Looking to streamline documentation and make your PT practice more efficient? Read this article for the top 7 ways physical therapists can speed up their notetaking procedures.
Getting your PT practice’s documentation airtight is a challenge many owners face. But the results are compelling, as streamlined documentation boosts productivity and lessens the workload on the entire staff—making for happier employees. But documentation in physical therapy isn't straightforward as thousands of software solutions, insurance payers, and other factors change how PTs take notes. So, what do practice owners need to know to make their documentation more agile? In this article, you’ll find 7 ways (which you can implement immediately) that you can make your documentation faster and more efficient.
Documentation is a process that requires a PT’s full attention. Whether you’re conveying skilled innervations or communicating the progression of care—accuracy matters. Knowing the goal of your documentation can significantly reduce the number of mistakes. Here are a few common mistakes PTs encounter:
Oftentimes, payers require PTs to get a plan of care certification from physicians before they send payment. And even if you’ve received a certification, some payers will require periodical recertifications—usually 90 days after the initial visit.
Showing forward progress on the established plan of care at least one in every ten visits is required for PTs receiving Medicare payments. Even if you document correctly, it can be tough to meet progress note requirements to satisfy the Centers for Medicare and Medicaid Services (CMS).
PTs need to document home exercise programs, timelines, and goals they want patients to complete. When patients receive a treatment program from PTs, there should be a step-by-step plan on paper.
When patients are injured, they often suffer a functional loss. This loss of movement needs to be documented all the pertinent injury information. Future sessions should recap on progress and reference the original injury throughout recovery.
Save time by implementing a patient portal on your website. When customers can book themselves and check their appointments—it eliminates friction and provides a better patient experience. It also frees up your administrative staff to take care of patients in-house. PTs who can implement digital filing will likely find their patient paperwork much easier to manage
While some pitfalls are impossible to sidestep, finding a robust software solution is key for PTs to streamline documentation at their practice. Practice owners should consider—at the very least—equipping the following features on their PT documentation software:
Having the flexibility of different templates can increase efficiency and give you complete control over the documentation process. Nagging mistakes are quickly stomped out with templates that form-fit your practice.
Dropping bins of physical paperwork and implementing a system that pulls up patient documentation in a snap is essential for modern PT practices.
Due to HIPAA regulations, documentation needs to be kept under lock and key. Ensure the software you choose keeps your patient data secure.
Using point-of-service documentation is a fabulous method of getting more accurate, real-time patient notes. However, there’s a fine line, keep the session on track and make notetaking feel natural. A great way to accomplish this is setting expectations upfront so patients don’t feel like you’re writing something down behind their back. Explain how real-time documentation can benefit future sessions and keep notetaking brief.
Notes shouldn’t read like an essay. Are parts of your EMR redundant? Try to keep notes brief by writing with goals in mind: fulfilling insurance requirements, giving a clear message to internal staff, communicating with external peers, meeting legal requirements and improving future care. Practice owners who want to m can use previous notes to give documentation workshops and one-on-one coaching sessions to improve performance.
Operating a PT clinic that’s well-oiled and efficient is sometimes as easy as putting staff members in the right roles. A team-based approach to documentation (and care overall) can supercharge productivity. If there’s a set way to conduct a patient visit, it doesn’t matter who’s in the hot seat—the job gets done. Creating a team-based system (where everyone does a bit of everything) can significantly increase overall knowledge and help PTs gain valuable perspective. It makes documentation and just about every other process easier once the team is fully operational.
Treating physical therapy notetaking like science can help you streamline documentation by providing a gradual boost of productivity. Test different templates, seek out ideas from competitors, and communicate results with staff whenever possible. Timing visits and analyzing the templates you have in place can have an impact over time. Even a slight adjustment that saves one minute can compound over an annual basis—especially in high-volume clinics.
Notetaking isn’t the most exciting part of being a physical therapist—but that doesn’t diminish how important it is to take concise, practical notes. By planning ahead of every visit, you can skip unnecessary paperwork through patient portals and make in-person documentation sync with customized EMR templates. By honing your process (and using the right software), PTs can boost productivity and provide a better care experience. If your PT practice is making documentation mistakes, it might be time to look at your physical therapy software. We provide the best, all-in-one software solution with patient portals, customizable EMR templates, and more ways to communicate than ever before. Try a 100% free demo today and see what MWTherapy can do for your PT practice!
