6 Techniques to Speed Up Physical Therapy Documentation
To guarantee that patients receive appropriate, effective, tailored, and high-quality healthcare services, physical therapy must maintain thorough, accurate, and timely documentation, just like all other medical disciplines.
Physical therapists (PTs) must maintain accurate clinical records to defend against a claim of medical malpractice and assure fair compensation. Despite the fact that electronic medical record (EMR) software for physical therapy is intended to increase the efficiency of documentation, reports claim that entering data into these systems takes a lot of time.
The good news is that there are a number of techniques PTs can employ to expedite documentation during an office visit while still guaranteeing that patients receive the care they require.
Key Considerations for Physical Therapy Documentation
Making entries in the patient's health record that describe the care or services rendered and the person's reaction to them, such as the consultation report, initial examination report, progress note, flow sheet, checklist, re-examination report, or summation of care. To guarantee that patients receive appropriate, thorough, effective, person-centered, and high-quality healthcare services throughout the episode of care, good documentation, communication, and coordination are essential.
In keeping records for physical therapy, it's important to:
- Accurate recording of details such as the first assessment and evaluation, visit, re-examination, and summary of the episode of care.
- Adherence to the various standards and procedures applicable to the context, such as payer, state, local, or accrediting agency rules.
- Real-time, historical accounts of interactions with clients and patients are essential for demonstrating care and the need for treatment in the case of a malpractice claim.
The American Physical Therapy Association (APTA) notes that PTs frequently see paperwork as "onerous, irrelevant, and unwarranted," although adequate documentation is required while providing patient and client treatment. The healthcare sector is generally concerned with documentation. Many doctors view medical documentation as cumbersome, taking away from face time with patients, and a major contributor to burnout, according to several studies. But it's not necessary to be. There are many options for PTs to expedite documentation.
Tips to Increase the Accuracy and Speed of PT Documentation
Here are some suggestions for simplifying and expediting physical therapy documentation:
- If you are a new PT or PT assistant: Familiarise yourself with the EMR software at your facility. Learn the basics of how the EMR system works, including where and how to submit data. To make the most of the software's features, document more quickly, and concentrate on the patient rather than typing, it is crucial to become familiar with it. You can quickly and anytime access all the information you need with the EMR.
- Utilize EMR quick cuts: EMR systems include a variety of shortcuts. For instance, auto-text entries enable the storing and insertion of free text into a note, saving a significant amount of time when typing lengthy texts. When you input just a few letters, the auto-text or predictive text feature fills in the rest of the phrase. Additionally, consult notes can be easily created in EMRs in several ways that allow previous visit data (such as HPI, Exam, Physical Exam, ROS, and Assessment) to be incorporated. Users have the option to check lab results, compare them based on the order date, or even visualize the results as a graph.
- Complete documentation every day: To avoid a backlog of documentation, systematic medical records documentation is required. You would be forced to spend hours on unpaid documentation at the end of your long workday if there wasn't consistent documentation every day. To document while interacting with patients, multitasking is required. If you are unable to fill your notes yourself, you can always rely on a medical transcribing service provider with expertise in physical therapy documentation.
- Keep your documentation to a minimum: The requirement for the PT intervention during treatment must be supported by thorough documentation that outlines the patient's status, the plan of care, and the reasons for the intervention. Clinical notes, according to sources, have been lengthier and less detailed in recent years. Make sure you don't record information that isn't necessary. Only record pertinent patient information to save time.
- Utilize customized documentation templates: PTs can save a lot of time by creating documentation templates. Advanced EMR systems have flowsheet templates that let therapists fill out whole treatment charts with a single click and alter them to only include pertinent data. PT Progress advises PTs to adopt the PRIMER approach to write correct notes quickly. Identifying the Problem, Relating to Activity, and PRIMER Patient education, reaction management, instruction, and plan review are the four steps. The PRIMER approach can be used in conjunction with SOAP notes and documentation templates to expedite and improve PT documentation.
- Plan the initial assessment: According to a CoreMedicalGroup blog that cites professional opinions on this subject, point-of-care recording can save time when the initial evaluation is carefully planned. When scheduling the initial evaluation, you can account for the time needed to write reports while the patient is in the clinic to clarify things and ask questions. It will save time to complete the Subjective and Objective tabs before leaving the treatment area rather than having to go back and do so at the end of the day.
Time can be saved on PT documentation by utilizing Speech Recognition Technology (SRT). You can speak patient information into an SRT-enabled tablet, smartphone, or computer and have it instantly converted to text.
Despite the fact that current speech recognition technology uses thorough medical terminologies, mistakes might nevertheless appear in automated documentation. This problem can be solved and accurate and timely PT documentation ensured by a plan that combines organized EHR templates with medical transcribing services for physical therapy.