As a new-grad PT, you already know the importance of defensible documentation—you’ve probably heard it from every professor, mentor, and clinician you’ve met—so, you understand that your PT documentation must not only tell your patient’s story, but also support your clinical decisions and the medical necessity of your services. If you haven't been told of the importance of defensible documentation yet, the practice owner of your first physical therapy job will certainly bring you up to speed.
Defensible documentation may seem like a tall order, but your license—and your clinic’s bottom line—depends on it. Luckily, there are actions you can take to optimize your PT workflow in a way that allows for defensible documentation at the point of care—without sacrificing efficiency or patient rapport. Check out the five examples below (adapted from this article and this one):
1. Get familiar with—and leverage—the documentation software you’ll be using.
According to WebPT Marketplace Director Brian Kunich, DPT, “You can’t pay attention to the patient if you don’t know where the information goes.” While that may seem like common sense, it’s easy to forget when you’re using a new EMR. So, take some time to get familiar with your clinic’s system from the get-go.
That way, when you start seeing patients, you’ll already be so comfortable with the flow that you can “spend more energy concentrating on the patient than on what or where you’re typing.” Once you’re familiar with the EMR, leverage its customization features to make it work for you. If your clinic’s EMR comes with smart text functionality and custom evaluation profiles, you’re in luck. Make sure you’re using both to free up some more time that you can spend treating and interacting with patients.
2. Use the right device.
WebPT Co-Founder and President Heidi Jannenga believes that the key to successful point-of-care documentation is “striking a balance between efficiency and relationships.” To do so, you must document using the device that’s right for you (i.e., desktop, laptop, or tablet). First, be sure you know which devices are compatible with your clinic’s EMR.
Then, choose the one you find most easy to use—and that doesn’t distract you from developing stellar patient-provider relationships. Some therapists choose devices based on their talk-to-type features. However, if you want similar functionality on a different device, you could use a dictation tool like Dragon. And if you’re working at a clinic that limits your choice of devices, you may need to make a case for being able to use the one you want. To get buy-in from your supervisor, use the same steps you’d use to pitch an EMR:
- Focus on the benefits.
- Be ready to overcome objections.
- Stay positive and confident.
3. Be transparent.
Jannenga recommends informing your patients that you’ll be using an electronic device to record information during patient visits. That way, everyone’s on the same page and knows what to expect. However, that doesn’t mean that providers should spend the entire appointment staring at their devices. In fact, you can minimize your typing time by replacing long paragraphs with short phrases or bullets—essentially, giving yourself enough real-time information to be able to flesh out more detailed explanations after the treatment session. Veda Collmer, OTR—WebPT’s In-House Counsel and Compliance Officer—suggests using documentation to get patients (especially patients who aren’t fully on board with therapy) more involved in their care.
“Therapy is an intimate relationship,” Collmer says. “Sit next to your patients so they can see the screen. Explain why you’re writing down certain things, review goals with them, and get their buy-in for their HEP.” Collmer also encourages providers to explain any negative documentation in a way that ensures patients know it doesn’t reflect on them personally—it’s simply a note about their conditions. “Transparency is key,” she says. However, that doesn’t mean you should voice frustration or complaints about the documentation process. If you maintain a positive attitude about it, your patients will, too.
4. Get organized.
According to WebPT Product Owner Doug Severson, ATC, CSCS, while point-of-care documentation should save time in the long run, it may require some extra effort upfront—especially during the initial evaluation. Kunich agrees, which is why he encourages therapists to “be meticulous in planning for initial evaluations so [they] can buffer in time for building reports”—and so the patient is available in the clinic to answer questions or provide clarification.
Severson also suggests preloading the initial evaluation before the patient arrives. That will give you the opportunity to include any patient info you already have from the patient’s intake form. According to Kristen Severson, PT, you may want to ask your patients questions directly from the Subjective tab. While this may add a few extra minutes to your evaluation, it will save you from having to go back to complete this section from memory at the end of the day. On that note, Kunich suggests completing both the Subjective and Objective tabs before leaving the treatment room.
And don’t worry too much about the upfront time investment; WebPT Senior Member Consultant—and former clinic owner—Shayne Peterson, PT, ATC/L, says you’ll make that time up during subsequent visits with the help of auto-populating fields and other efficiency-boosting features.
5. Make PROMs work for you.
PROMs measure the aspects of improvement that actually matter to patients—such as overall well-being, pain and fatigue levels, functional abilities, and mood. Now, it makes sense that asking patients questions about how they’re feeling/doing with respect to these factors—and then demonstrating that you’re interested in their answers—can bolster your relationships with those patients, right? Well, engaging patients in this type of dialogue can also encourage them to take a more active role in their care.
Thus, if your clinic’s EMR provides integrated outcomes tracking, you can actually use the time you spend entering PROM data to further engage your patient in his or her treatment. Instead of silently entering patient information into the system—or doing all your data entry after hours—get your patient involved in the process by discussing his or her answers as you enter them. You could also use this time to discuss how your patient is progressing toward his or her goal as a result of your therapeutic intervention. After all, you’ll have all the data you need to do so.
If you’re worried about juggling the need to document defensibly with the desire to build patient rapport, it’s okay. You’re not alone. But, you don’t have to worry any longer. It’s definitely doable. It just may take some practice—and the implementation of these five tips—to get your PT workflow fully optimized.
Have your own tips for optimizing your PT workflow? Share them with us—and your fellow new grads—below.