These days, it’s tough to get people to agree on, well, pretty much anything—but if there’s one thing we learned from our recent industry-wide survey, it’s that rehab therapists’ dislike of paperwork is fairly universal. In fact, the vast majority of survey-takers said that completing documentation was their number-one frustration at both the individual and company level. (Hooray for unity, am I right?) But, documentation isn’t going anywhere any time soon; so, many therapy providers have simply slapped the “necessary evil” label on the task and sought out any and all shortcuts to reduce the amount of time spent on documentation. However, cutting corners on patient notes can lead to some pretty serious consequences—and I’m not just talking overlooked CPT codes or inaccurate objective findings. That fact is, lackluster documentation has a direct effect on patient satisfaction. And on the flip side, better documentation leads to a more engaged patient-provider interaction—which in turn boosts the patient’s perceived value of care. Here’s why:
Great notes inspire genuine interactions.
I’ll let you in on a trade secret: your notes aren’t just for tracking patient progress and organizing objective findings. They can be a valuable resource for gathering subjective information that reinforces the connection between you and your patients. After all, there’s an “S” in “SOAP note” for a reason. Simply put, your patients don’t want to feel like just another passenger on the patient carousel—they want to feel like you value them just as much as they value you. So, if your patient offers up information that helps you form a genuine connection with him or her—anecdotes about a recent vacation, a new baby, or a wedding anniversary—a good EMR will have a place for you to denote this information. After all, studies like the one discussed in the book Putting Patients First have identified patient-provider interaction as a top factor in determining a patient’s satisfaction level—outranking even patient outcomes.
Patients—and everyone else—benefit from organized documentation.
When it comes to your documentation, it’s okay to be a bit of a perfectionist. After all, you’re not likely to lose a referral for keeping clear, orderly notes. However, messy and disorganized notes can reflect poorly on the provider who writes them, especially when they’re delivered to the referring physician or payer. After all, those parties might assume that substandard documentation is a sign of substandard treatment. So, if you want to protect your relationships with your patients and referral sources—as well as exemplify the efficacy of your services throughout each patient’s care journey—then clean, neat notes are a must.
Easy access to documentation improves patient satisfaction.
In rehab therapy—or any other healthcare discipline, for that matter—it’s not uncommon for patients to request access to their records. And when they do, those records should be neat, thorough, and easily obtained. Ideally, your EMR should have a documentation portal where patients and providers alike can access documents whenever, wherever. (If it doesn’t, that could be a deal-breaker.) Having an easy-to-use document portal means patients don’t have to find a fax machine or, worse yet, drive to your practice to pick up the documents in person. It also means they can receive documentation in a secure, HIPAA-compliant format—no paper-shuffling required. This is especially important for patients who need continuous, multidisciplinary care. Plus, it empowers those patients by keeping them involved in their own health management.
Let’s be honest: documentation isn’t going anywhere, especially in the healthcare sphere. It’s a vital, necessary part of the treatment process that ensures patients receive consistent care—and that providers receive appropriate payment for their services. More than that, solid documentation is a cornerstone of an exemplary patient experience. When your notes are at their finest, it kicks up your patient-centered care game from “okay” to “oh yeah!” And that’s what I call “ending on a high note.”