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Six Tips for Making PT Practice Documentation a Priority

PT practice documentation has to be a priority. It is vital to the overall wellbeing of patients and the quality of care that they receive.

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5 min read
April 28, 2011
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PT practice documentation has to be a priority. It is vital to the overall wellbeing of patients and the quality of care that they receive. However, it is hard for staff to always find the time to get this part of their job done. For many of them, this is also the most tedious part of their job. They want to interact with patients and to help them improve their abilities more than anything else.

A good PT practice documentation system is very important, so you have to find ways to make it take place in the PT setting. These six tips will help ensure that your staff is making PT practice documentation a priority as it should be:

#1 Understand what is required

Many PT practice staff members get confused when it comes to the documentation that they have to do for their patients. Make sure they understand what they have to do in terms of what is required. This includes what your practice requires and what is necessary for insurance reimbursements as well as what the law requires. A checklist of what has to be included for each patient is a good place to start. Employees can use that as a reference tool while they are creating the patient documentation for each record.

Over time, they will become familiar with each of those steps so that they no longer need that reference. However, in any job setting you will have employees that stay for the long term and those that don’t. It is important to have that reference material in place for the new employees that come along. That way they can become efficient in keeping up with PT practice documentation more quickly. If they learn how to properly do the documentation and to make it priority from the start, it will stick with them for as long as they work there.

#2 Standardization in the use of language

It is important that all of the PT staff documents patient information the same way. That uniformity in terms of language and lingo will ensure that any employee or therapist can look back on notes and understand them. Miscommunications can occur between PT staff as well as the medical professionals that rely on that information if there are too many variations of what is being said in that documentation. Uniformity will cut down on lengthy discussions to clarify information and that will also make the PT unit operate more efficiently.

#3 Recognition of PT staff members who perform practice documentation well

Take the time to recognize the PT staff that consistently do an outstanding job of their documentation. They deserve the attention and it offers role models for other employees to look up to. They can ask questions of those outstanding individuals, read through what those people have documented, and challenge themselves to do a better job at the documentation that is related to PT work.

#4 Be sure that PT staff are given adequate time to keep up with practice documentation duties

Be realistic about what you expect any PT staff member to accomplish on their shift. They need to have adequate amounts of time to get that documentation completed. Otherwise, they will feel too much pressure to get everything done and documentation is going to suffer.

Too often a large load of clerical PT practice documentation is assigned to a staff member but not enough time is put into the schedule to do a good job. This reflects a lack of priority from the top on down for strong documentation habits. Make PT practice documentation a priority at all levels of the organization and that emphasis will be reflected in the work habits of employees and staff members.

#5 Stress the importance of properly completed PT practice documentation

When you stress how important documentation is for PT work in terms of patient care, streamlining with other medical staff, and reducing billing complications, then your staff will be motivated to do their part. Let them know part of their employee performance reviews will be based on adequate documentation as well. That will put some real meaning behind your proclamations about the importance of this aspect of running the practice.

#6 Give them the tools that they need

You want to make sure the PT staff has the right tools to do their documentation successfully. If things are still being done the old-fashioned way with lots of duplication, then it is time to do some revamping. There are wonderful PT practice documentation software programs that allow for the documentation to be faster and more efficient and to reduce duplicating efforts. By providing your team with the most up-to-date tools for keeping up with their PT practice documentation duties, you will be making it possible for everyone who works for the practice to make these duties a high priority every day.

"With WebPT our documentation is much more streamlined and the entire practice is able toaccess patient recordsfaster and easier."  Luann Teetsell, One on One Physical Therapy


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