It’s tedious. It’s time-consuming. It’s the one thing most physical therapists wish would go away and never come back: patient documentation. However, documentation is a necessary part of any therapist’s day to day. After all, it not only helps justify your services so you can get reimbursed, but also ensures your patients receive appropriate, high-quality care (among a number of other things).
So, while we know you can’t stand documentation, you certainly can’t live (or in this instance, practice) without it. Thankfully, advances in technology—along with the growing online library of general efficiency tips—can majorly speed up the note-taking process. For efficiency’s sake, we’ve highlighted the top three we feel will move the needle most for you—and help you reclaim a sizable portion of your day.
1. Get to know your EMR.
If you’re unfamiliar with the technology you’re using to chart, your documentation process will likely be clunky, inefficient, and downright pain-staking. And no one likes the sound of any of those words—least of all those therapists who pride themselves on servicing their patients in the exact opposite way.
Getting to know your EMR will take some time upfront, but it’s well worth the investment, as it will save you time—and trouble—in the future. To help flatten the learning curve, see if your EMR provides any educational resources—like training modules or services—and take full advantage of them.
Designate a superuser.
While everyone on your team should be fluent in EMR (so to speak), it’s highly beneficial when at least one staff member has an in-depth understanding of the technology and how to leverage it for your team’s specific needs. We call this person the “superuser.” Designated superusers can:
- answer frequently asked questions;
- find solutions to issues and communicate them in an intentional manner to the rest of the team;
- alleviate confusion during system upgrades, downtime, and other anomalies you might face when using a documentation software; and
- stay apprised of cool new features the EMR is releasing and show the rest of the team how they can apply those upgrades to their own practice.
At the end of the day, superusers are there to help tailor your EMR’s platform so that it aligns with your team’s specific workflows—which is where the fun really begins.
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2. Configure your setup.
Contrary to what some physical therapists think, EMRs aren’t meant to be a “one-size-fits-all” solution. In fact, most EMRs flex in ways that allow you to create a custom documentation experience that suits your unique needs.
Luckily, configuring your setup isn’t too difficult. Simply follow these steps.
Audit your charts.
The best way to get a feel for how your EMR is set up is to take stock of what’s included as you’re completing your notes. Identify the fields you typically leave blank or the areas reserved for information that doesn’t serve a purpose for your services and/or patients; then, simply remove them. That way, you can stop wasting time scrolling or tabbing through the sections that are not relevant to you.
Build and use custom patient profiles.
Identify the types of patients you typically treat and create specific profiles for each—complete with procedures, goals, problems, and any other type of boilerplate content that might belong there. Once you’ve taken the time to tailor a profile to a certain type of treatment plan, you can use it again and again.
A word to the wise, though: You must still update profiles based on what you find during your conversation with each individual patient. These are templates, after all, and should serve only as a framework to shape each unique patient’s narrative.
Create templated activities and interventions.
Similar to creating profiles, having customized activities and interventions stored in your EMR can work wonders in terms of improving flowsheets and streamlining documentation. What’s more, these templates can sometimes be connected to certain CPT codes, thus helping therapists accurately bill for services, remain compliant, and document defensibly.
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Explore all available shortcuts.
Some EMRs have links or other shortcuts you can use to pull in things like patient demographics, past medical history, and past surgical history. That way, you don’t have to manually type or select this information. Additionally, check to see if your platform automatically deploys in-documentation alerts (typically found on the patient’s record or chart screen), which serve to flag risks and out-of-date information. If these alerts are available to you, make sure you’re checking them during each visit and modifying them as needed.
3. Engage your patients in the documentation process.
Patients are getting savvier by the day, with many taking a vested interest in their health and wellness. However, engaging patients in their care plan isn’t just a smart retention strategy; it can also be a viable way to expedite your documentation process.
Set up digital patient intake.
We’ve talked a fair amount about the benefits of digital patient intake forms in terms of creating a seamless patient experience, but they are also a major documentation time-saver when integrated with your EMR. When patients complete an integrated intake form, certain fields (like date of injury, medical conditions, pain location and type, current medications, and therapy goals, to name a few) will automatically populate in the patient’s initial evaluation.
What’s more, having this information from the get-go can help you make more informed decisions about your patients’ care plans, as well as drive deeper conversation around their goals and desired outcomes.
Get your patients on board with point-of-service documentation.
Point-of-service documentation (a.k.a. documenting while you’re with a patient) can turbo-charge your note-taking efficiency—especially for initial evaluations. However, some patients may be sensitive about you taking notes while they’re sharing personal information about their health. You can help smooth things over by telling them upfront that you’ll be documenting throughout their appointment in order to track pertinent treatment details and functional progress. You can even go so far as to seat the patient next to you so they can see what you’re writing down and how you’re tracking their goals.
This approach not only frees you up to take notes on the fly, but also can be a great way to get patients more involved in their care.
As a physical therapist, you do valuable work every single day. It is our hope that these tips help you not only streamline your charting, but also recoup some much-needed “you time” so you can continue to show up for your patients day after day. Have other time-saving hacks that have made documentation less of a struggle for you? Share them in the comment section below. You never know who might need to hear it!