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7 Clinical Documentation Mistakes and How to Solve Them

Sarah Lara

Jan 21, 2025
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Any physical therapist knows that clinical documentation is an essential step in treating patients. After all, with proper documentation, the patient’s treatment record is in order and the next steps to the patient’s care can be followed to the letter. This would allow them to recover faster and with no issues. Unfortunately, clinical documentation mistakes still occur and this can negatively impact a patient’s recovery.

In an article by the National Library of Medicine, clinical documentation errors are the reason for around 10-20% of medical malpractice lawsuits. These lawsuits can have severe consequences for a clinical practitioner, such as paying hefty fines or losing their license entirely. As such, common documentation errors must be avoided. But what exactly are the documentation mistakes that plague clinical practitioners?

Here are the seven common clinical documentation pitfalls that physical therapists (PTs) must look out for and how they can be resolved.

1. Inconsistent Documentation

Sometimes, a single patient's treatment course will be handled by different PTs. This could be either because the original PT was out sick or had a personal emergency to handle. Regardless of the reason, each session will require patient documentation. In doing so, the patient’s medical records are up to date. 

However, different therapists sometimes result in different documentation styles, causing inconsistencies in the documentation. Because of these inconsistencies, the patient could experience billing issues or incorrect diagnoses and treatments. As such, they should be avoided at all costs. 

Solution: One solution to inconsistent documentation is for clinics to provide continuous training and education to their staff on the SOAP (Subjective, Objective, Assessment, Plan) note template. Through this, consistency in documentation style is maintained even if a change in therapists is required. Additionally, constant monitoring of documentation practices can also uncover gaps in documentation. In doing so, improving clinical documentation could be achieved for the clinic.

2. Failure to Document Changes

Another common mistake that clinicians experience in their documentation duties is the failure to document changes as they happen. Changes in the patient’s health must always be recorded so their treatments are updated as well. However, some PTs fail to accomplish this, either because they forget or they’re catering to too many patients simultaneously.

Whenever changes in the patient’s status aren’t documented, it can cause a significant miscommunication within the clinical staff. In fact, according to a 2018 study by The Joint Commission, 80% of adverse events in the industry are the result of miscommunication caused by documentation mistakes. With that in mind, it’s essential that the attending clinician promptly performs this duty.

Solution: To ensure that your staff immediately adds any changes to a patient documentation, consider implementing clear policies that remind them to do so. Alternatively, clinics can also invest in AI scribe technologies that automatically add new information to the patient’s medical history for the PT instead. That way, the document remains up to date even without the attending physician’s interference.

3. Illegible Handwriting

Nowadays, many clinics prefer to document patient sessions using laptops or phones. However, some clinical practitioners still prefer to do their documentation by hand. Unfortunately, if the attending therapist is in a rush or doesn’t have decent handwriting to begin with, their handwriting could be illegible. This could lead to miscommunication and mistakes in the patient’s diagnosis and treatment plan, slowing their recovery as a result.

Solution: Similar to the failure to document patient status changes, the best way to solve this mistake is to implement AI scribe tools in your clinic and provide adequate training to your staff on their use. That way, clinicians can avoid handwriting any documentation for physical therapy as much as possible and any updates can be added automatically via recordings.

4. Missing Signatures

When documenting a patient session, the attending clinician must always affix their signature to the paperwork they created. By doing so, it’s proven that the information on the document is accurate. Despite the necessity of this step, however, some physical therapists sometimes forget to include their signatures in the documentation.

Without the PT’s signature, the validity of the PT documentation is brought into question. Additionally, should a physical therapist face a malpractice case, their position could be weakened further by the missing signature in the documentation they created. 

Solution: To solve this issue, PTs should always remember that they need to include their signature in every documentation they create for their patient sessions.

5. Incomplete Documentation

Administrative duties such as clinical documentation is a time-consuming task. In fact, a 2014 study revealed that administrative tasks consume 16% of a physician’s working hours. Some even take their documentation tasks home so that they can complete them within the day. Not only does this often lead to stress and burnout but it can also result in incomplete documentation for their patient sessions.

Because of the lack of time that physical therapists face in documentation duties, they sometimes commit one of the more common clinical documentation mistakes: failure to document all the necessary information they gathered in the patient session. This could lead to errors in treatment and diagnosis, resulting in decreased patient safety.

Solution: One of the methods that can help you avoid this mistake is implementing clear guidelines on how to document PT sessions. Apart from that, investing in AI scribe tools can also help PTs avoid this mistake as they can automatically add new information to patient records.

6. Lack of Patient Consent

Consent is something that every physical therapist must always obtain first prior to commencing the patient’s treatment course. This is because lack of patient consent can have legal repercussions for the PT should they suddenly decide not to undergo a particular treatment or medication.

Solution: PTs should always ask patients to sign a consent form and include it in their records before commencing the recommended treatments. The form should always include the date of consent, types of treatment, medications discussed, and the patient’s signature.

7. Using Vague Terms or Language

As much as possible, documentation for physical therapy should be clear, concise, and detailed. However, physical therapists can sometimes use vague terms or shortcuts because of the lack of time to handle their documentation duties. This could make the documentation challenging to interpret, leading to inaccurate treatments or diagnoses.

Solution: To avoid this common mistake, clinics can continuously train PTs in the guidelines and procedures for documenting patient sessions. Additionally, implementing AI scribe tools can also assist clinicians in quickly creating accurate documentation without sacrificing quality.

Physical therapy documentation can consume a lot of your time to get right. Fortunately, this can easily be remedied by turning to ScribePT, the leading AI scribe tool for rehab therapists. Try ScribePT for free for 30 days and see for yourself how it allows you to focus more on your patients and reduce documentation time by up to 95%

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