Physical Therapy Business Tips
August 28, 2024
If you asked a room full of physical therapists what their least favorite part of their job is, you would quickly learn that documentation is the unanimous answer. From not having enough time to just not enjoying staring at a computer screen, the reasons for dreading charting are endless.
The good news is that with the right physical therapy documentation tips, you can spend less mental energy on your notes and more energy on the patients in your clinic. Keep reading, because we’re going to unpack 7 of the most important PT documentation tips to make your documentation easier, faster, and maybe even more enjoyable.
Physical therapy documentation is the information that a physical therapist documents to record what happened during a patient’s physical therapy appointment, including details such as what was done during the session, how the patient responded, and recommendations for future treatments. This documentation is most often done using SOAP notes.
So now we can jump into our physical therapy documentation tips, right? Not just yet. Now that we’ve established what physical therapy documentation is, we can dive deeper into the specifics of what makes official and complete PT documentation.
Complete physical therapy documentation should include important patient details such as age and date of birth, the patient’s medical diagnosis and any relevant medical history, any medications and dosages, a physical therapy assessment and diagnosis, physical therapy goals and plan of care, and appropriate CPT billing codes.
Okay, that’s a lot of physical therapy documentation requirements to keep track of. Luckily there are PT documentation softwares like ClinicSense that help keep track of all this information easily and let you know when you’ve missed something. Let’s look at why each piece of the puzzle matters.
Although it might be the most obvious in our list, patient details such as name, date of birth, and gender are seriously important for your physical therapy documentation. After all, they’re some of the only details separating the notes of one patient from another.
Other relevant details such as a patient’s address and phone number are equally important because, in addition to solidifying that patient’s unique identity, they’re also essential for contacting the patient about their plan of care.
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Although physical therapists don’t provide medical diagnoses to patients, and not all patients will have a medical diagnosis if receiving physical therapy as a first line of treatment, most of your clients will have a medical diagnosis that’s relevant to their treatment plan.
Including all relevant medical diagnoses in your documentation is especially important for other healthcare providers who may be reviewing your documentation. If medical diagnoses are missing, then the reader isn’t able to get a full picture of the patient’s medical history.
One of the most valuable questions to ask a client during their evaluation is “have you had physical therapy for this issue before? How did it go?” Asking a patient about their prior PT experiences is an important piece of keeping an accurate treatment history and informing future treatments.
These types of questions aren’t always included in standard intake forms, making the ability to provide customizable intake forms to your patients exceptionally valuable for your practice.
A patient’s medication history is considered essential in physical therapy documentation because not only can the right medication treat a patient’s condition, the wrong medication (or the wrong dose of the right medication) can make a condition worse or cause a new condition altogether.
Although important for all patients’ treatment plans, medication history is especially important for older adult patients because polypharmacy - the practice of giving several medications to a patient at once - is very common for older adults, and they may not always remember all of their current medications without a documented list.
All physical therapy documentation should include a physical therapy assessment where the treating therapist summarizes how the patient is doing, what should be included in the plan of care next, and any other relevant updates on the patient’s status.
A physical therapy diagnosis is distinct from a medical diagnosis because it’s generated using the evaluation procedures specific to physical therapy, focusing on the patient’s functional limitations. A PT diagnosis is usually established during the first visit, but may be modified at any point during the patient’s plan of care.
Although there are many ways to write goals to document physical therapy treatment goals, the SMART format is the most popular. SMART goals are specific, measurable, attainable, relevant, and time-bound. Writing goals in this format makes assessing patient progress easier for any provider reviewing your documentation.
A well-written plan of care is usually based on the patient’s current condition, their SMART goals, and any barriers to receiving treatment the patient may have. A clear plan of care is also important if you work with any physical therapist assistants who are required to base their treatment off of your physical therapy plan of care.
No physical therapy documentation is complete without proper CPT codes, and for good reason. Physical therapy CPT codes are the brass tacks summary of what type and quantity of care was provided to a patient during their visit.
While CPT codes are essential for insurance reimbursement, cash pay clinic owners also use them to accurately record and bill for their services.
