Physical Therapy Haven

Keeping up on documentation can be challenging for new grads, especially if you have the added burden of learning a new EMR system. Putting off notes to the end of the day or later can be demoralizing at the end of a long day and often causes the quality of the documentation to suffer. Regardless of your practice setting or the specifics of your documentation system, there are some techniques that can help you manage your notes well and go home on time!

Before you start a new note, quickly review the patient’s last note so you can be aware of how you will mostly likely want to direct the treatment. Note any details in the previous Plan that you need to address this session. Consider what objective measures need to be obtained.

Subjective. Keep it short and sweet. If you are seeing a patient for 45 minutes or less, you should be able to complete your daily subjective exam in less than 5 minutes, leaving plenty of time for actual treatment. Set a timer if needed.

Ask specific questions and establish the expectation of specific answers. Instead of “how are you doing?” which will often lead patients to offer impertinent details about their personal lives, try “how is your knee feeling since I saw you last?” Now you are likely to get a better/worse/same type response. Try to quickly flesh this out. “How can you tell it is better?” or “what do you think is causing it to feel worse?” This will often get patients to offer some very good information about activity tolerance and/or pain.

Review the subjective report from the last visit and ask follow-up questions based on their previous complaints that have not yet been addressed for the current session.

Record numeric or other pain scale data as you see fit. If the timer goes off and the patient still has more to say, gently let them know that they can tell you more while they begin some of their exercises or while you are working on your objective measures or treatment.

Objective. Obviously it is not practical to run full assessments such as SFMA or Berg Balance Assessment at every treatment session, but for most orthopedic conditions you may want to consider tracking one or two specific objective tests/measures every visit, or picking a specific measure (such as ROM) to try to improve within the session that day. Even if it is just gait observation, you can do it quickly, record you findings and move on into treatment. This will improve the overall quality of your documentation and help the patient be aware of his or her progress on a very regular basis.

Treatment. Document reps, sets, and performance notes as the patient is performing his/her exercises. You can watch and give cues while you document. If you are doing manual techniques, set your timer again for 5 minutes. You can usually perform 2-3 techniques in this amount of time. When the timer goes off, direct the patient to do a prolonged hold or active movement on the new range or just get up and do some courtesy movement to counter-balance the treatment position while you document the techniques you did in the last 5 minutes. This way nothing gets forgotten and the note gets written as the treatment session progresses. Remember to do your post-test if applicable at the end of the session.

SmartText, etc. Many EMR systems have some form of short-hand or smart text function which can be very time-saving. Be sure you are taking FULL advantage of these types of functions for exercises and treatment sequences that you use often.

Assessment and Plan. Note the patient response to the treatment. Note any improvements made and the major impairments that remain. Review the goals and update them as appropriate. Briefly note any specific assessments or treatments you intend to do in the next session.

That’s it! By working on each note at various intervals within the session you can help ensure that nothing is left out or forgotten and you are not stuck at work late trying to slog through a backlog of notes.