A physical therapist office is all about caring for patients. In order to accomplish that goal and to serve a large number of patients, you must have well-designed PT documentation forms to take the patient from the moment he or she arrives for treatment until the treatment is done. The outcome is that in many ways, a PT practice is also very much about forms and documentation. That is a fact of life that none of us can escape. Instead, we should focus on developing or using PT practice forms that serve the process well.

As the manager or owner of your PT practice, it is up to you to review the forms that are used to make sure every step your clients take in their therapy is documented properly. This is not only essential to serve your patients well, it is essential for you so that you keep your practice in compliance with industry and legal regulations and so you have adequate documentation to file insurance forms for reimbursement. There are three steps to take to assure the PT documentation forms you use are adequate for the needs of your practice.

  1. First of all, review the standard forms you are going to use to make sure every data element needed is there so that your staff or patients can provide the information you need efficiently.
  2. Secondly, make sure the forms are understandable and easy to use. A form that is badly designed or hard to understand leads to confusion, so the form is not filled out properly or it can result in too many mistakes that can trip you up down the road.
  3. Finally, you need to have adequate forms on hand where the therapy is being offered. They should be in good supply at the office and packages of forms ready to go for sessions done outside of your office.

There is some information that must be carried forward accurately from form to form. That includes the patient's full name and the identification number that will be used both within the practice and when referencing the patient to outside agencies. If the patient came to you because of a referral, that referral information should be documented completely as well when the patient is being processed before treatment begins.

During treatment, specific forms having to do with examinations, treatments and medications must have places on the form to reflect that these steps were taken with the approval of a qualified physical therapist. Other types of information that will be collected on PT documentation forms includes details about employment, medical history, demographic data, relevant ethnicity information, family history, history of surgery or any serious illnesses, documentation of medications that the patient is using or has used in recent history, allergy information, the nature of the problem being treated and any clinical tests that would be useful to the therapist who is helping the client.

In some cases, you may need to consider customizing standard PT documentation forms if you do not find mass-produced versions that work well for you and your staff. The practice of maintaining a supply of blank paper forms, filling them out and filing these forms as well as supplementing the patient's file throughout treatment represents a considerable cost and loss of productivity due to redundancy of filling out the same information on multiple forms. It also represents a considerable risk for mistakes that could result in inaccurate treatment or billing problems that could slow or hinder reimbursement entirely.

One way to reduce the overhead of so many PT documentation forms is to consider moving to an automated PT documentation system. By using computerized forms, you get the paper out of the system entirely. Standard information is easily passed from form to form elinimating redundancy and the proper documentation can be accessed and updated anywhere the therapist is located. Most modern PT documentation software systems are networked using Internet resources allowing access from anywhere there an internet connection is available. This is an excellent answer for the age-old documentation problem that all PT practices face and it is a solution that saves time and money and leads to better care for your clients as well.

"We noticed an immediate improvement in consistent use of standardized outcome measures for Medicare but also our private insurance patients. This was always a quality assurance goal, but having the outcomes measures readily available in the records section of WebPT made it surprisingly easy for all clinicians to gather this data routinely. Our referrals appreciate the easy-to-read reports and the fact that we can fax or email them very rapidly if they have an urgent request. Our patients also report that they like that we are charting accurately and the improved communication with their other healthcare providers." Kenji Carp, Owner/Director, Cooperative Performance & Rehabilitation 

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