5 easy tips for managing physical therapy documentation

Proper documentation has become essential in the physical therapy industry for many reasons. For starters, it can help your practice avoid lawsuits and noncompliance penalties. It also ensures patient consent and maintains understanding between patients and therapists. An added bonus is that it can help keep your administrative team on task. Keeping a good documentation process going isn’t always easy, though. That’s why we’ve written out a list of 5 easy tips to help your clinic manage documentation in an effective way.

5 tips for managing documentation at your physical therapy practice

• Input patient exercises during every session — Make sure to immediately input your patient’s exercises into your system, whether it be a paper record system or an electronic medical record (EMR) system. Immediately inputting your patient’s exercises is beneficial to your practice for many reasons. For starters, it’s less time consuming for the physical therapist and, essentially, a more efficient way to complete documentation. Rather than trying to recall from memory the exercises a patient was instructed to perform, it’s easier to record them as the session happens. This reduces the amount of time that needs to be spent on documentation after a session, and it’s more likely to be accurate in real time.

• Input patient progress observations during every session — Tracking the progress of your patients is an essential part of their recovery. You can make the documentation of their progress easier for yourself by taking down your observations as they occur. It’s often harder to recall every important observation you had after a patient’s session, so it might be more effective to take notes immediately. It can also help to create detailed patient evaluation templates. With these templates, you can record the right information for accurate progress reports and billing purposes.

• Record reasons for continued care — On your physical therapist’s documentation charts, it may be a good idea to write down (in conjunction with progress notes), reasons that continued care could benefit the patient. It’s a helpful way to keep both care providers and patients on track and working toward their goals. It’s also a way to prevent patients from losing focus and failing to make necessary follow-up appointments.

• Create physical task reminders — Creating physical reminders can be a great way for your administrative team to remember important tasks and information. It can even help your clinic avoid running into noncompliance issues. Examples of these physical task reminders include sticky notes and to-do lists. While paper lists may seem old school, it’s always a good idea to keep an extra reminder around to avoid forgetting important tasks that need to get done.

• Use an EMR software system —EMR systems can be lifesavers for a lot of physical therapy practices. Many of these software systems have integrated organization capabilities that make documentation in a physical therapy clinic a lot easier. Some of these features include the ability to set up appointment and task reminders, create follow-up appointments, streamline billing and insurance processes, and even provide templates for session assessments. Overall, this technology is a great way to ensure an efficient and organized workflow.

AgileEMR can help you manage your practice’s physical therapy documentation

AgileEMR is a simplified health care practice management software solution designed for physical therapists and created by physical therapists. We officially launched our software in 2013 to address and fix several of the issues that our therapists frequently ran into with run-of-the-mill EMR systems: None of them were built with physical therapy in mind. We consulted with physical therapists and clinicians as we developed our unique software. This way, we knew without a shadow of a doubt that our physical therapy software program can meet the needs of those who work in the health care field. Since the time of our launch, AgileEMR has been used in more than 1 million patient cases by all kinds of providers. These providers belong to the outpatient physical therapy and hospital rehabilitation fields. We know that EMR systems are driving the future of outpatient physical therapy. To view our extensive list of physical therapy and rehabilitation partners, click here.

We hope you found our physical therapy documentation tips useful for your clinic. If you’re a physical therapy clinic owner who is looking for more information on EMR systems or the features of our EMR program, consider taking a moment to view our site. We’re confident that AgileEMR can meet your clinic’s needs and can help keep your physical therapy practice running as smoothly as possible.

Contact our team today for more information or to schedule a demo to see how AgileEMR can help your practice.