As a PT, your main priority is to take care of your patients.
You must treat your patient in the best and quickest way possible. In the process of treating and taking care of your patients, you have to do other things. One of those is writing down notes.
There is no getting around the necessity of writing down notes. Documentation in the form of writing down of notes is necessary because it proves that a treatment is necessary and that it has actually been provided. It is also needed for the therapist to be paid for the treatment.
In short, there is no getting around the need for documentation. That being said, taking down notes should not take too much of your time.
If you are noticing that writing down notes is taking too long then you have to make some changes with your practice. Documentation should be fast and easy.
The more time that you spend on documentation, the less time that you can spend on treating your patients.
Ways That You Can Make Your Documentation Faster
Part of ensuring that you can provide the best care for your patients is to ensure that you do your documentations quickly and accurately. The good news is that there are plenty of things that you can do to achieve that.
To help you out, here are the easiest tips that you can implement in your practice:
Don’t Let it Pile Up
It can be tempting to delay the writing of a note, especially after a long day. You can just say that you’ll do it later on. The problem is that if you keep on doing that, the notes that you have to write will start to pile up.
Also, the more that you delay the writing of a note, the longer it would take to do that. You’ll have to remember what actually happened during the treatment, maybe you’ll have to get some references.
Just get it done as soon as possible. It will cause you less trouble that way.
Go for Multitasking
Unfortunately, there is no magic tip that you can try which would take care of all your documentation issues. What you can try are the best practices that have been tried and tested by other practitioners. One of the best practices that you should definitely implement is to start multitasking.
While you are working with a patient, try to do a little documentation already. You can explain to your patient the importance of taking down notes. You don’t have to do the whole note while you are working with a patient, just get it started so it takes less time to complete later.
Focus on the Quality
Like other things, quality is more important to notes rather than quantity. Some therapists tend to over-document, which comes from a fear of being denied their claim because of insufficient documentation. That’s understandable. It’s better to have more notes than needed than less.
The problem is that over-documentation means that you will have less time to spend on your patients. The solution is to focus on the quality of the notes that you are making.
Make sure that you are only documenting what is necessary. Use your clinical judgement in determining what you have to write down.
Just remember, documenting more does not necessarily make you compliant. What it does is that it will slow you down.
Check Out What Others Are Doing
Each therapist would have a unique approach to documentation. It would be a good idea to reach out to the ones you know and find out if they have any good practices that they can share with you.
Find out if they are doing anything that might be particularly useful to you and which you can implement in your practice. There is nothing wrong with copying what others are doing.
Use the Right EMR
Finally, the tool that you use for documentation will determine a lot. Are you using a good EMR software? You might want to switch over to HelloNote if you’re not happy with your current software.
HelloNote will let you:
- Document the perfect note in less time
- Access the system from any location
- Set reminders for schedules & appointments
- Customize to fit the needs of your practice
- Generate bill and claim with one click
HelloNote is designed by therapists for therapists, which is why it is particularly well-suited for your practice.
These are just some of the things that you can do to speed up your documentation. There are other things that you can do to make your practice more efficient.
Check all the processes within your practice and determine which are the ones that need improvement. There are plenty of resources that you can use to streamline your operations.
Just remember that your main aim as a physical or occupational therapist is to help your clients and help them get better.