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

ICD-10 | 100 times more complicated – Free Webinar

Is your Physical Therapy Practice Ready for ICD-10?  Prepare your practice for the impending ICD-10 coding changes. 14,000 CPT and diagnosis codes will now become more than 65,000 codes. Learn what you will need to do in order to avoid a drop in your practice’s billing performance.

Growth | Tackling Task Management

Working It Out

Can Shannon get worked up enough about inefficient task management to make a change?

“One, two, three.” Shannon huffed and puffed her way through 20 repetitions on the bicep machine. “Ugh, I just don’t feel motivated today.”

“What’s the matter, Shannon?” asked Ariana, Shannon’s friend. “The machines seem to be winning against you today. What’s going on?”

The two went to an unoccupied corner of the gym. It was a quiet day,  they wouldn’t be bothering anyone over there.

“Everything seems to be going haywire at my practice,” said Shannon. “We’re all getting in each other’s way these days. The busier we’ve gotten, the more disorganized it feels.”

Ariana looked at her friend in surprise. She had always thought Shannon was unflappable, and she knew her practice had enjoyed steady growth. “What do you mean?”

“Well, I know Teresa is in charge of office orders but lately it seems like Tana and I are holding Teresa up by misplacing or checking over the list at the exact moment when she needs to be placing the order,” Shannon said. “Last week I needed a contact list so that I could make follow-up calls with patients but Teresa had it. She knew I was busy and made the calls for me, which was great, but I wasted 20 minutes looking for that list.”

“This sounds pretty familiar, I think any medical practitioner goes through the same annoyances,” said Ariana. “Typical growing pains. Except if you don’t get your processes under control, it makes growing your practice difficult to do.”

“That’s what I’m worried abou, what if we never get off this hamster wheel?” asked Shannon. “We’re wasting so much time getting in each other’s way that Teresa isn’t able to manage the office as efficiently and I’m not able to spend as much quality time with my patients.”

The two glanced toward the doorway as a mutual friend entered the gym, stopping to smile and wave.

“You know, Shannon, there are solutions out there,” said Ariana. “We are working with a company that is helping us through a program called a “ticket workbench.” It’s amazing: just by glancing at our screens, we can tell what tasks need to be done, what the deadlines are, and it enables us to prioritize. We can even tell who’s behind on their assignments so that another staff member can pitch in and help them get caught up.”

Shannon looked at her friend in amazement. “But how difficult is it to learn and implement?” she asked. “We’re already so overwhelmed, I’m nervous about causing additional stress to my team.

“Of course, there’s a small learning curve but most of us were up to speed by the end of our first day,” said Ariana. “I think the question you should be asking is this: what are you risking by not getting your practice under control? Without efficient task management, are you confident your files are compliant? Can you handle taking on any new patients? Will you be able to grow your practice, ever?”

Shannon looked thoughtful. “You’ve made some great points, Ariana, I think I need to do something about this situation soon,” she said. “But for now, I need to do something about my abs. Let’s get back to our workout!”

Now that Shannon understands that there’s a better way, can she find the will to tackle task management in her practice?

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.

Physical Therapy Documentation

Physical Therapists need good documentation. It needs to be complete and accurate. In a busy office, it can be difficult to document visits well, without spending your office hours, evenings and weekends with your notes, instead of spending more time with patients or doing something else. The correct documentation system can make all the difference here.

When designing the bestPT xDocs Evaluation for Vericle, experts on physical therapy, medical billing, user interfaces, and optimizing web performance got together to develop the premier solution for documentation accuracy, ease and speed.

The layout and design of bestPT’s Documentation has been designed to be understood by any user who is familiar with regular computer, phone, and tablet applications. The menus are laid out in traditional positions along the side and top. Hovering over non-obvious information yields information to help the user decide if that’s where they need to click.

It’s so fast though, if you do click something you did not mean to click, don’t worry because the loading is instantaneous. You won’t have to wait to see what your click requested or jump to something else.

Once inside a section of the documentation suite, options are easy to find and select with color coding and large touch friendly buttons. This means the user won’t have to click around multiple times if they are in a rush.

Our billing and physical therapy experts were able to balance including all of the important information, while cutting the unnecessary information. Your documentation serves to record information about the visit and explain medical necessity. Everything else is extra information that can be found in the patient file or is unnecessary.

Often times, this information can actually lead to claims being lost due to superfluous distractions or contradictory boiler plate language. Fast loading, intuitive layout, and easy controls means you can focus on entering or selecting the correct information and better ensure proper payouts by the payers.

Documentation | All Facets of Patient Care


Right at Your Fingertips

Will Shannon be thrilled with the bestPT Travel Card ¦ or overwhelmed?

“So did you finally get to see your friend, Ariana?” asked Teresa on Thursday morning.

