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

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 Scroll'

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 more

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 this patient viisit before the

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