Implementing an automated PT documentation system has a lot of advantages. One of them is the elimination of those cumbersome patient record filing cabinets and replacing them with a secure online database that is backed up regularly and easy to access. The better use of your staff, higher levels of reimbursement, and better service to your patients are all additional benefits that could result in you realizing payback on your investment in the system fairly quickly.

Along with these benefits, the ability to update patient records in real time is a tremendous leap forward for any PT practice. That term, “real time,” is worth defining. Real time means that you can update a patient record as the treatment is being administered. If the treatment is being given in your PT clinic, the automated PT documentation system can deliver the entire patient file on a workstation where treatment is being given. As soon as the documentation and notes about the treatment are entered, they are available to anyone who has access to the automated patient records system, and the session immediately updates reimbursement forms and records as well.

There are a couple of misunderstandings about the value and use of real-time PT documentation systems that are worth dealing with up front. The first one has to do with the requirements of Medicare or other insurance providers concerning real-time updating of patient records. It is not true that these support agencies are or will in the near future require that real-time patient record management becomes the standard. The requirements of CMS have to do with how complete PT documentation must be to satisfy their requirements and there is no stipulation as to when that documentation happens.

A second aspect of how you account for documentation is worth noting whether you perform your record keeping in real time or after the fact. It is important to be aware that time spent filling out PT documentation cannot be included in your calculations for the time you were performing treatment which is billable time. This could be tricky when you are updating a patient record as the treatment occurs but you should be aware of that requirement and develop some methodologies to satisfy that rule even if you are using real time PT patient record maintenance.

With those caveats in place, the value of real time PT documentation is not diminished. By being able to update patient records virtually instantaneously, you cut down the amount of time between treatment and recording what occurred. The result is the potential for mistakes or to forget pertinent details about the treatment are reduced dramatically.

Of course the potential of being able to update PT documentation in real time does not dictate how a therapist or staff performs this function. It simply means that you can update those records as you work with a patient. It is just as valid to take advantage of dynamic access to your PT documentation system to update patient records moments after the therapy concludes. You retain the value of capturing the details of the treatment before memory fades but you eliminate interruptions to the therapy time to update records. This approach also allows you to more accurately capture the time used in PT documentation and place that value in the notes so that you can keep therapy and documentation time separate which is important as we discussed earlier.

Modern PT practice documentation systems are putting the entire practice patient record system at the disposal of therapists virtually anywhere they go. Modern electronic medical records systems are often accessible via any wireless device. That means that the same PT records can be accessed from multiple offices under the same organizational system. IT also means that physical therapy that occurs outside of the clinic such as at a hospital, a rehabilitation center or even at a patient’s home can still be serviced by the PT documentation software system. That kind of convenience and technical sophistication is a huge leap forward for the physical therapy discipline and one that is worth taking advantage of to its fullest.

"WebPT costs less than having personnel type and print notes the old fashioned way. Now we don't have to worry about note transcriptions and multiple revisions. We can communicate faster with our referral sources and the Physicians like the typed, legible notes.  The transition to WebPT has been relatively straight forward." John Pearson, Owner, Pearson Physiotherapy Specialists, LLC