“Yes, I did, we’ve both been so busy for the last few months and it was great to have a chance to catch up,” said Shannon. “In fact, she told me about the new software they’re using at her practice. It’s helping them with their patient notes in particular, the entry is fast and accurate, and the system lets them know if there are any problems or areas of concern with the patient’s record.”

Teresa regarded Shannon hopefully. “So I expect you’ll be making a phone call to our good friend Tom today?” she asked. Tom was their bestPT coach.

“You bet I will be,” said Shannon. “Right after I get my coffee!”

A few minutes later, Shannon called Tom and, after some small talk, they settled down to business. Tom directed Shannon to the test system, and after giving her screen a quick glance, Shannon was ready to learn more.

“So my friend Ariana was raving about how her office has managed to cut down on their time entering patient notes all while increasing their accuracy,” Shannon said. “I’d like to see how this might work for us.”

“Of course, Shannon, I’ll be happy to take you through it,” Tom said. “To begin, I’d like to emphasize that our system takes all the facets of patient care and enables you to see it just as you would look at your patients. Just as you wouldn’t just only one symptom of a complex medical condition, we wouldn’t want your practice to see just one part of your patient’s record at a time. You can treat a patient most successfully if you can see his or her care plan, visit notes, appointments made and/or missed, where in the insurance cycle the patient is “¦ with bestPT, you can really have every detail at your fingertips.”

“That certainly sounds good, can you show me around a bit?”

“Of course, let’s have a look around the Travel Card!” Tom said. “First, you can see a column of patient visits down the left side. You know what’s really cool? Missed appointments are marked in red and that’s extremely valuable information to have at a glance.”

“Have you ever had a patient who completely flummoxed you? Perhaps they’re not getting better, or maybe they’re getting worse, and you’re starting to think that maybe it’s your fault?” continued Tom. “Well, if you were using bestPT, you’d see easily that, perhaps, this patient was missing one or two appointments each week. Maybe you don’t realize it because you’ve got a lot of patients and because memory management doesn’t always kick in until there’s an issue.”

“Sure, with our patient load I don’t always know how often a patient is supposed to be coming to see me,” admitted Shannon. “If I don’t have an easy way to see if they’re showing up or not, I won’t know if they’re getting the care I think they need.”

“Right! Now look at the bottom left-hand side of the screen. There’s a button you click when you need to add a picture or file,” Tom said. “Now look at the top for the billable codes: ICDs on the left, we recommend that method if you use XMR notes to enter a diagnosis using the assessment tab, and CPTs on the right.”

“Well that seems pretty straightforward,” said Shannon.

“It sure is! If you’re not going to use XMR notes, you just have to go to the diagnosis tab, select the area on the left and then choose the diagnosis code you need. Same for procedures, select the area or type on the left, and the procedure code from the right.”

“Mmm hmm,” Shannon said. She was surprised how easy this was to follow. She had expected to be more intimidated.

“Now when you bill, if there are any issues, you’ll get a message in red and a pop-up alerting you to possible problem, maybe with validation, or perhaps the service date is out of the care plan date range,” Tom said. “We even color code the billing section so that you’ll know if you’re in the insurance phase, cash phase or if the visit is free.”

“But is there a place where I can enter notes that are for my own purposes?” asked Shannon. “What if I have a conversation with my patient that I don’t need to document for insurance purposes, I just want to make sure I have important information readily available?”

“If you look to the right of the screen, you’ll see rectangular boxes, we call them “˜sticky notes,” said Tom. “They’re like Post-It Notes where you can document reminders for yourself, personal information the patient shared with you or perhaps even some thoughts for the next phase of the patient’s care.”

“This is incredible,” said Shannon. “By having all of this information right at my fingertips I feel like I could really maximize my time with my patients and much less time in the system.”

“That’s the whole point,” said Tom. “By connecting all facets of a patient’s care, scheduling, billing, personal notations, history, all of that is critical to ensuring that patient gets the best care possible.”

“Well let’s not waste any more time,” said Shannon. “We’re ready to put your system to work for us!”

Shannon is ready to launch her next bestPT adventure!

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.


Compliance | Investing in Documentation Software


The Java Blues

Will a glowing review of bestPT amount to a hill of beans with Shannon?

Shannon parked in the only available space in the bustling parking lot, grabbed her purse, got out of the car and practically ran to the front door of the coffee shop. With things so busy in her practice and at home, she felt like she was perpetually running behind. She hoped her friend Ariana hadn’t been waiting long.

“Hey Shannon!” she heard from across the room. Shannon broke into a smile and walked toward Ariana’s table. The two had so much in common” she was looking forward to catching up with her friend.

“How have you been, Ariana?” Shannon asked. “I know it’s been a few months but things have been so busy. Sorry for losing touch!”

“No worries, Shannon,” Ariana said, giving her friend a hug. “I’ve been busy too but things have never been better!”

“Tell me all about it,” Shannon encouraged. “I could use some happy news.”

