5 Clinical Documentation Rules to Save You Time and Effort in Your Practice

Documentation can be a headache every day. Rather than letting it consume your time, become a pro so you can put all your effort into what you care about: treating patients

“If you didn’t document it, you didn’t do it,” is a phrase to keep in mind every day you and your PTs are documenting treatment and interactions with your patients.

When it comes to reimbursements from payers and passing audits with flying colors, great documentation can save the day.

Here are 5 Golden Rules of Clinical Documentation to follow in your practice:

1. Only Include Relevant Info 

Only include information that is useful to the reader in your reports. Physicians and payers may need very different information. Send them reports that give them what they need.

2. BLUFF… (Not Fluff) 

Bottom Line Up Front. Include a brief summary of two sentences of your findings and plan of care at the top of your report.

3. Avoid Jargon

You may need to share your patient’s medical records with another physician. Most physicians won’t understand PT jargon and acronyms so spell them out and make sure it’s easy to understand.

4. Function

Relate your clinical findings to functional limitations and provide rational evidence of the dysfunction.

5. Tell a Story

Your documentation should tell a story the reader will understand. Patients often request to see their medical records. It is important they understand their records to make sure your documentation passes the “fifth grader test,” meaning, a fifth grader should be able to understand your documentation.

By following these 5 Golden Rules, your documentation will become less of a headache. Documentation is meant to be a helpful tool for you, your patients, and other readers. Own your documentation and it won’t own you.

Documentation can be made simpler with a great Electronic Medical Record (EMR) system.

Exactly how much time and effort can be saved by great EMR software? Check out the following research by Clinicient:

• How long does it take you to document an initial evaluation? Standard EMR software will slow you down on each patient evaluation. With an efficient EMR system for your practice, you can save about 6 minutes per evaluation. You can save around 25 hours a year.
• How much time do you spend on daily notes? The average therapist spends 42.4 minutes per day on notes using standard EMR software. With more efficient software, therapists complete notes 28% faster on average. That extra time can allow you to see more patients or actually take a vacation!
• How long does it take you to document a discharge? With a typical EMR, therapists spend an average of 14.4 minutes per discharge. With a customizable system, physical therapists say they complete discharge notes 47% faster (9.8 minutes on average).
• The Bottom Line: Physical therapists using the right tools document 30% faster, adding up to 82 fewer hours per year spent on documentation when compared to colleagues using standard EMR software.

It is important to find the system that works best for your practice and meets your needs.

FYZICAL already has the systems in place (and a relationship for a reduced investment on a kick-butt EMR for FYZICAL members) to help you most effectively use documentation for billing so that you don’t miss out on any money owed to you, and you save time, effort, and money through the process!

FYZICAL is a cooperative of independent PTs and some of the top business experts in the country, striving to help private practices succeed in a challenging healthcare landscape.

FYZICAL gives private practice owners EVERY tool needed to increase referrals, maintain at least 20% profitability, and free up practice owners to take on management roles or retire sooner and wealthier.

Every detail counts when it comes to reaching your goals. Documentation is one of many details that will affect your journey.

For more information and helpful tips, click here to download our free e-books and guides or to watch our free webinars. Or call us 941-444-2209 to schedule a call with a FYZICAL advisor to learn about FYZICAL's effective business model that has helped over 470 physical therapy clinics nationwide become thriving successful practices.