4 More Tips for Point-of-Care Documentation Domination

In part one of my two-part series on point-of-care documentation, I talked about four ways technology—and a helping hand or two—can make documenting in front of your patients less of a struggle. But, there’s still one pretty big hurdle between you and a smooth point-of-care documentation style: yourself. Don’t worry, though; our five therapy experts have some tips for that, too. In this second and final post, let’s dive into four ways you can help yourself—and your patients—as you work toward point-of-care documentation domination.

1. Change your perception.

WebPT Co-Founder and President Heidi Jannenga, PT, DPT, ATC/L, knows a thing or two about incorporating technology into a rehab therapy clinic (understatement of the decade?). Her advice to folks worried their patients will run for the hills the moment they pull out a laptop? “Patients are becoming more accustomed to seeing medical professionals use technology, so don’t be afraid of it.” Veda Collmer, OTR, WebPT’s in-house counsel and compliance officer, echoes Jannenga’s sentiment, assuring us that point-of-care documentation “is just another tool.” You wouldn’t not use your goniometer simply because patients don’t know why you’re using it or because you can’t look a patient in the eye while using it, right?

Therapists tend to believe they can’t manage documentation and the patient relationship at the same time, but Collmer knows firsthand that striking a balance between data collection and patient care is possible—because she does it herself as a practicing OT. And as a lawyer, Collmer knows that not documenting at the point-of-care could be bad for business: “It’s so critical that you have the most accurate documentation. It’s a legal document.” That means saving your notes for the end of the day—when you’re tired and just trying to crank through paperwork—is a bad idea. Taking care of your documentation at the point of care can save time—and your hide.

2. Rethink your approach.

WebPT Product Owner Doug Severson, ATC, CSCS, reminds us that “point-of-care documentation is meant to save time” in the long run; upfront, though—like during the initial evaluation—it will require a little more investment of your time (cue heavy sigh). That’s why WebPT Marketplace Manager Brian Kunich, DPT, advises providers to “be meticulous in planning for initial evaluations so you can buffer in time for building reports.”

During the initial eval, WebPT Senior Member Consultant and former clinic owner Shayne Peterson, PT, ATC/L, suggests saving notes as drafts if you aren’t able to complete them during the appointment. Then, you can pop back into the note later in the day to make sure it’s accurate and complete before you finalize it. And remember, you’ll make up for any lost time by increasing efficiencies during subsequent visits; thanks to auto-populating fields, you should be able to process daily notes in less than two minutes.

3. Leverage time with patients.

You likely only have 30-60 minutes with a patient during an initial evaluation; don’t waste any of it. Severson recommends preloading the initial evaluation form before the patient arrives so you can pull in any patient info you already have as you review the patient intake forms. Sure, you’ll still need to collect more specific information and confirm details during the appointment, but you’ll only have to make a few edits at the computer instead of starting from scratch. Collmer also stresses the importance of having a backup plan, especially if you work in home health: “Your technology may not always work the way you want—for example, you may not be able to access WiFi—so it’s important to be flexible.”

If you can, Kunich suggests blocking out extra time on your calendar for those initial exams to leave yourself more time to document while your patient is at the clinic and thus, easily available to you should you have a question or need to confirm details. That way, you can record the information you need without sacrificing critical one-on-one time. According to Peterson, the best time to get any remaining documentation done is when the patient is performing modalities or working with a tech.

4. Engage with your patients.

Heidi Jannenga encourages providers to give patients a heads-up about note-taking at the outset of the appointment. Inform patients that you’ll be using an electronic device to record the information you collect from them during their appointment. Jannenga cautions providers to “be upfront—and don’t spend all your time typing.” Jannenga and Peterson both suggest not getting too narrative while documenting in front of a patient. Instead, take notes using short phrases or bullets—but give yourself enough information that you can simply flesh out your notes after the appointment.

If you work with older patients, acknowledge they “may not appreciate that [you are] spending more time with the computer than with them,” Severson explains. Collmer counsels providers to tell older patients that their doctors will see their records, as those patients may be concerned about their doctor reviewing their documentation and thus, may be more inclined to engage with you.

Furthermore, Collmer notes that not all patients are in therapy of their own volition, and they may not want your help. Documentation can be a great way to get patients—especially those who are skeptical about therapy—more involved in their care. “Therapy is an intimate relationship,” Collmer says. “Sit next to your patients so they can see the screen. Explain why you’re writing down certain things, review goals with them, and get their buy-in for their HEP.” If you have any negative notes, Collmer encourages you to explain to the patient that it’s not a reflection of him or her personally, but rather an observation of his or her current condition: “Transparency is key,” she says. (Whatever you do, don’t complain to your patients about having to complete documentation; it happens more often than you’d think!)

Inputting data while simultaneously working with patients requires a certain level of skill and expertise that can only be developed with practice, explains Peterson. So, don’t expect to be a rockstar at documentation right away. Instead, focus on filling in the most crucial pieces of the documentation puzzle without compromising your provider-patient connection. Kunich strongly advises therapists to make sure they’ve completed the subjective and objective sections before leaving the treatment room: “What takes you five minutes in the room takes you twenty minutes at home; find a way to make it happen.”