes under the SOAP format: subjective, objective, assessment and plan.
Cutting the fluff from your documentation means writing everything down that you need and nothing you don't. After you've gotten comfortable with your EMR platform and customized templates—there's often redundant information. PT practices should attempt to normalize the use of abbreviations, enable auto-complete, and experiment with other software features that facilitate faster documentation.
If you have physical therapists who stick around finishing paperwork every night, it might be time to ask the pros for advice. Every PT practice works differently, so collecting insight from PTs who excel at documentation can improve and teach PTs who need the extra help. Make documentation a focus in team meetings and set goals in one-on-one sessions to push for progress.
In-person or point-of-service documentation is a great way PTs can stay on top of patient paperwork. It's also the most effective method for notetaking because you're taking notes in real time. PTs should try to get through one or two letters of SOAP during the visit. An effective way to get the best notes and make your patient feel at ease is to set expectations before you start plugging away at your keyboard. If every PT takes just a few notes in-person during every visit, the practice will save hours on paperwork.
Aside from EMR templates, there are many ways PTs can speed up the intake and follow-up process with patients. Going digital speeds up documentation, assists patient recovery, and makes practices more profitable.Toss the clipboard and use a HIPAA-compliant digital intake form to accelerate documentation. Digital intake eliminates the administrative duty of transferring sensitive patient information into the system and allows patients to go straight into their appointments. Another way practices can go digital is with appointment reminders. And while patients showing up actually increases the amount of documentation you'll need to do—a patient no-show is a huge time-wasting event. According to a report on the impact of missed appointments, nearly 1 out of 5 PT appointments fall through in the United States. By using automated texts, emails and call reminders, PT practices can take control of their missed appointments. Finally, consider switching to online scheduling. When patients can schedule their own appointments, it removes the friction of calling within business hours and determining the best time to book. It also frees up your staff to help patients at the clinic and focus on necessary paperwork.
As cliché as it sounds, staying organized is a powerful tool to accelerate your PT practice's documentation. Analyze every step of the process from the initial appointment, file keeping practices and scheduling follow-ups. Know what processes are in place, ask for feedback, and attempt to streamline them through trial and error. Practice owners can even shadow the patient process from start to finish to identify areas of opportunity.
Physical therapy documentation isn't the most exciting part of the job, but it's necessary. PTs who are ill-prepared often work longer hours, leading to burnout. Getting ahead of documentation is simple when you've mastered the EMR platform and have a hand in customizing templates to your practice's needs. Furthermore, these templates help reduce costly documentation mistakes and can make taking notes in person a breeze. If you're struggling to find time to implement these and other documentation hacks, consider streamlining everything at your PT practice using a powerful software solution. MWTherapy is the leading physical therapy software that provides an all-in-one platform for navigating EMR, telehealth, compliance, and everything else busy PT practice owners need to manage. Get started today with a free demo and see how our software can streamline your PT practice!