Even if your practice is using the latest physical therapy software, it’s not enough that it’s automated and meets the standards. It should be flexible to what your practice needs.

Nitin Chhoda imparts the importance of software flexibility in order to maximize the use of your physical therapy EMR, and help your practice continually grow.

While it is important to stick to certain standards of physical therapy documentation, your EMR should allow flexibility.

No two practices work in exactly the same way, so high quality physical therapy software will not restrict your documentation options.

To help make the practice truly more efficient, you will need customizable forms as well as integrated systems for the different aspects of the practice.

Platform Flexibility

Making the most of physical therapy documentation software will require that your practice has all the available tools with which to track patient progress, billing, and scheduling. That means investing in technological tools.

At first, you may not want to invest in portable electronic devices, such as tablet computers. You may feel that the staff can only make a few adjustments at a time, and you may want to wait for a bit of a financial shift before investing in these technologies.

However, if you want to make the most of the physical therapy documentation software that you are investing in, eventually you should allow it to be portable, too. Whether or not you’re ready now, the EMR should include options such as iPhone and iPad apps, cell phone alerts via SMS, and an online browser-based platform.

These options will allow scheduling, billing, and patient care to proceed smoothly and in a timely manner. Time stamping can be incorporated into the daily routine, no matter where a physical therapist is caring for a patient.

Reporting Flexibility

As you can probably imagine already, without flexible and intuitive physical therapy documentation reporting options, many of the benefits of physical therapy documentation software will be lost.

There are so many benefits to having accurate reports on productivity, claims acceptance rates, and referral rates and success, but if the reports system is hard to work with or requires a lot of time, the reporting capabilities will not be used to their maximum effect.

Reporting should be integrated in a way that allows practice management to cross-reference data.

Time stamping and number of patients should be integrated so you can identify the number of patients seen per day by each physical therapist.

Scheduling should also be linked to reports, so you can determine which patients frequently cancel appointments. Physical therapy documentation and billing claims should be reported so you can identify insurance companies that reject an unusually high percentage of claims.

Patient Interaction

Another way that physical therapy documentation and time management can be improved is through patient options. If you want to integrate a patient portal so patients have the option of entering their information online even before they come to the practice.

Intake forms should be flexible and available online or on mobile devices, so that patients have a more streamlined experience when they come for their appointment.

Customizable templates or forms are one of the most important features of any EMR and physical therapy documentation solution. But the entire physical therapy documentation software should be built with flexibility in mind so that you have the option to expand and grow.

In order to avoid malpractice and negligence of your practice, make sure that your documentation and management systems meet the required standards. Nitin Chhoda elaborates on the importance of being and remaining in compliant with the laws.

Physical therapy documentation isn’t just a tool for the physical therapists who work with patients, it is also critical to the success of the entire practice.

If physical therapy documentation standards are not set and maintained, errors in coding and billing are likely to occur and the practice will waste money and time on correcting rejected or denied claims.

There are legal requirements as well as insurance and government program requirements that need to be followed to ensure your physical therapy documentation is compliant.

Medicare Compliance

With the increased attention from the federal government, physical therapy documentation practices cannot afford to be incompliant with Medicare regulations.

In an effort to reduce waste and fraud, HIPAA and the HITECH Act give more power to regulation agencies so that the money spent on physical therapy actually goes to programs that are necessary and efficient.

Medicare defines skilled care and has requirements for what is deemed “reasonable and necessary” for physical therapy treatment.

If your practice does not use waivers and modifiers correctly or doesn’t supervise assistive personnel, you may be jeopardizing your Medicare reimbursements. Review of the minimal documentation requirements from Medicare is essential for all physical therapy staff.

Legal Compliance

The legal concerns of a physical therapy practice can be mitigated if physical therapy documentation standards are kept high. The dangers of noncompliance will not be revealed until it is too late. Most legal action against physical therapy offices will be related to negligence or malpractice, and noncompliance falls under both legal categories depending on the situation.

If a physical therapist is knowingly keeping poor physical therapy documentation and that leads to incorrect treatment of a patient, the therapist is liable for malpractice. If the practice management knows about the therapist’s actions and does nothing to avoid the situation, the practice is also liable.

And if records are poorly kept and an issue arises, whether or not the practice or the physical therapist is aware of the problem, either or both can be liable for negligence.

Insurance Company Compliance

Insurance companies seem to be looking for any reason to reject or deny a claim.

In the current system, it is absolutely necessary that your practice follow the particular rules set by insurance companies, otherwise you may find that you are billing and never getting compensated.

Some companies require reevaluations on a regular basis, to determine that care is still required and that the current treatment plan is having a positive effect. Other companies may have different physical therapy documentation policies.

The only way to avoid losing money is to check the rules beforehand and be sure that each physical therapist or staff knows what those requirements are.

Staying Compliant Mean High Standards

The best way to avoid a bad situation, whether to do with legal or healthcare insurance compliance, is to keep high standards of physical therapy documentation as the norm within the practice.

There are a number of ways that staff can be encouraged to learn and improve their physical therapy documentation practices, and it is the management’s role to ensure that standards are maintained.

Nitin Chhoda explains the different stages of physical therapy documentation.  Pointing out important guidelines to follow to ensure a smooth documentation process and avoid redundancy.

The speed of physical therapy documentation with which a patient recovers with physical therapy is determined by many factors.

But one thing that physical therapists have control over is the level of care a patient gets, from one appointment to the next.

If each step isn’t documented well, the patient may end up repeating things or wasting time going over their own history with the physical therapist rather than working on getting better.

Physical therapy documentation is extremely important to the process of helping patients to recover and become stronger.

Initial Evaluations

The first stage in physical therapy documentation is the initial interview and examination of the patient. This is an incredibly important process, as it will determine the rest of the treatment plan for the patient.

Of course, the basic patient information will also be gathered and input, assuming electronic health records have not been transferred by a referring physician, as well as details about the injury or pain that the patient experienced.

Every detail is not only important, but may be vital for compliance. And the entire course of the physical therapy documentation and treatment will be determined from the current state of the patient’s health. Goals must also be established so that the progress of the patient can be measured against those goals.

SOAP and Other Details

While taking care of the patient should be the primary concern of the physical therapist, there should also be attention paid to the way the patient’s insurance company will be billed. Some insurance companies have very specific requirements for continuation of treatment and reevaluations.

Rather than risk a rejected or denied claim due to incorrect or insufficient physical therapy documentation, ensure that all physical therapists follow procedural guidelines for documenting the intake of each new patient.

SOAP, or subjective, objective, assessment, and plan, is the standard system of evaluating a new patient. This standard is important for a few reasons.

First of all, it ensures that there is a standard for all physical therapists. Second, when using SOAP, the most important parts of each initial evaluation will be included in the physical therapy documentation.

Subsequent Visits and Treatment

The actual physical therapy documentation and treatment plan should be on a realistic schedule with various stages and goals worked into the physical therapy documentation plan.

Patients are often helped greatly if they can imagine what their life will be like when they feel better. And to have some intermediary goals will keep them thinking ahead and about improvement.

And of course, each session should be well documented with details about the patient’s recovery and activities. The next session will go more smoothly if a detailed physical therapy documentation account of the current session is in the patient record.

This will help the patient to recover as quickly as possible and to make the most of their time with their physical therapist.

Conclusion of Treatment

Just because a patient is done with their treatment, doesn’t mean it’s okay to forget about physical therapy documentation protocol. The patient’s last visit does not signal the last responsibility of the physical therapist or the practice.

Discharge notes will identify what the billing staff can bill for and the information may be useful for future patients or for the management staff, so assessments can be accomplished with real data.