Documentation remains one of the biggest headaches a physical therapist has to deal with, and perhaps the biggest operational bottleneck for organizations of all sizes. Fortunately, with some effective training, you can improve your documentation practices and get your clinic running more smoothly in 2023. That’s why we’ve assembled some strategies to help your staff make the most of every session.
1. Find a training schedule that works for your team.
It can be hard to find time for training given how busy your practice is on the daily, which is why it’s so important to ensure they aren’t unnecessarily burdensome. Here are a few tips on how to do that:
- It can be tricky, but try to stick to a training schedule that works around everyone’s responsibilities and avoids disrupting workflows as much as possible.
- Keep your training sessions tight so that there’s no wasted time. This will require a bit of organization on your end prior to, but it help keep your staff focused and your sessions efficient so everyone can get back to their work in a timely manner.
- Make training a regularly-scheduled event. If you’re trying to schedule training sessions on an ad-hoc basis, there’s a greater chance they may never happen—especially given everything else going on at your clinic.
2. Set the standard for documentation requirements.
If your organization doesn’t have any documentation standards, you could be making the process harder than it needs to be for your providers and billers. Just as overdocumenting can take up too much time, underdocumentation can make for far less useful SOAP notes. And notes that lack detail and data or are otherwise incomprehensible to people outside your practice can come back to bite you in the form of an audit. Walk your team through the right level of detail needed to ensure that they’re documenting in line with your clinic’s workflows and goals—without any wasted effort.
Unsure of what precedent you should or shouldn’t set for documentation standards? Consider these best practices to help chart your organization’s course.
Teach defensible documentation.
It can be easy to forget that your staff isn’t the only audience for your patient notes. If you’re using shorthand or abbreviations, failing to fully detail dosing or fill out progress reports, or otherwise commiting documentation missteps, you’re not documenting defensibly. Defensible documentation is pretty much what it sounds like: creating a thorough record of a patent’s evaluation, treatment, and progress that demonstrates to anyone reading it why both the services of a PT and the prescribed course of treatment were necessary. And in the event that you need to justify treatments to payers, auditors, or other third parties, you’ll need a record that stands up to scrutiny.
This blog post lays out a few rules-of-thumb for defensible documentation, including:
- Would another provider be able to read your records and understand that patient’s course of care?
- Would a non-clinician be able to understand your records?
- Does your documentation make the case for your intervention as a PT?
If you’re looking for resources to get started, you’re in luck—we’ve got the defensible documentation toolkit to bolster your training regiment.
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Emphasize proper coding.
Part of the documentation challenge for providers and billers is the struggle to find and use the correct diagnosis codes. Even though ICD-10 has been the coding standard for years, that doesn’t make it any less complex and confusing for many clinicians. Difficult as it may be, however, proper treatment—and billing—requires using the most specific codes for each condition. Your training schedule should include time to go over the most common diagnosis codes used in your practice, as should include time to go over any coding questions your team might have.
Strive for point-of-care documentation.
One of the most common documentation complaints is the amount of time that clinicians have to spend on documentation, with many providers having to take documentation home with them at night. By emphasizing point-of-care documentation as an accepted best practice, you can help improve your providers’ efficiency and give them back time in their day.
Implementing point-of-care documentation also requires getting patients on board with the process. Some patients might not like seeing their provider on a device during the limited time they have with them during an in-office visit. Instruct your staff on how to explain to patients why they’re taking notes during the session, and why those more detailed notes will help them provide better treatment. Better yet, have providers engage patients in the documentation process. Sitting with patients to explain treatment notes or working with them to establish a treatment plan encourages patients to take a more active part in their treatment and recovery.
3. Refresh your training periodically.
Everyone needs the occasional training reminder, so set aside time to go over documentation best practices as well as your own standards and expectations a few times a year (or as often as you deem appropriate). It’s not only a great opportunity to keep best practices fresh in the minds of your staff, it’ll offer your trainer(s) the chance to go over new processes and procedures, or to explain the latest rules and regulations. And be sure to document these training sessions; it will help you track what’s been covered and who has attended.
4. Make sure EMR training is part of your program.
As important as what you’re documenting is how you’re documenting—which means making sure your team is familiar with your EMR. Part of your documentation woes could be that clinicians and support staff don’t know their way around the EMR workflows, or perhaps aren’t as tech-savvy as we might assume them to be in 2023. Your training should include the ins-and-outs of your EMR, including the tools and functions providers will need on a daily basis.
Encourage staff ownership of the documentation process.
Key to the long-term success of your documentation process is getting staff members to buy into and take ownership of the PT practice documentation system. It requires a bit of patience, but if you can communicate the importance of proper documentation for both the practice and for their individual effectiveness, you’ll have far better luck with implementing the right processes.
To that end, it’s a good practice to have a “superuser” on your staff—a star pupil who has the expertise needed to answer questions and troubleshoot issues as they arise. You may have a clinician or staff member particularly interested in adding “tech maven” to their resume, and thus is well-suited for the role.
Customize your EMR for your needs.
- Audit your charts to eliminate fields you don’t need, creating custom forms for exactly the information your team needs—and nothing they don’t.
- Build custom patient profiles based upon the types of patients you most commonly see, including the treatments and goals associated with those conditions.
- Use shortcuts and custom triggers to pull in necessary information from a patient’s medical record, like medical history and patient demographics.
Not only will customization make training that much easier, it’ll save time on your daily workflows, and considerable frustration for your staff. Because your ultimate goal with documentation training is as much about efficiency as it is accuracy.
Training might seem like an obvious candidate to be cut for time constraints, but it’s an essential element to running a well-oiled clinic. With an effective documentation training program, your staff will be hitting the mark for documentation requirements while also providing high-quality patient care.