Physical Therapy EMR

Physical Therapy EMR | Adding Flexibility and Speed to the Treatment Journey

• Having to see more patients in less time. Then pivot to an increasing volume of documentation to stay clear of potential payment issues.
• What therapists would instead like to do is treat patients and not get bogged down in an endless stream of documentation and charges entry.

EMR Making a Difference

No wonder that burnout is a topic of discussion. The right physical therapy EMR could help clinicians gain crucial productivity advantages. It would all come down to notes. There are two types of notes to contend with:

• Evaluative notes initial evaluations, re-evaluations, progress notes, and discharge summaries.
• Recurring notes — daily notes and flowsheets with charges that are accessed from the flowsheet.

With an increasing number of appointments and notes, what would count is flexibility and speed:

• Therapists should be able to move seamlessly from one appointment to the next with ease. And document smoothly and rapidly. It could be an initial evaluation for a new patient or a daily note/flowsheet for a follow up visit.
• A patient information card that would include important information like the number of authorized visits and date of authorization expiration would be helpful. Adding follow up tasks based on displayed warnings would provide valuable context and closure.
• Charges that are missing diagnosis codes would be a problem for billing. The codes would need to be selected and added. Once that is done, the selected codes would be included in the patient information card, generated charges, as well as any notes that are created.

Multi-tasking would be crucial and would have two dimensions to it:

• Multiple patients, same time: Reviewing documentation for multiple patients at the same time.
• Single patient, going back in time: Previous notes for past appointments for the current patient.

EMR on the Treatment Journey

At each stage of the treatment journey, the EMR would add flexibility and speed through data and workflow automation:

Initial Evaluation

• Notes would be created using templates, clinical libraries, and content. One such note would be the initial evaluation using a pre-built evaluation profile.
• Free text and snippets with pre-filled text would form the building blocks along with checkboxes, radio buttons, comment boxes, and tables.
• The right signer would need to be assigned for the document. Only filled in areas would show up on the final document.
• Adding the right outcome measurement test would incorporate it to the evaluative documentation along with functional limitations and corresponding codes.
• The documentation would include outcome history tests and scores on previous visits to show improvement through primary and secondary outcome tests.

Entering Goals

• After the initial evaluation is done, the next activity would be entering goals. This could be a pre-built goal selected from a library of goals or a unique custom goal.
• Reviewing goals from previous dates of service would be followed by editing them to make them specific with timeframes and including them on the initial evaluation.
• Goals that have been met could be hidden from future documentation. But deleting goals that have been part of previous documentation should not be a permissible step.

Creating the Flowsheet

• When creating a flowsheet, the first step would be to add a new treatment plan. Adding the plan and selecting a template would populate the flowsheet with the template.
• It would be possible to add multiple flowsheets and treatment plans for different body parts and document the plans at the same time.
• The next step would be to add treatments to the flowsheet/treatment plan: category, treatment, and tissue. This could be a new treatment that is not currently in the library.
• Treatments used in previous flowsheets should not be possible to delete, as a systemic control. Exercises where the patient has progressed past could be hidden.
• For each treatment, it would be possible to see its history, what was done on past dates of service time, sets, reps, weight, and tension.
• Checking off exercises done on the current date of service would be followed by adding time, sets, reps, weights, and treatment notes.
• Some of the exercises would be linked to CPT codes. Entering time for these exercises would automatically generate charges.
• For time-based CPT codes, the system would check who the payer is and what the rule set is, and automatically generate the right number of units.
• For visit-based CPT codes, the EMR would generate only one unit irrespective of the amount of time entered. Inactive CPT codes would be grayed out.
• Users would be able to add or change CPT codes for the exercise while ensuring consistency between documented exercises and charges.

On to the Daily Note

• The flowsheet and SOAP note along with session time-in and time-out would form the daily note. Documenting all three at the same time would ensure consistency.
• What would also help would be copying forward the previous daily note from the last arrived appointment to provide a starting point for the days documentation.
• Once the daily note is completed, finalizing the note would follow: Setting time in/time out, locking the note, and printing/faxing the note.
• Locking the note would be signing off for the full appointment and finalizing both the note and the flowsheet for the appointment.
• PT assistants would need to select the supervising therapist for the co-signature on the document to ensure that charges go out under a licensed therapist.
• Initial evaluations may also need to be signed off by the referring physician. Through e-faxing, they could be sent to the referring physician, primary care physician, or payer.

Plans of Care, Progress Reports, and Discharge Notes

• The plan of care would spell out recommended treatments and how long the patient should be coming in for therapy, and then be sent to the referring physician for signoff.
• This would include all items in the plan section of the initial evaluation along with goals added to the note and would form a streamlined plan of care.
• The progress report would show progress made since the first visit, copying forward the values from the initial evaluation or the previous progress note.
• Printing the report would compare both the initial and new values, carrying forward goals from the initial evaluation and showing progress made.
• The discharge note would selectively carry forward notes from the previous dates of service. Selecting the discharge date in the system would discharge the patient in the EMR.

Customizing Anytime

• Finally, there would be the need to customize clinical content in the note and create own templates to address the practices unique needs.
• This would be accomplished by selecting specific items in the library and adding default text into the template that would load the next time the template is used.

A streamlined process of creating notes in the EMR would help therapists raise productivity and make documentation less challenging. Taking on documentation for multiple patients at the same time or going back in time for the current patients documentation should be a matter of a few clicks. Flexibility and speed on the treatment journey is at hand.