6 Physical Therapy Documentation Struggles—And How to Solve Them

Problem #1: You’re instructed not to use shorthand—but typing everything out takes forever.

Your supervisor tells you to stop using all your favorite shorthands like “FWW” and “tol.” What the heck?! Before you get too upset, remember that one of the main reasons we document is to ensure that our patients, other medical professionals, and utilization review professionals can understand our treatments and the rationale behind them. While most PTs realize that “FWW” means front-wheeled walker and “tol” means tolerate, many other folks who end up reading your notes will be left scratching their heads. And with so many insurance providers basically looking for reasons to decline payments, why make it even easier for them to do so? 

The solution: Use shortcuts to save time on documentation.

Many electronic medical record (EMR) programs have a built-in capability to extend shortcuts into full words. If you’re not sure whether your program does this, reach out to your facility’s IT department—or even to the EMR company itself. (If you use the WebPT EMR, you can learn how to use its auto text expander tool with this tutorial.) You might be surprised by how much time you can save by leveraging a few simple tricks!

Problem #2: You’re over-documenting.

You’re always behind on charting—but nobody else seems to be. Does the following scenario sound familiar?

It’s 6:15 PM. Your coworkers are texting you to see why you haven’t joined them at happy hour. (I’m pretending we’re not in a pandemic right now—indulge me.) You’re ready to pull your hair out, and you still have three more notes to write.

I’m gonna go on a limb here and guess that at some point in your career, you were admonished, “If you don’t document it, it didn’t happen!” So, you write really, really, detailed notes. In fact, you probably receive a lot of compliments on your comprehensive documentation—but it’s coming at the expense of your sanity.

The solution: Stop documenting irrelevant information.

It’s tempting to err on the side of providing way too much information, because we’re scared of the consequences if we don’t. Many of us learned to provide overly detailed documentation from overzealous clinical instructors. But, it’s typically safe to cut the irrelevant info. For example, you probably don’t need to say, “Patient was found sitting in bedside chair.” Or, “Patient requested volume on TV be increased.” That’s fascinating information, of course, but it’s really not relevant unless there was some sort of incident involving the patient, and you need to denote where you found the patient upon entering the room. Unless you think the omission of ancillary information will somehow hurt you or the patient—or cause you to become embroiled in a legal battle—it’s probably safe to skip it. 

Problem #3: You’re under-documenting.

Your patients are repeatedly denied treatments. Nothing ruins a beautiful day in the clinic like finding out that your patient can’t receive therapy, especially when you know that therapy is 100% indicated.

The solution: Justify your treatments so insurance providers know why your care is indicated.

I know, I know! You’re juggling a lot of moving parts, and documentation is one of the biggest stressors for any rehab practitioner. Before you come at me with the pitchforks, let me assure you that I’m not telling you to design your care around insurance companies’ whims! However, it’s important to realize that denials of care come when insurance reps read things in your notes like, “Patient tol treatment well.” Or, “Continue POC as tol.” That type of verbiage is likely coupled with cookie-cutter frequencies (like seeing a patient “3x/week” for months on end, with no real appreciable increase in functional status). That type of approach is going to raise some eyebrows, even if the care is fully warranted. This is why it’s crucial that you clearly note any functional gains or setbacks that help justify continued skilled care. Consider saying something like, “Patient demonstrates increased dynamic balance with ambulation, based on Berg Balance Scale results and subjective reports of more confidence walking on grass.”

Problem #4: You have a mountain of documentation to complete every night.

You pride yourself on being a hands-on, engaged therapist. You refuse to let notes get in the way of providing focused one-on-one care. But, that usually means you’re dealing with hours of documentation at the end of your long day.

The solution: Strive for point-of-service (POS) documentation whenever possible.

It’s easy to feel guilty about spending precious patient-facing time writing notes—but if you wind up burning out due to hours upon hours of unpaid documentation time each night, you’re not doing your patients any favors. Communication is key to negotiating the balance between getting your notes done without seeming disengaged from your therapy sessions. Let your patients know from the get-go that you might take some notes during their session. Explain that it’s your way of justifying treatments to their insurance company, tracking their progress, and keeping yourself focused on their treatment goals.

Problem #5: Isolation precautions keep you from taking adequate notes in a patient’s room.

You’re following strict infection-control precautions, so it can be hard to to get all the information you need to write your notes. This is super frustrating. Not only does it preclude you from leveraging the point-of-service documentation method mentioned above, but it also makes it tough to gather adequate information for completing your notes after the fact.

The solution: Use the buddy system.

Julia Kuhn, SLP, is a travel therapist and owner of The Traveling Traveler. She recommends taking a single piece of paper into the room and prompting the patient ahead of time to set a pen aside for your use. “Take all of your notes on that one piece of paper,” she recommends, “and have your ‘PPE buddy’ waiting outside for you.” When you exit the room to remove your PPE, your buddy can take a picture of your notes and send it to you. “You can immediately throw your paper away with your PPE and have your notes saved to your phone for later use,” she explains. However, she cautions against including any protected health information (PHI) on your piece of paper.

Problem #6: You haven’t customized your EMR platform to your needs.

You have to re-enter the same information over and over. Or, you constantly have to enter irrelevant information. Maybe you only work with tweens, and you’re sick of being forced to enter Medicare-required information. Or, maybe you are ready to pull your hair out because you have to click through three unnecessary screens for every patient you see. You’re not alone if you think that charting online takes way too long—but there are usually ways to make things run much more smoothly.

The solution: Tailor your setup.

Most EMR platforms let you tweak things to fit your needs—at least to some degree. (Check out this article to see some of the documentation time-savers WebPT Members love most.) The problem is that many therapy professionals don’t know how to use their system’s customization options—so, they use the “factory settings” that come with the platform by default, and thus spend way too much time on charting. Many times, such presets exist to ensure Medicare compliance; in other words, they’re meant to save your tail! But if you only see kids, you’ll likely get frustrated typing “N/A” over and over because so many of the fields don’t apply.

Some clinics fall into that dangerous trap of avoiding change because “this is how we do it here.” Don’t let that happen. If the main reason you’re contemplating leaving patient care is documentation, speak up! Get in touch with your IT department if your facility has it. Work with your supervisor to speed up your clinic’s workflow. You can sometimes even work directly with your EMR company to create customized templates for your clinic’s needs. Who knows; this experience might even provide you with some hands-on experience that could lead to a future role in clinical informatics!

I hear from many therapists who fantasize about switching to non-clinical PT jobs primarily because they feel overwhelmed by documentation. Rather than leaving a career you otherwise love, explore some ways to speed up your charting. What are some of the tips you’ve found helpful when it comes to alleviating documentation struggles? And what are some of the biggest challenges you’d like to see addressed? Let us know in the comment section below!