How to Document Effectively at Point-of-Care

By: Cheryl “Chae” Dimapasoc, PT, DPT;  OptimisPT Director of Implementation and Compliance

Documenting at point-of-care is natural for some, but has often been reported as a challenge, as something that gets in the way of focusing on the patient and as “more time consuming”, especially if you don’t have an efficient workflow established for your initial evaluation.  The most effective approach to documenting at point-of care: balance.

Your entire documentation during the initial evaluation does not need to be completed at point-of-care.  In fact, one study demonstrated that: 

• Therapists who documented 1-25% of their notes at point-of-care demonstrated patient progression that was 13.2% lower than best practices.  
• Therapists who documented 100% of their notes at point-of-care resulted in 7.5% lower patient progression than those that documented 0% at point-of-care. 
• Therapists who documented 75-99.9% of their notes at point of care yielded the best results boasting top-ranked outcomes in 6.7% fewer visits vs. therapists who waited until after the patient visit to document.

Point-of-care documentation is meant to save time.  If you have not developed a specific workflow to bring the computer around during the evaluation process, the initial evaluation is going to take considerably more time at first.  This is one reason that many therapists never make the leap past the 1-25% of their notes.  If you use an EMR that has customization and functionality that you set up ahead of time, it’s a time investment up front, but the time it takes you to set up the customization is the same amount of time it should save you on evals in the future. Not only can patient outcomes be improved with thoughtful point-of-care documentation, but you’ll go home a lot earlier versus if you save most of your documentation until after the patient leaves. 

However, even the statistics above demonstrate it’s about balance.  The key is documenting the subjective and objective information with the patient present and creating the long-term goals together.  In addition, you should go over their treatment and home exercise program, and how they relate directly back to the functional goals that were created together.  Not only does this save time, but it helps engage the patient in their treatment.

Tip:

If the patient provides subjective information that is being typed out while the patient is talking, simply letting the patient know ahead of time that you are going to take copious notes so you have a detailed record to send back to the physician and for other therapists to reference and then repeating back what the patient told you in your own words, allows the patient to see that you are hearing them.  This helps build rapport.

Tip:

Following this process can help to improve overall patient engagement, patient satisfaction and patient outcomes.  First, create the goal with the patient.  Be sure to tie the identified impairments related to the activity to the treatments that will be rendered, including the patient’s participation with their “homework”.  Then regularly assess their progress toward their goal by using objective measures.

Tip:

To get started with point-of-care documentation, consider allocating the first and last 5 minutes of the session to capture all the important data. This may feel less intrusive and more streamlined than taking notes throughout the session. When you are wrapping up, you can review your notes together with the client.

Tip:

Do not position the computer so that it is directly between you and your patient. It seems logical, but we see this happen all the time.  Doing this, may inadvertently make it appear that you are putting a barrier between yourself and the patient. 

Tip:

Show the patient the information you are entering and use it as a teaching opportunity.  This is not top secret information you are recording.  Let the patient view it so they feel more comfortable with the process.

Tip:

“Less is more”.  Quality of your documentation is important.  When you use your clinical decision making and it is evident in your documentation, you are more likely to get reimbursed for your claim.  Documenting more does not make you more compliant; it simply makes you slow and inefficient.

Good documentation is part of good treatment.  It protects you and allows the progress of the patient to be evident.  Balancing how you complete your documentation is key.   You do not want your method to take away from the quality of your care or the accuracy of your notes.   When done efficiently, documentation at point-of-care can help to make your life as a therapist easier so you can go home earlier and start fresh the next day.

For more information on best documentation practices please visit our previous blog: Best Documentation Practices for Rehab Therapists