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Physical Therapy

Physical Therapy

  • Zak Bartley

Effective Physical Therapy Documentation in Less Time: 4 Proven Techniques

What is Physical Therapy Documentation?


Physical therapy documentation is the process of recording all the relevant details of a patient’s physical therapy treatment. This includes the patient’s medical history, evaluation, progress, treatment plan, and goals. Physical therapy documentation is a crucial part of the physical therapy process and is necessary to provide evidence-based care that is tailored to the individual patient's needs.


What are the Challenges of Physical Therapy Documentation?


The challenge of physical therapy documentation is that it can take a significant amount of time and resources to document notes accurately. In order to provide the best quality care, physical therapists need to reduce the time spent on documentation while still providing defensible and necessary information.


Why is it important to minimize physical therapy documentation time?


Reducing the time spent on physical therapy documentation has numerous benefits for both the therapist and the patient. By streamlining the documentation process, therapists can spend more time focusing on providing high-quality care and improving patient outcomes. This can also lead to increased patient satisfaction and a more efficient clinic. Additionally, reducing the time spent on documentation will reduce therapist burn out. 70% of therapists report that documentation speed using their EHR was the biggest factor contributing to burn out. Overall, reducing the time spent on physical therapy documentation can improve the overall quality of care and increase the efficiency of the clinic.


Strategies to Reduce Time Spent on Physical Therapy Documentation


1. Utilize Templates

Utilizing templates allows physical therapists to quickly and easily complete documentation without having to start from scratch. Templates can also be customized to provide more specific information, allowing physical therapists to provide more detailed documentation in less time.


Many clinics are likely to see the same types of patients repeatedly, depending on the patient demographic and referral sources. For example if a practice gets a steady amount of patients in recovery from ACL surgery, the therapists might consider starting from a “Postoperative Lower Extremity” template. This template could start with specifics such as a semi-written subjective narrative and prior level of function. Ideally, the objective section would have measures for pain scale, Lower Extremity Functional Scale (LEFT), Strength, ROM and potentially GAIT.


2. Automate Data Entry

Automating data entry allows physical therapists to quickly and easily enter patient data into their documentation system. This eliminates the need for manual data entry and saves time.


The best place to start is with Online Patient Forms. By creating a digital intake process you can automate the collection of patient demographics, medical history, medications, chief complaint and more. Additionally, by moving away from paper, clinics can completely eliminate printing, scanning, shredding and manual EHR data entry.


3. Utilize Pull Forward Documentation Software.

Physical therapy documentation software typically includes a feature called "copy forward" that allows therapists to easily populate fields in a new therapy note with information from a previous note. This can save time and ensure that important details are not missed or entered incorrectly. Copy/pull forward fields typically include things like the patient's name, diagnoses, measures collected, and current treatment plan.


This can also include subjective information about the patient's progress and any changes to functional abilities. By using copy forward fields, therapists can quickly and accurately document their interactions with patients and track their progress over time.


4. Utilize Progress Note Reminders

According to the Medicare Benefit Policy Manual, physical therapy progress reports must be submitted at least once every 10 treatment days. The first day of treatment, whether it is an evaluation, reevaluation, or actual therapy, marks the beginning of the first reporting period. The progress report period ends either on the 10th treatment day or on a date chosen by the therapist, whichever comes first. The next treatment day marks the beginning of the next reporting period.


Modern physical therapy documentation software should track the sessions remaining until a progress report is due. This would alert the therapist to complete a progress note by the 10th visit, in order to remain compliant with CMS standards.



Progress Note Physical Therapy Documentation


Benefits of Reducing Time Spent on Physical Therapy Documentation


Reducing the time spent on physical therapy documentation can provide numerous benefits to both therapists and their patients. For therapists, it can free up more time to focus on providing direct patient care and can reduce the risk of burnout. For patients, it can lead to more efficient and effective treatment plans, as therapists will have more time to devote to developing and updating these plans.


Spending less time typing out notes has a direct correlation to employee morale and reducing staff burnout. Overall, reducing the time spent on physical therapy documentation can lead to better outcomes for both therapists and their patients.


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