50% of patient documentation mistakes are from erroneous records, details, and prescriptions.
(World Health Organization)
Patient expectations continue to rise as more technological developments take place, making accurate physical therapy documentation non-negotiable in practices.
Mastering precise, skilled PT documentation requires the utmost attention to achieve via regular training, especially with coding guideline updates taking place regularly.
To help you stay ahead of your physical therapy documentation, here are six best practices you should integrate into your training regimen:
Six Best Practices For Physical Therapy Documentation Training
1. Doing Regular Medical Record Reviews
- Emphasize note quality and completeness in the medical records.
- Note common documentation mistakes for future reference.
- Identify action steps for integrating insights into documentation training.
Although regular medical reviews seem time-consuming, they actually streamline practice efficiency in the long term. They give physical therapists data-driven insights on the best documentation practices.
Besides studying patient histories, medical record reviews can be done to standardize note quality, generate insights into documentation performance, and identify common mistakes for future training.
2. Enforcing Note-Taking Standards
- Meet with the healthcare team to discuss note-taking standards.
- Implement guidelines that standardize documentation quality.
- Reinforce documentation workflow protocols through refreshers.
One of the best ways to learn how to improve physical therapy documentation is to cover the essentials of note-taking.
While each provider has their own documentation style, having note-taking standards is vital to ensuring quality and completeness.
Meet with the team to define standards that everyone will agree to follow. Provide refresher training regularly to help them further comply with accurate documentation protocols.
3. Providing Routine Equipment Orientation
- Standardize documentation workflows (from appointment to EMR) for record quality and consistency.
- Provide refresher literature that helps remind providers of what to do whenever necessary.
- Update or replace equipment regularly to ensure smooth workflows for all providers.
The EMR and other equipment are fundamental aspects of a provider’s workflow. However, some providers either remain unfamiliar or lack the time to adapt to the equipment.
Help them by integrating equipment orientation into their training regimen. Provide training on standardized documentation methods for using your practice’s EMR so everyone is well-versed with the equipment. You can also provide refresher literature via physical or digital guides to keep them informed.
Most importantly, you should keep your equipment updated and replace it if it’s malfunctioning or outdated. Additionally, you can consider integrating AI-powered tools such as ScribePT to automate the medical documentation process.
4. Distributing Literature On Coding Guideline Updates
- Research payor documentation requirements and guidelines proactively.
- Stay abreast of coding and billing guideline updates.
- Disseminate updates to your healthcare team as soon as possible.
One of the challenges of medical documentation is keeping up with ever-changing payor requirements, causing provider burnout in the long term. Complying with these changes is crucial to avoid claim denials that can push back your practice’s revenue cycle.
Hence, it’s vital to include coding guideline updates into their training regimen. Constantly research payor documentation requirements and guidelines, as well as coding and billing duieline updates to inform their training. It’s crucial to disseminate those updates to your team as soon as possible so that their knowledge is timely.
5. Conducting Role-Playing Activities
- Assign providers to play out a mock patient encounter during scheduled training sessions.
- Focus on how each provider deals with engaging the patient and writing notes simultaneously.
- Formulate action plans for each provider to improve their workflows based on physical therapy documentation examples.
Role-playing activities are excellent for keeping your providers prepared. A large portion of medical documentation takes place during the patient encounter. The challenge, however, is in the provider having to split their focus between note-taking and engaging the patient.
Assigning providers with role-playing activities can help them adapt to specific patient situations while coping with medical documentation. After each training session, you must develop action steps for each provider to enhance their ability to engage with patients while simultaneously writing notes.
6. Having 1-on-1s With Each Provider
- Hold regular individual sessions (monthly or quarterly) for every provider to discuss their well-being.
- Encourage providers to be open with their concerns with documentation.
- Facilitate a positive environment where providers can share tips and tricks to make documentation easier.
86.3% of providers agree that administrative burden is one of the causes of burnout, according to a 2023 APTA report.
Meeting with each provider individually helps them release steam from the difficulties of medical documentation. Ideally, the meeting should be done monthly or quarterly.
Providers should be actively encouraged to be open with their concerns to ensure the success of the 1-on-1 sessions. You should also facilitate an environment where providers can share their insights and best practices to make documentation easier, creating an atmosphere that benefits everyone.
Transform Your Physical Therapy Documentation With AI
With these six best practices, you can ensure that your healthcare team’s documentation stays consistent, accurate, and more compliant with ever-changing requirements and guidelines.
On the other hand, if you’ve implemented these trends and still find yourself with a lot of room for improvement, you may want to consider integrating AI tools that can help further streamline the documentation process.Make your physical therapy documentation well-rounded with ScribePT, an AI scribe tool that streamlines documentation and allows your providers to focus on the patients more directly.