“We made some big changes in the office” we had been going around and around about whether or not to invest in that software that helps us to manage the practice but we finally dove in,” Ariana said. “It was intimidating at first but it has made a huge difference in our operations.”

Shannon sat back and stared at Ariana with renewed respect. She and her friend had talked many times about bestPT, but she never thought Ariana would be the first to go all in. “Tell me all about it,” Shannon said.

“You and I have always complained about how documentation is so tedious and takes away time from patient interactions,” said Ariana. “Plus data entry mistakes can be so costly” whether they hold up insurance reimbursements or take away from patient care because we don’t follow up on missed appointments. What put us over the edge was our poor performance on our recent audit.”

Shannon nodded, knowing what was coming, since she and Teresa had been talking about this just last week.

“We made it through our audit relatively unscathed but one area the auditors pointed out needed drastic improvement was our patient notes,” Shannon admitted. “We’d all rather just scribble notes and stuff them into files so that we can maximize our time with our patients, but that never works out well. I’m pretty good at documenting patient visits and conversations but I haven’t always documented in ways that are compliant with state, federal and insurance rules. We got ticked pretty good on that. I made a vow that we’d change things for the better and gave our bestPT coach a call the next day, after the audit was over.”

“So how are things working out with your new system?” asked Shannon.

“I couldn’t be happier” in fact, everyone seems to be enjoying things more,” Ariana said. “We have become more efficient and accurate in documenting patient notes. Not just the SOAP notes but also getting in the related images, forms, test results and verification of benefits that are required to give the proper overview of care. All of us from reception to treatment room are now able to spend more time with our patients and ensure a great experience.”

“Best of all,” Ariana continued, “I know our patients are happier too. This month we saw a 10 percent increase in referrals. Our investment in the bestPT software is going to pay off in no time.”

“That does it, you’ve talked me into it,” said Shannon. “Tomorrow I will call Tom, our bestPT coach. Today, the coffees are on me!”

Shannon is finally ready to take the plunge and start using bestPT to help with documentation. So what is the next step?

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.


Yup, it’s definitely a case of frozen shoulder


Have a laugh with “It’s a Stretch,” our weekly physical therapy cartoon. And be sure to let us know what you think in the Comments section. Share it with friends, colleagues and co-workers.

Let me guess, right foot red.

Our Physical Therapy cartoon is becoming very popular.

Have you ever needed Physical Therapy after playing the floor game called Twister?

physical therapy cartoon is popular.

Have a laugh with “It’s a Stretch,” our weekly physical therapy cartoon. And be sure to let us know what you think in the Comments section. Share it with friends, colleagues and co-workers.

Wrenched m’elbow again

Here’s another Physical Therapy cartoon for your amusement!


physical therapy cartoon

Have a laugh with “It’s a Stretch,” our weekly physical therapy cartoon. And be sure to let us know what you think in the Comments section. Share it with friends, colleagues and co-workers.


Physical Therapy Documentation Shortcuts

Our most popular xDocs templates:

  • Insurance Verification: Have relevant insurance information right there on the page with our v.2014.
  • Check lists: Create a custom checklist to review treatments with your patients, plan future treatments, or provide your patients with what they need to complete.
  • Grids: Keep a top-down view of all the details you need but don’t necessarily need for reporting.
  • Daily Notes: Some providers like a simple template with basic info. Others prefer a little more detail. Either way, xDocs can provide a fast solution.

Our documentation platform is maturing into an essential part of Physical Therapy practice management. Providers are loving our improvements and new template designs for editing and printing. In the last 12 months, the number of patient visits documented on xDocs has tripled.


Physical therapists are beginning to realize the power of having fast, simple documentation in the travel card and on patient files. It’s easy to create, edit, review and sign documents in xDocs. Here are some trends we’ve noticed from our practices with the highest visit rates and the lowest A/R over 120 days:

  • Less is more. Extra information makes it harder for you to find relevant information later. Place only the most relevant details in addition to the compliance requirements. Payers make it hard enough on you already; there’s no need to complicate it further.
  • More than just a paper substitute. If you find yourself writing the same things again and again, you can request that the xDoc have those phrases built in as defaults, or as an option to click and fill out the form automatically. Clicking or tapping a field is much quicker than writing it out.
  • Not all in one form. The providers who use xDocs the most get paid the most — and they’re not paying for bulkier, slower systems. xDocs is organized to be quickly accessed and reviewed; providers have much better results when they keep the documents organized for their purpose. While we have and are improving the comprehensive evaluations, the providers who treat more patients and get their payments, split the reporting documents from the recording documents. The insurance companies and Medicare don’t need to see many of the visit’s details; you’re just giving them more ammo to come up with reasons to delay or withhold the payments for your work. Our combined experience is used to help ensure you document everything that you need for your payors and nothing that you don’t need.

If you do not currently use xDocs, ask your Coach about getting started.
Your Coach can review your existing documents to help you get the best results.