Physical Therapy Documentation Challenges

Clinicient recently created an advisory group of senior clinical leaders that have graciously volunteered to give us feedback and advice on our product roadmap and industry trends.  I will be regularly blogging on what we are learning from the group in this space.

During a recent meeting, I asked this question: “What is the biggest challenge you face guiding your staff in creating concise, compliant, and relevant documentation?”  Here is what we learned from their responses:

  • Importance of Standardization:  Scot Campbell at PT Northwest, made the point that trying to follow another staff member’s documentation of functional and clinical progress can be a challenge without having some documentation standards.  Brad Deal from Stewart Physical Therapy agrees that fostering consistency site to site, day to day across a multiple clinic organization is a challenge.  Sean Mckeown from PRN Physical Therapy noted that clinical reports are a product of the organization and reflect the quality of care of that organization.
  • Concentrate on Function:  Paul Christensen at OPTM Physical Therapy Group has found that he needs to coach hist staff to quit concentrating on “what we are doing to the patient” and more on “what the patient needs”.  In other words, in his experience, therapists have a difficult time converting their thinking about impairments (strength, range of motion, etc) and translating that into thinking about function.  Darlene Pope of Sports, Spine and Industrial Physical Therapy and Matt Van Campen at PT Northwest both commented on the importance of supporting medical necessity by documenting functional limitations and goals.
  • Beliefs Change Behavior:  John Woolf at Proactive PT pointed out that “eduction does not change behavior, beliefs change behavior”.  Utilization of an EMR has little to do with changing behavior.  As part of his mentoring to staff, he asks very specific questions about the therapist’s beliefs about documentation.

Give us your comments below, and tell us your challenges!

In a future blog, I will share what we learned from the group when I posed this question:

“What is the single most effective thing you have done as a leader in your organization to improve clinical staff productivity?”

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