When you ask any therapist what they dislike the most about their job, the answer is always the same. The paperwork. Unfortunately with such stringent insurance requirements these days, the paperwork has been amounting to more and more each year. The clinical team in our practice seems to have meetings on this a lot; how can we cut down on the amount of time it takes to complete the chart each visit? Here are some tips that our staff came up with without sacrificing the quality and hands-on care of our patients!
1. Enter your exercises as you have the patient complete them.
If they require hands-on assistance, or cuing, mark it in the chart as soon as they finish. This way you are also able to document just how much assistance they needed.
2. Input the subjective, what the patient is telling you, right away.
This way you are sure to remember to put everything in there. If you wait until later, chances are you’re going to forget parts of it.
3. When completing your evaluation, take the time to input all of the subjective and objective data you can with the patient in front of you.
If you wait until later, it will take you so much longer and you’ll probably end up staying after your shift to finish up your paperwork. Don’t write your objective measures on a piece of paper. Input it directly into the system. When your patient walks out the door the only areas of the eval to complete should be their assessment and goals. The same should go for any plans of care or discharge reports.
4. Have your team create patient education handouts.
This can be anything from body mechanics and posture to basic neck stretches. They can organize them in a way to be able to quickly grab them to give out to patients. We’ve used the tool for our staff to be able to educate each patient daily on something related to their condition; ultimately empowering them to take control of their rehab potential.
5. Use physical therapy EMR software.
Sometimes it is tough to get away from paper because we are creatures of habit. But once you’re on a good EMR system, you’re able to copy and paste items, pre-populate fields and make your life a whole lot easier in the land of documentation. If you aren’t on one yet, check this out!
We’re all in this documentation-crazy world, so I would love to hear your input and tips for how you complete your charting faster! Check out the link below for a great PT, OT and SLP group where we can share ideas and help each other!