There are many patients who come in for needs revolving around physical therapy every day. Proper documentation is needed to make sure that information is safe and easily accessible. However, there are some possible issues in physical therapy documentation that could compromise the efficiency of your practice. Here are some of the physical therapy documentation problems that you could see and what you can do to get these problems resolved.
You are Over-Documenting
Do you find yourself constantly swallowed up by all the notes you need to write? Perhaps you are the only one behind on charting. In either of these scenarios, it is possible that you are writing incredibly detailed notes. While there is nothing wrong with being detailed and precise, you don’t want to overdo it because you don’t want to spend an exceedingly long amount of time on any one note.
To remedy this problem, refrain from documenting any irrelevant information. Pieces of information that sound trivial do not need to be documented, such as witnessing a patient raise the volume on a television. Only keep the information documented if you think it could hurt you or your patient not to have the information written down.
You’re Under-Documenting
We know we just mentioned that documenting too much is an issue, but there is also such a thing as not documenting enough. Your patients might be getting their treatments denied, and it can really ruin the mood when you learn that your patients are not able to get therapy. This is especially true if you’re certain that the therapy in question is indicated.
To fix this problem, make sure that you’re keeping track of all of the functional gains and setbacks that a patient experiences. We understand that documentation can be an incredibly large stressor in the medical industry, and we don’t mean to say you have to bend to the will of insurance companies and design your case around them specifically. However, it is important to be able to justify treatments by keeping track of the progress patients make.
Your EMR Platform Isn’t Customized For Your Specific Needs
It is tedious when you have to punch in the same data time and time again. The same goes for entering all kinds of irrelevant information. Perhaps you must go through many different screens with each patient who visits you. If you find charting online as a chore that takes too long to complete, you are not the only one. Fortunately, there will often be methods of making everything run more smoothly for you.
Something we advise that you do is tailor your EMR platform to suit your needs. Many therapy professionals are not familiar with how to customize their EMR systems, so they end up using “factory settings,” which are more or less the default settings. This causes professionals to allocate too much of their time to charting. Now, a lot of presets are put in place to help keep you in compliance with Medicare, which is appreciated. However, for those who only have child patients, there will be many fields that do not apply, and typing “N/A” a seemingly endless number of times is something you won’t want to do.
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