Ten Ways to Speed Up Physical Therapy Documentation

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As physical therapists, our number one priority is always patient care. Most physical therapists get into private practice to treat patients their way, with the best possible quality of care. Visit http://intouchemr.com/10-ways-to-speed-up-physical-therapy-documentation/

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  • Ten Ways to Speed up Physical Therapy Documentation

    As physical therapists, our number one priority is always patient care. Most physical therapists get into

    private practice to treat patients their way, with the best possible quality of care.

    If we had a choice, all of our time and energy would be spend on patient treatment, and little or no time

    would be spent writing notes.

    However, we have to document. We can't avoid it. Documentation proves that treatment was provided,

    was medically necessary, was compliant, and is a pre-requisite to reimbursement.

    The burden of proof proving that the treatment was justified and medically necessary for that visit falls

    squarely on the shoulders of the clinician.

    The Speed of Documentation Matters

    What does this mean to private practice owners? It means you have to do everything within your power to

    make sure that your documentation is done quickly (speed) and correctly (compliance).

    You may have the best marketing person in the world. You may have a full patient schedule. However, if

    the documentation isn't getting done on time, the claim won't go out. If the claims don't go out, the

    payments won't come in. That's why its important to complete documentation as quickly as possible.

    The current problem is that the majority of physical therapy software systems force the therapist to

    become a data entry machines, basically a glorified typist.

    They force the physical therapist to do lots of clinical documentation, telling you that this is 'compliant'.

    Some physical therapy software systems can actually make the clinician slower.

    The truth is: Clinical documentation should be quick. It should not be an ordeal.

    Physical therapy software should empower clinicians to complete compliant documentation quickly. When

    combined with the right physical therapy documentation templates and physical therapy cpt codes, life

    becomes easier.

  • Less time spent entering clinical data, allows the private practice owner to spend more time on important

    areas like increasing staff productivity and efficiency, marketing, and generating internal referrals from

    patients.

    Let's face itno one likes spending seemingly endless hours each week doing documentation; we all

    would much rather be using that time with our families and loved ones. However, documentation must be

    done. So the question is: how do you complete documentation quickly and effectively? Here are 10 ways

    to complete clinical documentation quickly.

    No Note Left Behind... Pace Yourself All Day

    Before you wrap up for the day and go home, your objective should be to finish all of your documents.

    You cannot have documentation piling up. When patient documentation starts to pile up, it can become

    extremely frustrating, creating pressure on the clinician who has fallen behind. This creates a culture of

    inefficiency within the clinic and cripples your cash flow. It is vital to establish a plan for yourself and

    other therapists within your clinic that facilitates the consistent completion of clinical documentation on a

    daily basis

    .

    Become great at MULTITASKING

    When you are working with a patient, you have to document on-the-flywork with the patient and then

    take a moment to document. You must be able to treat and document simultaneously. The problem arises

    when a therapist spends 30 minutes or more with a patient without documenting anything. They then try

    to cram as many notes in as possible in the short interval between the first patient's treatment session

  • ending and the start of the next patient session. This type of workflow can create an ever-escalating

    mountain of documentation that the therapists will find to be extremely hard to get a handle on (do you

    hear the weekends and off-hours calling you?). Physical therapists experience such a downward spiral

    into this "documentation black hole". It makes clinicians question the validity of their choice of an

    occupation that demands they cut themselves off from family and friends in order to sit joylessly for hours

    in front of a screen entering data.

    Use AUTO-TEXT technology

    In Touch EMR has pioneered 'auto-text technology'. We call this 'the creation of customized short

    codes'. With this technology, a therapist types out a few letters and the system automatically populates

    the rest of the phrase. Auto-text technology can allow a therapist to populate several phrases by simply

    typing in a 'short code'. This feature will allow the end-user to save a substantial amount of time. For

    example, the therapist types in 'stg' (a shortcode) and the system automatically populates entire phrase

    "The short term goal for the patient is the ability of the patient to climb up two flights of stairs without pain

    and discomfort".

