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8 Tips for Point-of-Care Documentation Domination

Here are some top tips from six therapy experts to help you perform point-of-care documentation like a boss.

Lauren Milligan
5 min read
December 22, 2020
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In the past, clinicians have been either relationship-driven or data-driven, but now, they’re expected to do it all: document quickly and thoroughly while simultaneously developing (and maintaining!) great relationships with their patients. To make that balancing act even more difficult, documentation has become an ever-more arduous and lengthy process over time. As former clinic owner—and former WebPT Member Consultant—Shayne Peterson, PT, ATC/L, put it, “The struggle is real.”

One way to reduce the struggle? Point-of-care documentation. While it may seem like a hassle, this method of documenting can actually improve your efficiency, especially for initial exams. We know that collecting info while assessing a patient and determining a plan of care is no easy feat. We also know that you don’t want to lose rapport with the patient because you’re spending so much time collecting and inputting data. Good thing WebPT has a slew of kick-butt resources at our (and your) disposal. On that note, I’ve interviewed five of WebPT’s best and brightest—and one rockstar former WebPT user—and put together their top eight tips to help you perform point-of-care documentation like a boss. Let’s dig in:

1. Get to know your EMR.

A wise man once said, “You can’t pay attention to the patient if you don’t know where the information goes.” That man was Brian Kunich, DPT, WebPT Senior Product Manager (and yes, he’s very wise). How many times have you scrolled through the same page looking for that one particular field? Getting to know your EMR means you can “spend more energy concentrating on the patient than on what or where you’re typing,” says Kunich. And here’s a pro tip from Kristen Severson (a physical therapist, former WebPT user, and wife of WebPT Director Product Management, Doug Severson, ATC, CSCS): Once you’ve familiarized yourself with your EMR, ask your patients questions directly from the Subjective section in order to streamline the process. It may take you a bit longer to complete the eval, but it will save you time at the end of the day.

2. Leverage your EMR’s resources.

What’s even better than learning the ins and outs of your EMR? Customizing it so it learns you, too. This will take a little time upfront, but it’s well worth the investment. All of our experts advise therapists to customize wherever they can. Tailoring your EMR to fit your specific needs will help you document smoother—and with less typing—while still enabling you to collect all the data you need. Does your EMR come with smart text? If so, Severson recommends presetting common phrases and goals so you spend less time retyping the same information. And if you can create custom initial evaluation profiles, do it. If you often feel like two fields are appropriate for the same piece of information, then it’s totally worth it to invest time in creating an initial evaluation profile that syncs with your workflow. With customized forms, you’ll waste less time and energy sifting through irrelevant fields.

3. Secure a scribe.

It’s nice to have a scribe for complicated cases; and honestly, in an ideal world, every therapist would have a scribe all the time. That’s what makes this next tip so helpful: if you have therapy techs on staff in your clinic, set them up in your EMR with permissions to document. Once you train them on the software, you can enlist them to record patient info during evaluative visits, thus freeing you up to perform assessments distraction-free. (And yes, this is a Medicare-friendly tip!) And here’s a hidden benefit: WebPT Co-Founder and Chief Clinical Officer Heidi Jannenga, PT, DPT, ATC, explains that using a student or tech as a scribe is a “great way to introduce the patient to who else will be working with them and help them establish a relationship.”

However, keep in mind that if you’d like to employ a full-time scribe, it may not be cost-effective for your practice. Peterson urges any clinic owner considering this option to perform a cost-benefit analysis before adding a dedicated scribe to the payroll.

4. Choose the right technology.

According to Jannenga, the key to point-of-care documentation is “striking a balance between efficiency and relationships.” Thus, she considers the biggest barrier to point-of-care documentation to be the device on which you document. Jannenga strongly encourages you to pick a device that’s compatible with your EMR—and one that makes typing easy. Alternatively, you could use a device that features talk-to-type functionality—or consider adding a dictation tool like Dragon to your technology arsenal.

If you’re a WebPT user, we suggest choosing a laptop, which makes it easy for you to move around within your EMR and your clinic. Whatever device you decide to go with, Peterson recommends keeping it on the charger whenever you’re not actively using it. That way, it’s always ready to go when you need it. And if you aren’t yet totally comfortable with using your preferred device, lean on your more tech-savvy colleagues (shoutout to all our #FreshPT friends!) to help you adjust.

