Physical Therapy EMR and Documentation | Achieving Efficiency and Outcomes

Physical Therapy EMR and Documentation

Physical therapists are constantly seeking to improve patient outcomes and raise patient satisfaction. Efficiency with care is the goal. Here is a look at how the physical therapy EMR and clinical documentation come together to strengthen processes and outcomes.

Get Documentation Started

Review follow-ups

The therapists day typically begins on the EMR dashboard by reviewing all follow-ups that were assigned to someone (including self) and those that were created during the documentation workflow. Follow-ups are a key part of the EMR task management system. All tasks with a patient context have their detailed history closely tracked in the EMR.

Track appointment information

The clinical workflow starts with appointments for the day along with tracking of information like status of documentation including if any notes or flowsheets have been started, the number of visits for current patients, number of visits since the last eval, and charges status i.e., whether charges have been entered. Documentation for the day is carefully reviewed. Then, there are the hotlists to check: encounters that are missing charges or missing finalized/locked documentation for the day. Using the EMR scheduler, therapists can optionally schedule one-time or recurring appointments for a patient as needed.

Get clinical notes started

From the appointment screen in the EMR, the therapist navigates to internal EMR pages for the patient including patient documentation, notes, and flowsheets. When it comes to notes, there are several types. The initial evaluation represents the first encounter with the patient. Different types of notes could be created in the same appointment.

Patient complaints are added to notes that are forwarded to future sessions. A visual, interactive body chart makes it possible to record single or multiple complaints with complaint type, severity, frequency, and cause of aggravation and/or alleviation.

Notes templates provide flexibility

A template library provides additional latitude to the therapist in selecting the exact document type and format needed. There are several template sections with different types of questions: Free text boxes to provide narratives, checkboxes, dropdown menus, to name a few. Some of these could be required for sign-off. These templates are typically firmed up during EMR implementation.

Add Charges and Diagnosis

Add diagnosis to the case

At some point in the evaluation, the therapist adds the diagnosis for the patient. This is where the integration with the BlueJay Engage platform kicks in, specifically to the provider dashboard. The platform acts as a data warehouse of patient information. Selecting the diagnosis in BlueJay passes it to the corresponding case in the platform. Then the therapist proceeds to complete the assessment and plan section of the eval. Charges are updated when documenting treatments and interventions in the flowsheet.

Finalize interventions in the flowsheet

Based on the diagnosis, matching templates are appended to the flowsheet. Commonly billed CPT codes for the diagnosis are also inserted into the sections of the flowsheet. Treatment interventions are included. Time is filled in for each intervention along with sets, reps, weight, tension, and treatment notes. Information entered into the flowsheet carries forward to the next encounter.

All this makes documenting and billing for the date of service a breeze. In the past, the therapist may have had to run through a huge list of CPT items to choose from in the EMR. No longer though. With the integration, the list of CPT codes is brought down to the most used CPT codes. Based on treatments selected, charges are automatically generated.

Complete the Encounter

Complete visit and conclude encounter

The therapist proceeds to finalize the encounter by signing the notes. Information in the EMR is rolled forward from one encounter to the next. The therapist goes right to the flowsheet from the previous appointment in the schedule and updates all that was done in the previous encounter with the latest procedures. Similarly, the daily SOAP note is created as part of the flowsheet by copying forward previous SOAP notes. And then on to the next patient encounter.

Take advantage of patient reported outcomes

Signing the note in turn transfers visit information to BlueJay, which enables the patient reported outcomes updates. Logging information for each visit produces clinical outcome measurements that record clinical progress over time. When the visit is logged, the patient gets an email/text alert asking the patient to rate severity of symptoms. These are tracked across visits.

Patient reported outcomes and patient feedback regarding symptom severity and progress compared to baseline are looped in. This also creates significant efficiencies for sending home exercise programs to the patient as the system adjusts based on how the patient is progressing. Timely outcomes data helps negotiate contracts with payers and gets reported to referring providers.

Step Up Efficiency and Patient Care

All this results in better patient outcomes and higher patient satisfaction (while lowering the number of patients exiting the clinic as a self-discharge). This also provides valuable information to the practice on how patients have responded to care provided without even having to ask them. While creating a more efficient visit, this keeps the practice alert as to how the patient is doing. End of the day, you have a more efficient physical therapy practice that is free to focus on patient satisfaction and quality of care.