In the past, clinicians have been either relationship-driven or data-driven, but now, they’re expected to do it all: document quickly and completely 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 WebPT Senior Member Consultant Shayne Peterson, PT, ATC/L, puts 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 is a great route to making the process as efficient as possible, especially when it comes to initial exams. We know that collecting patient info while assessing the patient and determining his or her plan of care is no easy feat. We also know that you don’t want to lose out on building 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. In today’s post, you’ll find the first four tips (be sure to check back tomorrow for the final four). 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, who manages the WebPT Marketplace (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 Product Owner Doug Severson, ATC, CSCS): Once you’ve familiarized yourself with your EMR, ask your patients questions from the Subjective tab in order to streamline the process. It may take you a bit more time 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. Ever feel like two fields are appropriate for the same piece of information? If this happens to you frequently, you likely don’t need every available field (at least, not every time). 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: once your tech is set up in your EMR with permissions to document—and he or she is fully trained on the software—you can enlist him or her to record all the patient info, thus freeing you up to perform assessments without sacrificing your connection with your patients. And here’s a hidden benefit: WebPT Co-Founder and President Heidi Jannenga, PT, DPT, ATC/L, 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 charging at all times so 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.


And just like that, we’ve covered the first four of our top eight point-of-care documentation tips. Like Vanessa Williams, we’ve saved the best for last, so check back tomorrow for part two. We’ll talk transparency, limitations, mental blockers, and the surprising way documentation can increase patient engagement.