Physical Therapy Documentation: Love It Or Hate It

physical therapy documentation

If you were to ask a group of professionals in a room to raise their hand if they loved to document their work tasks, how many hands would you expect to go up? It is no surprise that most physical therapists have a love/hate relationship with physical therapy documentation. Documenting in paper may even be faster for some. But when it comes to striking a balance between speed, efficiency, and compliance, there is likely no alternative to the EMR and the checks and balances that it provides. The answer is therefore to make the most of your EMR and the documentation task as painless as possible.

A good EMR solution should provide a solid head start. If it is easily customizable with training and support included as part of the deal, even better. Analyzing business processes in the clinic as a prelude to EMR automation would be a good idea. Are your therapists carrying out tasks that could be more easily handled by the front office or by assistants? Fixing these issues would make the EMR even more valuable.

Notes, notes, and more notes

Once the EMR is in place, things should work out fairly smoothly. You could start your day by reviewing all follow up activities like taking care of any charges as well as appointments for the day along with pending documentation. Being able to quickly zoom in on things that need a fixing like missing charges, unsigned notes, and arrived appointments that don’t have finalized documentation would be helpful. Therapist assistants could mark notes as ready to review and the supervising therapist could sign off the note.

Let us look at how a specific patient encounter could unfurl. The software would quickly load up notes on the screen and enable you to copy forward any previous notes that you would like to reuse. A summary of patient information on any page – with demographic, case, and timeline/authorization information – would keep everything in context. Accessing past appointments/notes for the patient or setting tasks for yourself, right from the patient screen, would make life a lot simpler

There are so many different kinds of notes to stay on top of. Evaluations, discharge reports, progress reports, plans of care, you name it. The list goes on. By checking off multiple notes from your list in one go, productivity would get a nice boost. What would be even more rewarding would be productivity boosters like a robust clinical library of templates that could be tailored anytime. Different types of questions, scoring tables for standardized tests built into the system, and snippets or shortcut texts to rapidly and automatically update the note. Anything that would save time when creating notes would be welcome.

Goals and charges go hand in hand

Adding personalized goals from a goal bank with goal tracking would make progress tracking easier. Goals met, goals mastered, and goals in progress. As long as you refresh goals to keep them relevant and compact, you would be able to stay aligned with the patient’s journey across each episode of care from intake to discharge by setting goals on the initial evaluation and reviewing them on every visit. Any goals marked as “green” would automatically get attached to the note and show up on any documents for the day (eval, daily note for the day), thus unifying the documentation.

Charges would get baked into the template with codes that match up with evals and disciplines, ICD pointers would get attached, and place of service codes would be driven by the appointment. Payer specified modifiers and place of service code rules would automatically set the right modifiers and settings. Controlling credentialing at the individual therapist level with claims held back for the specific payers that the therapist is not credentialed for would help stay compliant.

Applying the final touches

Once you complete the notes, just the areas that you filled in would show up in the final printed output. Designating certain questions as mandatory or required at the time of configuring/implementing the software would prevent the provider from signing off on documentation too soon. This would bring in standardization and clinical compliance across the several templates. Less to worry about in the future.

Automatically faxing notes to the referring provider/payer on file by seamlessly merging data from the patient record would be another task to not have to think about. Tracking certifications from the dashboard would make sure that you have it all set.

The physical therapy documentation should describe the treatment journey and make it clear to anyone who reviews it as to why the treatment was necessary, why the treatment plan was appropriate, why it was effective, and why it was preferable to alternate courses of action.

At the end of the day, expecting a physical therapist to love to document would likely be asking for too much. Resigned acceptance may be a more reasonable outcome. A question to ask: How much value is your current EMR adding?