Physical Therapy Documentation | Best Friends Unlikely, Close Second Possibly
Documentation a clinician?s best friend? Unlikely. After all, you would rather spend your time treating patients. Efficiency in documentation would therefore go a long way, which is where workflow automation could help. After all, one less documentation task to perform could mean one more valuable task for patients.
When it comes to documentation workflows, several applications could come together to execute the note taking process including:
EMR at the ?center?
Patient portal
Third-party apps like BlueJay Mobile Health
When all component apps play their parts to perfection and seamlessly integrate with each other, the result is a smooth and efficient note taking process that delivers a great experience for the clinician and the patient.
First the Patient Portal
Patients would complete the clinical intake questionnaire and outcome measurement tests in the patient portal. Importing the patient?s responses would trigger several automated actions in the EMR:
Bringing in the intake questionnaire and any functional scales associated with the body part.
Pulling in the patient?s responses into the current document for clinicians to review.
Kickstarting the evaluation process by populating some of the subjective parts of the evaluation.
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On to the Eval
Let?s assume the patient is coming for a back injury. Here are some of the possible steps:
We would select the back template in the EMR. After adding the patient?s responses from the patient portal and loading the appropriate clinical templates from the clinical library, we would have the different sections available for the evaluation.
Documenting complaints would be accomplished by opening the body chart followed by selecting single or multiple body regions where the complaint is reported.
This would be followed by selecting the complaint type like pain and selecting properties like pain type, severity, frequency, and intensity, along with aggravating and alleviating factors.
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Also, we might need to add a complaint about a different body part. It would be possible to document multiple complaints with each complaint adding a new row to the template. Editing or deleting rows and copying forward complaints from one visit to the next would be a nice time saver. These complaints could be pulled into progress reports or reevaluations.
Another body chart feature would be one for documenting palpations. We could select one or more of the options like tenderness, edema, or spinal levels, select the body part, and check if it is mild, moderate or severe. Optionally add a comment. We could also document spinal levels. Saving it would populate the chart. When converting, the document would change into a sentence structure.
Bringing it Together in the Flowsheet
It would be possible to access all these sections in the flowsheet:
Besides the daily SOAP section, the body part section would be part of the flowsheet.
Body part subjective would be the complaints section and the body part objective would be palpations section.
We could also copy forward complaints and palpations sections and document them while on the flowsheet.
Switching Gears to the BlueJay Integration Anytime you are on the documentation page in the EMR, either on the note taking side or on the flowsheet side, you would be able to open BlueJay directly from the EMR and navigate to the patient?s dashboard in BlueJay.
We would be able to drive the selection of the diagnosis from BlueJay, and the integration would pass the diagnosis back into the EMR system. In BlueJay, you would be able to take advantage of the evidence-based decision making that is available through that system.
Let us say that you are in the middle of your eval and you want to select a diagnosis code. You could do that from BlueJay:
Selecting the ?BlueJay tab? at the top of the EMR screen and clicking on ?open patient? would take you to the patient?s ?diagnosis tab? in the BlueJay application.
You could then select the diagnosis code in BlueJay. This would add the diagnosis into the BlueJay platform.
It would also transfer the diagnosis back into the EMR and add additional content and templates.
There is also a ?case dropdown? in BlueJay to select the EMR case that you want to assign the diagnosis to. It is possible the patient is being seen simultaneously for two different injuries which would mean two different cases inside the EMR. We would need to make sure that we are linking the diagnosis to the right case.
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We could now easily verify that the integration has achieved all that it set out to do:
Opening the patient information card in the EMR would confirm that the diagnosis added in BlueJay has been automatically updated in the card.
If we navigate to the flowsheet, we would be able to see that it has automatically loaded treatment plan templates that are associated with the diagnosis code, which was automatically dropped inside.
There could be multiple phases of treatment say phases 1, 2, and 3 and these would be automatically loaded for the diagnosis code.
In the treatment plan templates, we could proceed to mark down exercises, activities, charges, and so on.
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The entire daily notes encounter would now be handled on one single page in the EMR: Complaints, body chart, and the daily SOAP. Both BlueJay and the EMR are now perfectly synced.
As an additional component of integration, when we are documenting in the EMR and taking care of the daily note, we would be able to log the visit from the EMR over to the BlueJay system. It would no longer be necessary to go into BlueJay and manually log the visit.
For each daily visit when you lock or sign off on the documentation, it would automatically populate the visit in BlueJay:
Clicking the ?Sign button? inside the EMR to lock the note would open the BlueJay ?visit log window.? Based on appointment scheduling information, the EMR would detect if there were more than one care provider associated with the care team and transmit the information to BlueJay. It would also be possible to set pain levels and functional loss levels in the visit log window.
If we were to add multiple diagnosis codes in BlueJay, we would see a separate tab and listing for each diagnosis in the visit log window. We could submit all diagnosis codes at once. Or we could choose different pain levels, function loss, and providers for each diagnosis code. From the visit log window, we would automatically log the visit to BlueJay. Then, we would be able to see the locked note.
Going over to the ?BlueJay tab,? we could confirm that the visit was indeed appropriately logged. ?Opening? the patient would take you to the patient?s ?diagnosis tab in BlueJay. We would then verify that the visit has been logged.
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Clinical documentation can clearly be complex with several touch points and data requirements. An integrated workflow would help you take advantage of the strengths of each individual application while saving precious time. Documentation may not be your best friend. But with the right technology, it could come in as a close second!
