Common Problems With Current Medical Documentation Practices And How You Can Solve Them

Behind every successful physical therapy (PT) practice lies the constant toil of medical documentation.

As important as it is, current practices with documentation have led to a decrease in patient engagement and quality of care, as well as a compromise in workflow productivity.

For a PT practice to stay ahead, it must be able to resolve the common problems of medical documentation.

Here’s what you need to know:

What Does Current Medical Documentation Look Like?

A snapshot of current documentation practices looks like this:

1. PT gets into an appointment with a patient
2. PT either records the entire patient encounter or takes notes during the appointment
3. After the encounter, PT finishes taking notes and places the medical log into a secured place electronically or in paper form
4. PT allocates a portion of their time doing a quality assurance check on the record to ensure it complies with regulations and guidelines
5. PT completes the document and logs it into the electronic medical system (EMR)

Providers undergo this process repeatedly throughout the course of their careers. Unfortunately, this practice gives rise to numerous challenges that hinder productivity.

Common Issues With Medical Documentation And Their Solutions

Time-consuming process

Physicians spend approximately 35% of their work time on medical documentation, according to a 2018 study on time management with patient care and documentation. Providers constantly face the dilemma of either reducing the time spent interacting with patients or compromising the quality of their note-taking.

Solution: Streamline your current workflow to allow your providers to allocate more time to patient care. Consider allocating medical documentation to properly-trained staff or a trusted third party. Implement up-to-date documentation tools to streamline logging and access to patient records.

Maintaining accuracy and completion

According to a 2022 study on medical malpractice, 10-20% of malpractice cases were due to inaccurate or incomplete medical records. Accuracy and completeness of medical logs are vital to ensure clarity and quality of care. Otherwise, your practice may struggle with declining patient care, misunderstandings, or even legal issues.

Solution: Create comprehensive guidelines on documentation. Implement protocols to double-check records and conduct regular audits to identify and minimize errors.

Lack of standardization

While every physical therapist has their own note-taking style and methodology, standards must be in place to regulate the quality and accuracy of every medical log. Without standards in place, miscommunication and workflow bottlenecks can increase and deter your healthcare staff from performing properly.

Solution: Multiple studies have confirmed that standardized documentation can lead to an increase in medical record quality. Research and adopt industry-standard protocols to promote uniformity in note-taking practices. Hold forums among your providers to discuss potential practice-wide templates to improve communication and reduce confusion.

Privacy and security issues

According to the HIPAA Journal, every 194 of about 500 patient records have been reported to have undergone a data breach as of 2022. Without proper security protocols, relying on pen and paper-based documentation can risk violating HIPAA regulations and lead to data breaches. Electronic medical records (EMRs) that are poorly secured due to a lack of protocol or outdated equipment can also lead to privacy issues. In either case, your practice will be legally liable for negligence.

Solution: Research, evaluate, and implement robust data security measures that cover employee workflows, regular audits, and quality assurance. Train and refresh your healthcare staff regularly on HIPAA and other relevant legal regulations to actively protect patient data. Conduct risk assessments on a regular basis to identify and address potential security flaws.

Difficulty of access

Traditional paper-based documentation has become inefficient in the face of growing standards in delivering speedy care. This is especially when providers need to share medical records with other providers in a timely manner. Providers also struggle with digital platforms that are slow and have a clunky layout, resulting in bottlenecks and frustration.

Solution: Transition to an EMR system with a simple, intuitive interface and train your staff in using that system. Implement a secure cloud-based storage system for faster collaboration and sharing of information among providers while ensuring security.

Streamline Your Medical Documentation Process

As medical documentation continues to burden PTs, supporting your providers is a top priority to ensure that patient data quality and confidentiality are maintained. By recognizing the common problems of current documentation practices, you’ll be able to proactively resolve them and ensure that your practice runs smoothly.

Have you tried every solution we listed and still have room for improvement? Consider transforming your documentation process with the tools and expertise of ScribePT so that your providers can focus on doing what they do best. Try ScribePT's revolutionary features for yourself with our 30-day free trial!