Ten Ways to Speed Up Physical Therapy Documentation
As physical therapists, our number one priority is patient care. After all, we want to treat patients as best as we can, and get them better as quickly as we can.
If we had a choice, all of our time and energy would be spent on treatment, and little or no time would be spent writing notes.
After all, who likes 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 truth is, we have to document. We can’t avoid it. Documentation proves that treatment was provided and was medically necessary. It is a pre-requisite to reimbursement.
The burden of proof – proving that the treatment was justified and medically necessary – falls squarely on the shoulders of the clinician, and we have put together this resource and checklist on how to speed up your documentation.
Clinical Documentation should be Quick and Easy. It Should NOT Be an Ordeal.
In order to provide excellent care (and to get reimbused by payers), and you have to do everything 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 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 it’s important to complete documentation as quickly as possible.
The problem is that the majority of physical therapy software systems force the therapist to become data entry machines, basically glorified typists.
They force the physical therapist to do lots of clinical documentation, forcing you to accept that this is ‘compliant’.
That’s why 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.
Freedom from the burden of endless documentation opens up new possibilities. A clinician can now spend more time on important areas like improved patient treatment, boosting staff productivity and efficiency.
Let’s face it…no one likes spending endless hours doing documentation; we all would much rather be using that time doing other things – perhaps spending time with family.
So the question is: how do you complete documentation quickly and effectively? Here are 10 ways to complete clinical documentation quickly.
1) No Note Left Behind… Pace Yourself All Day
Before you wrap up for the day and head 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 cashflow for the clinic.
It is vital to establish a plan for yourself and other therapists within your clinic to facilitate the consistent completion of clinical documentation on a daily basis.
2) Embrace MULTITASKING
When you are working with a patient, you have to document on-the-fly. Work with the patient and then take a moment to document as you are interacting with the patients.
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 in as many notes in as possible in the short interval between one patient’s treatment session ending and the start of the next patient session.
This type of workflow will create an ever-escalating mountain of documentation. The therapist will inevitably struggle, working weekends and off-hours to try and catch up. The clinician will experience a downward spiral into this “documentation black hole”. In severe cases, 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.
3) 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 clinician 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”.
4) Use VOICE Recognition Technology
When your tablet, mobile device or computer supports voice recognition, your EMR system should be able to automatically recognize your voice and translate it into text.
While voice recognition has its advantages for documentation, it has some 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 HIPAA violation so you want to be careful while using voice recognition.
5) 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”.
Also, “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 responsible for changing / updating clinical status to demonstrate progress. You are documenting a change or improvement 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.
6) 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 auto-section redirect capability is another way to minimize clicks and scrolls. For example, 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.
7) QUALITY matters… Less is More
Sometimes, we tend to over document out of fear – the fear of a claim denial due to insufficient physical therapy documentation.
If you use your clinical judgment every single time, the quality of your notes will improve dramatically. 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. A clear and precise description of clinical judgment is more important than robotic, data driven outcome measures in your documentation. 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.
8) Flowsheet TEMPLATE creation
Your flowsheet is supposed to not only document what you did with the patient (how many reps, sets, etc.), but it should also reflect what you are billing out.
In addition, it should also contain treatment precautions and supporting documentation. The ‘old school’ flowsheet is a list of exercises with reps and sets.
To be compliant, and to survive audits, your flowsheet should resemble 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, why you did it and how you billed it out.
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 flowsheet capabilities.
9) Automatic Functional Limitation G Code 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. This is critical if you see a lot of Medicare patients.
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.
10) 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 improve speed of documentation.
Software should help analyze the note-taking speed of different clinicians by comparing their documentation output.
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 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 aggresive 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 finish billing for this patient visit before the patient leaves the parking lot?”
All these tips and strategies should improve your systems, and software should make things much easier. For example, your physical therapy EMR software should automatically transmit a claim to the billing software.
In an ideal world, documentation and billing should be complete before the patient has left the premises. Imagine what this will do to your cash flow.
This will change your practice forever.
Need More Information about In Touch EMR? Contact Us
In Touch EMR is a fully integrated scheduling, documentation and billing software for physical therapy practices. It is a simple and user friendly web-based, ICD-10 and HIPAA compliant EMR, and it offers customizable templates for notes, the ability to attach files, electronic signatures, and the ability to track progress notes, treatment plans, and assessments.
In Touch EMR has grown to over 1000 clients, our company / founders have been mentioned on CNN, Forbes, Huffington Post, Amazon, been featured as a Cleardata success story, received the prestigious ONC certification, 2015 and 2016 PQRS registry designation, integrated with Microsoft’s cutting edge patient portal technology and initiated groundbreaking healthcare partnerships with companies like Novartis. All of this is possible thanks to clients across the country, who have embraced In Touch EMR.
In Touch EMR is featured on our HIPAA compliant hosting partner (Cleardata) website along with other industry leaders such as the Cleveland clinic, Nexttech, Saint Mary’s regional medical center and UCLA health.
SIMPLE, TRANSPARENT PRICING MODEL
At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts.
Clients also get a self-paced video training program on how to get up and running, custom documentation template builder, iPad app – one touch document import, Instant Intake iPad app, unlimited patient manager and patient portal.
Every license unlimited ongoing support (phone / email / live chat), billing software integration, unlimited appointments, unlimited documentation, unlimited document uploads and unlimited electronic faxing.
