Healthcare providers are one of the most susceptible to experiencing burnout. This is due to the endless clinical tasks in addition to providing patient care. Providers are not only responsible for providing their patients with the best possible care but also need to document their appointments, submit claims, and handle tons of paperwork. Endless documentation is a crucial aspect of every practice. But more importantly than documentation is being accurate. Accurate documentation ensures clean claim submission, improved patient care, and data-driven decision-making. This increases the revenue of the practice.
Thus, documentation is part of a therapist’s routine. It is an avenue through which therapists show their clinical reasoning, interventions, and progress assessments. This is why it is crucial to keep accurate documentation. In this article, you will learn how therapists can improve their clinical documentation to improve the overall functionality of their practice.
Strategies to Improve Therapy Documentation
Therapy documentation involves keeping a record of all services provided to a patient. This includes the current diagnosis, treatment progress, and other pertinent information. Accurate physical therapy documentation helps provide high-quality care. Precise documentation helps track treatment outcomes throughout the treatment process. Physical therapy documentation aids in proper reimbursement and faster claim processing. According to state and federal regulations, services not properly documented are not only not paid for but may also result in legal repercussions. Thus, it is important to ensure your documentation is complete and fast. The following strategies can help improve clinical documentation:
Customized Templates
Therapists spend a significant amount of time on documentation. In therapy practices, the workflows all follow the same pattern. Thus, using customizable templates helps save a lot of time. Some EHRs can precisely customize your templates according to your workflows, so you do not have to do repetitive clinical documentation.
Complete Documentation As Soon As Possible
This may sound like a no-brainer, but some providers often leave documentation for later and provide incomplete documentation. Therapists should complete clinical documentation as soon as the visit ends. This helps reduce errors as providers forget critical details as time passes. This also ensures that patient records are complete and up-to-date. Completing documentation not only improves practice finances but also improves patient outcomes.
Clear and Concise Information
Proper and complete documentation is not the only goal in improving clinical workflows. Therapists also need to ensure the information in the documentation is clear and concise. Specific details of the encounter help improve data-driven decision-making when making patient treatment plans. Keep your notes organized and ensure relevancy to avoid any misunderstandings. Make sure to use terms that are easy to understand so that other providers and specialists do not find it difficult to refer to your notes. Proper documentation is also useful in ensuring regulatory compliance. Clear and complete documentation helps accelerate claim processing.
Ensure Compliance
Medical billing is not without its challenges. With a long list of regulations to comply with, keeping documentation that follows all regulations can be quite challenging. Therapists must stay on top of all regulatory changes to have the correct documentation that helps them get reimbursed faster. Outsourcing medical billing to skilled and trained professionals relieves you of the worry of catching up on the newest changes and reduces the chances of error.
Determine Keywords
One of the best things you can do to ease your documentation process is to determine the keywords used in your documentation. Writing the same phrases repeatedly contributes to a lot of wasted time. A quick hack is to make a database of all the commonly used keywords specific to your therapy workflow. Next time you document patient encounters, you can refer to your keywords to speed up your documentation process.
TalkEHR for Therapy also provides the feature of customizing your forms so that you can spend less time writing your documentation and refer to a blueprint to save time.
Leverage Technology
Technological advancements have completely revolutionized the healthcare industry. The newest telehealth solutions, like EHRs, telemedicine, and more, are improving provider workflows and patient outcomes. Our therapy EHR is specifically customized to therapists’ workflows and include features specific to therapy practice. They can customize documentation, including templates, common keywords, and treatment protocols that help therapists save on documentation.
Conclusion
Documentation is not just a formality. It serves as a foundation for future decision-making and determines the reimbursements provided to the practice. Thus, keeping complete and proper documentation in your therapy practice is crucial.
With the right software, you can elevate your documentation game. ICD-10 enabled and MU3 certified, talkEHR for Therapy helps you manage patient records, improve clinical documentation, and make referrals on a single platform, improving your practice’s workflow. Create patient cases and plan of care and share it with providers, all through an intuitive dashboard.
