Physical Therapy Documentation – Turning Attention to the Patient

Perhaps the most common thread across all physical therapists (PT) regardless of practice setting and specialty is that each of us became a PT with the intention of helping others. The process of deciding to become a physical therapist may have began at a young age (such is the case with myself at the tender age of ten years old), or perhaps for some this is a second career, but each one of us set out with the intention of participating and guiding people in healing and rehabilitation. The common thread of wanting to provide the highest level of care to our patients tends to drive us to continuing education courses, to certifications, and the most optimal practice settings. This hard work and attention to detail is reflected in the improvement of our patients. More importantly, and more concretely, this attention to detail is reflected in the thorough documentation of our treatment and plan of care.

Those of us who grew up without a cellular phone, laptop computer, or Netflix may have envisioned spending the working day one on one with patients, and quickly knocking out our written evaluations and SOAP notes before leaving at a reasonable hour each day. Or perhaps my ten year old vision of my future professional life was a little too rosy for my own good. As difficult as it can be to recognize, our ability to continue to practice in the manner we see fit is dictated by our ability to receive reimbursement for our work. In order to help others, our clinic’s lease must be paid and our lights must remain on.

Herein lies the struggle to maintain a healthy business in a phase of history where insurance requirements for reimbursement and Medicare laws are changing at the speed of light. We must reconcile the fact that there is no returning to a more simple time, and that reimbursement is most likely going to continue to become more complex. Thankfully, with every problem there comes an opportunity for growth.


Click the image to enlarge it and see the new bestPT Physical Therapy Documentation System.


A screenshot depicting the ease of Physical Therapy documentation by clicking through pre-programmed evaluation templates made unique for each Physical Therapy clinic. bestPT programmers are able to create unique specialty templates as well for various clinical specialties.

Several months ago our clinic underwent a significant change in how we document. Prior to this change we wrote daily SOAP notes in paper charts, and wrote initial evaluations and progress reports in PDF templates. We saw patients one on one for forty five minutes, and utilized an additional thirty minutes built into our clinical day for documentation. These initial evaluations and progress reports were typed into the PDF form and then printed by the therapist during designated charting times outside of patient treatment hours. Once printed these documents were manually faxed to the referring physician by front office staff. Prudent therapists know that medicare documentation as well as other third party payers mandate that documentation be completed within twenty four hours of patient contact. This expiration date made for a very long evening if a therapist experienced day with several evaluations and progress reports on the same day.

Once all staff members were trained in the use of bestPT electronic health record system, laptops were implemented by physical therapists to utilize for documenting during treatments. Returning to the initial rosy vision of altruistic patient care wherein we provide best services possible, there was initial worry by the staff that documenting into a computer in front of the patient would detract from building patient rapport. Some therapists worried that the time they spent documenting during treatment times would detract from actual treatment times. In reality once the system was put to the test, staff found that the easy clicking capabilities offered in the system expedited documentation time. Faster than manually writing in tests and measures, the electronic record allowed for concise documentation of all components of care from subjective report to plan of care.

Perhaps the most interesting finding throughout this transition has been patient response: there really wasn’t one. Patients were generally unphased by this transition because every other healthcare provider under the sun is already using electronic medical records. I asked a 65-year old Vietnam War veteran to Please pardon the computer as reviewed his prior medical history and he replied Oh honey you all do what you gotta do with those things, it don’t bother me none. A sweet gentleman to be sure, but truly we did not receive a single complaint during the initiation of the system.


Click the image to enlarge it and see the new bestPT Physical Therapy Documentation System.

Recording prior medical information is easy with the template. It is easy to return to this screen from others in the electronic medical record, and leads to easier continuation of care from one therapist to another as it offers a thorough and easy to read format.

Therapists now are able to complete an entire document as they treat for each and every patient. Upon completion of an initial evaluation the report is quickly sent to the physician for approval, eliminating several steps in our prior system. This has eliminated the need for additional paperwork time and actually freed up all of our schedules and allowed us each to see one additional patient per day with some remodeling of our scheduling template.

From a business perspective this has resulted of course in increased revenue. We are able to offer our services to more patients, and the turn around time on reimbursement is significantly decreased. We can all rest assured that we complete our paperwork on time, and indeed get home at a reasonable hour. This is how we have managed a win-win scenario in our clinic. We are able to provide the high quality services, still one on one, that we envisioned when we commenced physical therapy school, bright eyed and ready to heal the world. We are also able to maintain a healthy business without compromising or cutting corners. I believe that my ten year old self would be impressed.

-Amanda Olson, DPT