5. Change your perception.

As the co-founder of the market-leading rehab therapy software solution, Jannenga knows a thing or two about incorporating technology into the clinic (understatement of the decade?). Her advice to folks worried their patients will run for the hills the moment they pull out a laptop? “Patients are becoming more accustomed to seeing medical professionals use technology, so don’t be afraid of it.” Veda Collmer, OTR, WebPT’s former in-house counsel and compliance officer, echoes Jannenga’s sentiment, assuring us that point-of-care documentation “is just another tool.” You wouldn’t not use your goniometer simply because patients don’t know why you’re using it—or because you can’t look a patient in the eye while using it, right?

Therapists tend to believe they can’t manage documentation and the patient relationship at the same time, but Collmer knows firsthand that striking a balance between data collection and patient care is possible—because she’s done it herself as a practicing OT. And as a lawyer, Collmer knows that not documenting at the point of care could be bad for business: “It’s so critical that you have the most accurate documentation. It’s a legal document.” That means saving your notes for the end of the day—when you’re tired and just trying to crank through paperwork—is a bad idea. Taking care of your documentation at the point of care can save time—and your hide.


6. Rethink your approach.

According to Severson, “Point-of-care documentation is meant to save time” in the long run; upfront, though—like during the initial evaluation—it will require a little more investment of your time (cue heavy sigh). That’s why Kunich advises providers to “be meticulous in planning for initial evaluations so you can buffer in time for building reports.”

During the initial eval, Peterson suggests saving notes as drafts if you aren’t able to complete them during the appointment. Then, you can pop back into the note later in the day to make sure it’s accurate and complete before you finalize it. And remember: you’ll make up for any lost time by increasing efficiencies during subsequent visits (thanks to auto-populating fields, you should be able to process daily notes in under two minutes).

7. Leverage time with patients.

You likely only have 30–60 minutes with a patient during an initial evaluation; don’t waste any of it. Severson recommends preloading the initial evaluation form before the patient arrives so you can pull in the info you already have as you review the patient’s intake forms. Sure, you’ll still need to collect more specific information and confirm details during the appointment, but you’ll only have to make a few edits at the computer instead of starting from scratch. Collmer also stresses the importance of having a backup plan, especially if you work in home health: “Your technology may not always work the way you want—for example, you may not be able to access WiFi—so it’s important to be flexible.”

If you can, Kunich suggests blocking out extra time on your calendar for those initial exams to leave yourself more time to document while your patient is at the clinic and thus, easily available to you should you have a question or need to confirm details. That way, you can record the information you need without sacrificing critical one-on-one time. According to Peterson, the best time to get any remaining documentation done is when the patient is performing modalities or working with a tech.

8. Engage with your patients.

Jannenga encourages providers to give patients a heads-up about note-taking at the outset of the appointment. Inform patients that you’ll be using an electronic device to record the information you collect from them during their appointment—but “don’t spend all your time typing,” she says. Jannenga and Peterson both suggest not getting too narrative while documenting in front of a patient. Instead, take notes using short phrases or bullets—but give yourself enough information that you can easily flesh out your documentation after the appointment.

If you work with older patients, acknowledge they “may not appreciate that [you are] spending more time with the computer than with them,” Severson explains. Collmer counsels providers to tell older patients that their doctors will see their records, as those patients may be concerned about their physician reviewing their documentation and thus, may be more inclined to engage with you.

Furthermore, Collmer notes that not all patients are in therapy of their own volition, and they may not want your help. Documentation can be a great way to get patients—especially those who are skeptical about 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.” If you have any negative notes, Collmer encourages you to explain to the patient that it’s not a reflection of that patient personally, but rather an observation of the patient’s current condition: “Transparency is key,” she says. (Whatever you do, don’t complain to your patients about having to complete documentation; it happens more often than you’d think!)

Inputting data while simultaneously working with patients requires a certain level of skill and expertise that can only be developed with practice, explains Peterson. So, don’t expect to be a rockstar at documentation right away. Instead, focus on filling in the most crucial pieces of the documentation puzzle without compromising your provider-patient connection. Kunich strongly advises therapists to make sure they’ve completed the subjective and objective sections before leaving the treatment room: “What takes you five minutes in the room takes you twenty minutes at home; find a way to make it happen,” he says.

Got any other point-of-care documentation tips that you’d like to share? Drop a comment below, and share your expertise with the world! 

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