How to Solve Physical Therapy Documentation Issues

Documentation is time consuming. It’s a common struggle in the physical therapy world because time with patients needs to be documented well in order to receive payments, but clinicians don’t want to spend all their time writing extensive notes. 

To find a happy middle ground, use these tips to streamline documentation.

1. Use templates

A lot of physical therapy clinicians can save time on documentation by using templates. AgileEMR’s Documentation lets clinicians template an entire document, including the assessment. This makes it easy and efficient to edit sections for specific patients, saving valuable time. 

2. You’re providing too much information

We understand the urge to provide more information than less, as we want our procedures and documentation to be clear. But this is likely causing you to spend too much time on information that doesn’t actually need to be there. A good rule of thumb to remember is that if the omission of certain ancillary information will somehow hurt you or the patient, legally or otherwise, it’s probably ok to leave it out of your documentation.

3. You’re not documenting enough

Of course, the flip side of providing too much information is not providing enough. This can cause denial of treatments for patients because an insurance provider denies payment. The balance here is to justify your treatments to insurance providers but not completely designing your care treatments around a faceless insurance company.

When vague language is coupled with cookie-cutter frequency,  insurance reps are more likely to deny care. “Continue POC as tolerated” and “continue to see patient three times a week” with no real insight into functional status or improvement will likely not get the approval you and your patient are looking for. Instead, considering noting things like “Patient demonstrates increased flexibility and dynamic balance with ambulation, based on Berg Balance Scale results.”

4. There’s too much documentation to complete every day

If you’re the type of therapist who wants to spend as much hands-on time with patients as possible, you may see a repeating pattern of having to spend hours at the end of every day completing notes and paperwork. 

But it doesn’t have to be split like this. You can still provide engaged care and facetime with patients while taking notes during your session. Communicate to your patients that writing notes during the session will not only improve their course of care and your understanding of what needs to be done, it will also ensure their treatments keep getting approved by their insurance company.

5. You aren’t effectively using your physical therapy EMR

You are not alone in thinking you’re paying too much for an EMR that makes documentation clunky and time consuming. If you’re constantly having to enter in the same information or are forced to click through three unnecessary scenes, it may be time to make a switch. 

If your current physical therapy EMR is making documentation clunky and time-consuming, AgileEMR is here to help. AgileEMR is not only an affordable option at $80 per month per user, but it’s efficient. Everything in the software is one click away from everything else. 

Don’t let the excuse of “This is who we’ve always done things” allow for needless hours to be wasted on unnecessary documentation tasks. Schedule a demo today to improve your clinic processes.