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Physical Therapy Documentation Software | Winning The Battle Today And In The Future

Physical Therapy Documentation Software
Physical therapy documentation software continues to be front and center as documentation challenges persist in the PT world and pose risks to the clinic’s patient and financial outcomes. Reimbursement rates in physical therapy are down. At the same time, patient volume is up. One, there is increased demand for physical therapy services. Two, clinics are trying to compensate for the lower reimbursement rates with higher volumes. This in turn dials up clinical documentation volumes resulting in more notes needing to be created in less time. There is therefore a significant likelihood that the quality of notes could suffer as a result (“notes don’t reflect medical necessity or skilled careâ€). This could lead to a higher rate of denials from payers and reduced payments. Certainly, this seems to have the elements of a vicious circle! Even worse are perhaps clawbacks where the payer pulls back the payment a year or two or even later citing poor documentation that did not show skilled care, possibly well after the PT has moved on to a different clinic. This is not what therapists likely set out to do when they launched their PT career. Getting trapped in a never ending pile of documentation to be completed would seem like a nightmare scenario to many. “Documentation is the bane of our existence,†is what many a therapist might say today.

But then documentation is important

Maintaining clear and complete physical therapy clinical records helps the therapist to:
  • Provide the best care to patients. Keeping accurate records of the patient’s initial problems and their journey toward recovery ensures that the most appropriate care could be delivered to them that matches their individual needs and underlying pathology. On the other hand, inaccurate notes could lead to unintended, or even negative, outcomes for the patient.
  • Ensure continuity of care from one therapist to the next. It is likely that that the patient could consult with multiple therapists for the same condition. Accurate medical documentation will make it easier for the new provider to create a treatment plan that picks up from where the earlier provider left off.
  • Submit compliant, detailed claims. Detailed notes will go a long way in creating methodical insurance claims for the physical therapy services that reflect the quality of care provided and make it difficult for the claims adjuster to delay or deny the claim.
  • Stay clear of potential malpractice. With clinical documentation that is legally admissible in a court of law, the clinic would be able to defend the care provided in court, should the need ever arise, and provide proof that the standard of care was met or exceeded.
So, there is no getting away from documentation.

Also, documentation is not a one size fits all

There are several types and forms of clinical documentation that therapists need to stay on top of. These include:
  • Initial evaluations and re-evaluations
  • Daily notes
  • Progress notes
  • Discharge notes
  • Plans of care
The need is for:
  • Structured process for conducting the patient evaluation to make it an easily repeatable activity with a clear sequence of steps.
  • Organizing information in an effective way that demonstrates the therapist’s skills and expertise in no uncertain terms.

A word on the underlying SOAP methodology

In the world of clinical documentation, SOAP looms large and forms the underlying methodology for nearly every documentation type. SOAP – an acronym for Subjective, Objective, Assessment, and Plan – is by far the preponderant method of documentation used by all healthcare providers to enter documentation into patients’ medical records. Dr. Lawrence Weed, professor of medicine and pharmacology at Yale University, developed the SOAP note in the 1950s! 70 years is a long time and it may be appropriate to revisit the SOAP format as used today. As pointed out by this author, the SOAP note has been stretched well beyond its original intent to “distinguish relationships between various problems†into “cluttered, auto-populated data, leading to a note that is overloaded with information and that is often difficult to read†where reimbursement takes precedence over clinical decision making. But that is a different discussion!

So then what is the solution?

As with so many other problems, automation once again comes to the rescue of overworked therapists in the form of physical therapy documentation software! The solution clearly lies in automated workflows for creating repeatable, scalable documentation that conveys the right message to payers, physicians, and patients. The scope of automation would include:
  • Customizable documentation templates that speed up note creation and help select appropriate and matched ICD 10 codes.
  • Treatment documented with skilled care language that matches both the CPT code as well as ICD 10 code.
  • Automatic charge creation for CPT codes with the correct units and modifiers that guides the therapist through the compliance minefield.
  • Use of the SOAP layout with compliance checks built in to ensure that the language and information are ready to be consumed by all stakeholders.
  • Dropdowns and data entry fields to guide therapists through completing the clinical note quickly and easily with a minimum number of steps.
  • Outcome questionnaires that could be completed by patients through the patient portal from the convenience of their homes and that seamlessly import into the subjective portion of the eval.
  • Automated text generators that enable appropriate text to be quickly added just by typing just a few letters like “bad balance†for instance.
  • Accurate tracking of all patient visits and action items like a Medicare re-eval or progress note for clinical and compliance purposes.
  • Creation of a plan of care and then tracking of compliance with the plan to identify patients who are dropping off the plan, well in advance.
  • Brief, concise plan of care document that can be quickly reviewed by the referring physician with assessments and goals populated.
  • Signed clinical notes that are ready to be billed out and that automatically trigger the claims review, scrubbing, and billing and collection workflow.
Creating documentation is probably not why PTs went to PT school. But given there is no escaping it, the next best option is to make the process as painless as possible. In the future, with technologies like AI, physical therapy documentation software may become a source of insight in and of itself for therapists. For now, if we can try to ensure that no therapist ever needs to carry documentation home or prioritize documentation over care, the battle is half won!