Okay, that’s enough background information on PT documentation. Let’s get into the 7 physical therapy documentation tips that you can use to take your charting to the next level.
Best practices for physical therapy documentation include understanding why quality documentation matters in the first place, using the right physical therapy software, emphasizing point-of-service documentation, leveraging shortcuts to save time, cutting out irrelevant information, documenting all activities performed, and justifying all treatments provided.
Mastering all of these physical therapy documentation tips and making them part of your standard documentation process is sure to boost your productivity and make your clinical life easier. Let’s take a closer look at each of these tips.
Although most physical therapists write notes on a daily basis, it’s not always clear why documentation is actuallyimportant.
Put simply, documentation is a universal way to ensure all patients can have a standardized healthcare experience and easily work with another provider down the road using your notes. Without quality notes back it up, your time and effort with your patients can’t be verified or replicated.
Although physical therapy documentation used to mean writing paper notes for all of your clients, electronic medical records (EMRs) have now become the standard. To make the most of your documentation, you can use physical therapy software to optimize your EMR experience and consistently create top-quality notes from your patient visits.
Knowing what to look for in physical therapy software is half the battle. ClinicSense is a leading physical therapy software specially designed for physical therapists and clinic owners who need to spend less time on notes and more time with their patients. You can get a SOAP notes free trial right now to boost your documentation and enhance your practice’s efficiency.
In today’s physical therapy world, treating and charting have become one and the same - that is, it’s expected that you take care of your documentation while you’re working with your patients. This is called point-of-service documentation.
Although point-of-service documentation might seem like an easy way to lose focus on your patients and provide sub-par care, it only takes a little getting used to and can actually significantly increase the accuracy of your charting. After all, who can remember everything that happened after a long day of appointments anyway?
Just like how well-designed treatment packages can make selling your services a lot easier, intuitive shortcuts can simplify your documentation routine.
For those who want to save even more time during their physical therapy documentation, there are a number ofshortcuts to consider. For example, you can use shorthand phrases and acronyms to abbreviate longer words and phrases. Just make sure to include a key somewhere in your note!
Always remember that the quality of your documentation should be prioritized over the quantity of it. Irrelevant or otherwise unnecessary information ultimately wastes time, brings down your productivity, and distracts from the most important information in your note
One great way to minimize irrelevant documentation is through customizable note templates. For example, having the ability to skip over unnecessary fields and checkboxes that you don’t use during your physical therapy evaluations can help you enter everything relevant much quicker, and with more accuracy.
ClinicSense is offering a free SOAP notes template for physical therapists looking to cut irrelevant documentation out of their notes and improve their patient care.
It’s often said in the healthcare world that if you didn’t document it, it didn’t happen. This is especially true in the modern age where we have the means to document everything that happens during a visit with relative ease.
Documenting every activity and treatment with your client sets you up for success by preparing you for any scrutiny down the road if your notes need to be evaluated by your client or a third party, and it also helps with the accuracy of data analysis to improve your business.
In addition to documenting all of the treatments and activities from a session, you’ll also want to provide a brief justification. This allows the reader to quickly understand why something was done should your plan of care ever come into question.
While details like documenting every treatment and providing treatment justification might seem superfluous, they are absolutely necessary to protect yourself and your patients throughout their episode of care and beyond.
Physical therapy software is a key component to making documentation easier because it simplifies the charting process, reduces errors, and optimizes efficiency. ClinicSense is an ideal documentation software for physical therapists because it’s built specifically for the workflows and details that physical therapists care about the most.
One of the biggest reasons ClinicSense works so well for physical therapists is because of its customizable physical therapy SOAP notes that can be adjusted to meet the exact needs of your clinic. On top of that, intuitive financial and messaging features like patient appointment reminders improve billing and client retention to help your clinic thrive.
Among all of the physical therapy documentation tips we’ve covered today, having physical therapy software that works for you and meets the needs of your clinic with features like customizable consent forms and billing reminders may be the most important. ClinicSense helps you provide the best care to your patients by improving documentation, streamlining business operations, and enhancing your day-to-day flow.
Happy charting!
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