Every Note, Every Day: Sequencing and Phrasing to Never Stay Late Again

I attended PT school in the nineteen-hundreds. Fortunately, most of you were not trained to write notes in the “rubber stamp” era of PT charting. Unfortunately, I was. During my career, I’ve had to relearn to write notes that are both compliant and useful. I’m still learning, but improving.

I struggle with the feeling that typing while treating can be a communicative barrier. When I was a clinic director, I occasionally treated my patients and then completed notes at the end of the day. I can tell you from experience that this leads to less accurate and less meaningful documentation. In addition to that, though, is the invisible strain it puts on your coworkers who have to figure out what you’ve actually been doing with that patient should they be scheduled together going forward.

Recently, I’ve moved into a role that involves covering at a variety of clinics. Each day holds a new case load, and a new challenge. I’ve seen more documentation “styles” than I care to admit, and I’ve also uncovered deficiencies in my own. Being a coverage therapist, each note has to be descriptive, concise, and always complete at the end of every day because you likely won’t be there again tomorrow.

Here is my current pattern of charting, shaped by those experiences:

As soon as a patient walks in, I check them in and open a tab with their note. It remains open until their note is complete. When multiple people are there at once, or when things are a bit hectic, the ability to have multiple tabs open at once has been an incredible organizational tool. Nothing gets lost in the background.

Subjective

I’ll greet the patient and ask them how they felt after their last session. If you can see their last note as they walk in, all the better. Your questions can be specific. “I saw Ben added a new exercise on a foam mat last session? How did you feel after that session? Tell me about how you’re doing today”

As the patient describes their response to their last visit, you can digest it into a meaningful subjective response. this only works if you keep your questions open ended. Asking, “Are you feeling better?” doesn’t work. Starting sentences with “tell me about…” is powerful in a lot of ways.

Functional Limitations

Next, I’ll ask, “Is there anything you’ve done since your last session that gave you particular difficulty because of the pain you’re having?” I’ll listen before typing and then generally write a single sentence that sums up their experience.

Treatment

When I open the treatment log, I’ll ask about exercises that were recently added and ask about the patient’s response to them. I’ll also look at the “Plan” section from last time. If it suggests incorporating new activities, I’ll jot those into the log while reviewing what’s comping up with the patient. For instance: “It looks like Ben increased the speed of the treadmill last session. How did you feel with that? He also suggested your ankle was tight in the direction of bringing your toes up to your nose, so we’ll work on that today as well with some extra time spent mobilizing that joint. Does that sound good to you?”

I ask that last question because it confirms that we’re moving forward together down an established path. This allows me to immediately pull the exercises forward in the log and add anything we discussed. From that point, the only time I need to touch the computer again until after the session is to make minor modifications to the exercise log where needed.

Objective

During the session, or just after, I make a note in this section about ROM, strength, or exercises where the patient had particular difficulty or required assistance (verbal cues or specific tactile feedback).

Assessment

Prior to the patient leaving, I ask the patient how they feel. This serves two purposes. It’s an immediate test/retest assessment for new interventions. It’s also a way to reinforce that all the things we did resulted in them feeling better. I’ll jot down any attribution or professional assessment that requires my skill in this session. I like to think about a situation in which their physician asked me, “How did their appointment go today?” The answer to that question from their doctor is typically a pretty solid assessment. Don’t waste time, don’t leave out what’s really on your mind.

Plan

Write specifically what you plan to do based on today’s treatment at the next treatment. Logically progress interventions. Emphasize some elements over others. Plan something specific. “Continue” is too generic for the next therapist to connect the dots between this visit and the next one.

At the end of the session, I’ll remind the patient of their next appointment time and date, reinforce, or revise the HEP, and have them check in at the desk for any front office elements that still need to be settled. At that point, the log and note should populate the billing information, and I’ll sign the note and close the tab. If for some reason, I can’t get it finished in the moment? The open tab will be a constant reminder of a loose end that needs to be tidied up.

Except for evaluations (which require more intentional detail, depth, and time), it is a rare note that isn’t complete as the patient walks out the door. That wasn’t always the case, but I assure you from my experience, it’s liberating to know you don’t have to stay late struggling to remember the details of several similar patients or take work home every night.

Ask your patients questions that help your documentation be better, jot down their perspectives on what’s pertinent in a structured way, be present with your patients during treatment, and then close the loop every visit and you’ll finish every note every day.