OFFICE OF THE NATIONAL COORDINATOR CERTIFIED ELECTRONIC HEALTH RECORD TECHNOLOGY
We are a premier vendor in the rehabilitation space, and on the prestigious, certified Health IT Product List, which is a division of the office of the National Coordinator for Health Information Technology, a division of the Department of Health and Human Services.
Very few vendors can make this claim, and they generally won’t bring this up (in some cases, out of ignorance) mostly because this is not a mandatory certification, it is optional and requires a significant investment of time and effort. This certification is a sign of our commitment to a HIPAA compliant, secure and stable EMR system for your clinic.
If you ever get audited, the fact that you are using ONC-certified EHR technology (CEHRT) will work in your favor. CMS looks favorably on the use of CEHRT since HHS is trying to encourage the adoption of CEHRT amongs providers nationwide as part of a long term push towards electronic documentation and interoperability between EMR systems. Your practice can state that it carefully vetted and selected “a rehabilitation-specific vendor that passed all of the ONC HIT 2014 Edition EHR Certification criteria required to satisfy the Base EHR definition”
Since In Touch EMR has been very proactive at staying at the forefront of emerging guidelines for EMR vendors, you are assured higher quality, higher security and more compliance with CMS and other payer regulations.
For more information about the ONC, please visit: http://www.healthit.gov/newsroom/about-onc
In Touch EMR is one of the only EMR vendors in the rehabilitation space to pass all the 2014 Edition EHR Certification criteria required to satisfy the Base EHR Definition as stated by the Office of the National Coordinator for Health Information Technology, as listed here:
In Touch EMR is on the Certified Health IT Product List (CHPL) website.
The product is listed here: http://oncchpl.force.com/ehrcert?q=chpl
Search for In Touch EMR > CHPL Product Number: 150002R00
PRAISE FROM THOUSANDS OF SATISFIED CLINICS ACROSS THE UNITED STATES
“In Touch EMR has emerged as a comprehensive, customizable EMR solution for our growing organization. Support is always there when we need it, options to customize options to match our workflow are endless, clinicians find it simple and easy to use, front desk and billing love the integration between documentation and claims and compliance is built-in. This is exactly what we needed and it has boosted our efficiency. Couldn’t have asked for more. In Touch EMR is a leader in web-based EMR for our practice. Thank you!”
Julie Edelman PT, DPT – Avanti Therapy
“Moving to In Touch EMR was a process of adjustment, but it was worth it, for several reasons. Not only has the staff at In Touch EMR been proactive in adding new features and responding to support calls and streamlining our billing processes, they have been understanding, professional, polite and patient. The ability to create our own documentation templates, generate professional reports on demand and submit claims to billing with one click has allowed us to streamline our practice. The billing software is extremely versatile – I can review number of claims sent / on hold, payer breakdown, charges per visit and collections per visit. Our biller is able to pull up detailed reports, exactly the way we want. My front desk staff has the ability to track authorizations and create progress note alerts, physician prescription alerts and fax reports to physicians with the click of a button in In Touch EMR. My management is now exploring analytics to identify areas of growth and efficiency and expect to drive our practice further with analytic insights. Best of all, the transition for our entire staff was streamlined and consistent and help was readily available. I like that we are able to talk to someone whenever we need to. If you are looking for a powerful, reliable, and responsive team to help you implement EMR and billing software to grow your practice, look no further than the team at In Touch EMR. We support this therapist owned EMR company wholeheartedly.”
Matthew S. Fischer, MSPT – Fischer Physical Therapy
“In my 30+ years as a compliance auditor, author and instructor, I have yet to see an EMR and billing software as comprehensive as In Touch EMR. If you are looking for compliant ICD-10 documentation, and a ‘gold standard’ that can survive auditing, get In Touch EMR. A well defined workflow for the front desk, clinicians, billers and coders makes this a one-stop shop for quick, compliant documentation and flawless billing. I’m impressed with their HIPAA compliance, PHI protection and data breach prevention protocols. The front desk automation (certification alerts, patient portal, birthday reminders, e-newsletters) and clinician automation (progress note and reevaluation countdown, autotext technology, flowsheet templates, tasks and messages) are sufficient to set them apart. They didn’t stop there. The billing automation (claim cleanser, automatic transmission to billing, CCI edits – modifier 59 automation, autopost ERAs) and the administrator functions (access controls, audit logs, time tracking, productivity metrics) result in an incredible EMR and billing software combination for all clinicians. It’s a no brainer – forget the hype from other products and get In Touch EMR”
Cheryl House RMC, CHI Compliance Auditor, Author, Coder and Instructor at Illinois Valley Community College
“I was looking for a Practice Management Software that combined both documentation and billing platform systems that work in unison. I had previously tried more complicated systems that made me exhausted at the end of the day. In Touch EMR and In Touch Biller Pro represent a united and unified package that helps the private practice clinician govern a practice. It’s easy to use, it is concise, and it has a plenty of analysis variables to study.”
Sammy K. Bonfim PT – Rehabilitation & Performance Center
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Schedule a Demo of In Touch EMR Now
At In Touch EMR, we charge a flat fee per licensed clinician (no hidden fees or surprises) and it includes everything, unlimited claims and notes and infinite custom template creation. We are also a CMS recognized PQRS registry, we automate the reporting of PQRS and Functional Limitation G codes and provide automatic alerts for plan of care expirations, authorizations, progress note reminders and KX modifier alerts. Schedule a demo to see why practices across the country are switching to In Touch EMR.