    Use VOICE recognition technology

    When your tablet, mobile device or computer supports voice recognition, your EMR system should be

    able to automatically take your voice and translate it into text. While voice recognition has its advantages

    for documentation, it has practical limitations. When you are working with a patient, you may not always

    want to openly narrate the patient's circumstances. This is especially true if there is even the slightest

  • chance that you may be overheard by someone nearby. This could be a HIPPA violation so you want to

    be careful while using voice recognition.

    Use CARRY FORWARD to pre-populate notes

    l'

    e

    Let's say a clinician creates a daily note, and this is daily note number 3. The physical therapy software

    system should automatically 'carry forward' data from the previous note, daily note 2. What this means is

    that "daily note 2" will be a copy of "daily note 1" "daily note 3" will be a copy of "daily note 2" and so

    forth. All of your data is re-populated when you are documenting. As a clinician, you are only changing

    data as necessarydemonstrating what has changed or improved in the patient's condition. You should

    also be able to 'override' this setting and choose any previous document as the basis for carry forward.

    The DEATH of the 'Endless Click and Scrol

    Some EMR systems transform the clinician into a glorified 'data entry person' constantly 'clicking and

    scrolling.' It's a tedious process that is repeated over and over again. Software should include auto-scroll

    technology. It should allow the user to click one button and get redirected to the top of the page. An

    additional feature is the auto-section redirect. Clicking one button will allow the user to automatically save

    all data under Subjective and Objective and then re-direct the user to another section.

    QUALITY matters... Less is mor

    Sometimes, we tend to over document out of fear - the fear of claim denial due to insufficient physical

    therapy documentation. If you use your clinical judgment, you have nothing to fear. When you use your

    clinical skills to document, you can reasonably expect to be paid for a claim. The jury is still out on

    outcome measures. Outcome measures do not make or break your documentation. When the therapist

    documents clinical judgment, outcome measures become less of a factor. The bottom line: use your

    clinical judgment and expertise to document as much as necessary. Documenting more does not make

    you more compliant. It makes you slow and inefficient.

    Flowsheet TEMPLATE creation

    Your flowsheet is supposed to not only document what you did with the patient (how many reps, sets,

    etc.), but should also contain treatment precautions and supporting documentation. Your flowsheet

    should evolve into a billing log and a treatment justification log. Auditors will not be able to deny your

    claims when you are able to demonstrate what you did and why you did it. In Touch EMR includes

    flowsheet templates that allow the therapist to populate entire treatment charts with one click and edit

  • them to select the things you did or did not do. Schedule a demo if you want to see some of the In Touch

    EMR flow sheet capabilities.

    Automatic FLG and PQRS code reporting

    Your EMR should automatically alert you when it's time to report functional limitation G codes and

    when it's time to report PQRS. Choose EMR vendors that are listed as PQRS registries with CMS. All

    PQRS logic should be coded into the software, and trigger automatically. The system should

    automatically alert the user to select the most appropriate PQRS or FLG codes depending on the

    encounter.

    Comparative ANALYSIS

    Let's face it. Some clinicians document faster than others. It's important to identify clinicians who are

    lagging behind with documentation and help them. Software should help analyze different clinicians by

    comparing their productivity at a glance. It should display the number of clinical hours, notes completed

    and revenue generated. This will allow management to determine EXACTLY which clinicians need to

    improve documentation time.

    If you are doing everything described in this article, you should be able to complete all of your

    documentation before you leave at the end of each day.

    Conclusion.. and Taking it One Step Further..

    Efficient documentation results in increased productivity, increased employee satisfaction and improved

    cash-flow.

    The next time you see a patient, ask yourself this question:

    "Can I finish documenting for this patient visit before the end of the day?"

    We can take this one step further, with a more aggressive objective for the clinician:

    "Can I finish documenting for this patient visit before the patient leaves the parking lot?"

    and the biller should be asking this question:

  • "Can I finiish billing for tthis patient viisit before thee patient leavees the parkingg lot?"

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