Tuesday, August 09 | Care Coordination, EHR Solutions and Operations, Thought Leadership

Top 5 Physical Therapy Documentation Tips

By Netsmart

Whether a clinician has been practicing for one year or twenty, they always find themselves on the hunt for physical therapy documentation tips! Documentation can help prove that a patient received the treatment they needed and can help the clinic receive reimbursement for their services. With that said, the documentation process can be overwhelming, challenging and extremely tedious; however, physical therapy EMR software has saved the day when it comes to providers spending less time on their notes and more time treating their patients. Below are five tips to help PT providers complete documentation efficiently.

Complete Physical Therapy Notes in a Timely Manner

Although this tip sounds obvious, many physical therapy providers fall victim to allowing several days to pass in between treating a patient and completing the documentation for that visit. Ideally, the provider should strive to complete all documentation as close to visit completion as possible. This minimizes the chances of forgetting information that should be documented as well as helps to identify any problems that may be occurring with a patient’s care. Additionally, it ensures that the patient has an up-to-date medical record which is critical to providing that person with the exact care they need. Clinicians should make sure to complete PT documentation as soon as possible to avoid delays in providing quality care.

Be Clear and Concise Without Sacrificing Important Therapy Information

Use bullet points or lists whenever possible. This makes it easier to remember what was discussed and can also speed up the process of documenting physical therapy patient information. Make sure all relevant information is added to the note. Establish a certain flow within the note by keeping it organized and focused. Additionally, utilize common terminology and concepts throughout the document so that everyone, both colleagues and referring physicians, can understand the note with ease. 

Customize Your Physical Therapy EMR Software to Fit Your Workflow

Oftentimes, physical therapy software programs are set up a certain way by default; however, that way may not be the best option. Make sure to take advantage of all trainings, guides, and other resources that the software vendor provides so that the appropriate steps can be taken to make the software work how you need it to. Luckily, TheraOffice comes with a wide variety of documentation customization options including evaluation templates, common phrases and dropdown boxes, and treatments and protocols. Although it may be time consuming to customize the software to your exact treating style, in the end, it will be that much faster to complete physical therapy notes. This results in spending more time with patients and less time behind a computer screen.

Understand and Stick to All Physical Therapy Compliance Requirements

As all clinicians know, there is an endless list of rules and regulations when it comes to compliance. Between state obligations and payer requirements, it can be quite difficult to complete documentation in a way that allows you to get reimbursed in a timely fashion. It is highly recommended that providers have legitimate, verifiable resources that they can rely on to ensure they are staying up to date on any changes. Once compliance requirements are understood, providers should determine how their documentation software will accommodate them to minimize the chances of completing documentation inaccurately. This could be as simple as flipping a setting or may require a new update, but it is important to leverage the changes that are made to make documenting less burdensome.

Have a Routine and Stick To It

Creating a process and sticking to it is vital to staying on top of notes. Completing a patient’s note prior to starting the next patient or committing to filling out at least 75% of the note while the patient is in the clinic or reviewing all notes at the end of the day and finalizing them before the morning could all be some processes that physical therapy providers consider implementing. If a process is in place and upheld, providers are naturally more likely to complete documentation efficiently without letting their to-do lists spiral out of control.

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