Everything You Need to Know About Clinical Documentation

Sarah Lara

Jun 21, 2024

When treating patients, healthcare providers must follow various steps to ensure that the patient is properly cared for. Physical therapists are no exception to this rule; like any healthcare professional, they must adhere to proper procedures. Otherwise, they might miss pertinent information or make a mistake in the patient’s treatment course, preventing them from recovering on time. One procedure that all providers have to follow when treating patients is writing proper clinical documentation for every session.

“What is clinical documentation?” is a question that sometimes crosses patients' minds when they hear it. In a nutshell, clinical documentation is a document where important information regarding the patient’s case, such as symptoms, diagnosis, medication, and even treatment courses, is recorded. As it’s such an important document, it must be as accurate as possible. That way, any mistakes in the patient’s treatment can be avoided.

Clinical documentation is a process that may sound easy to grasp. However, there are also other factors that should be considered when recording patient sessions. Read on to gain some valuable insights regarding documentation for physical therapy.

I. Importance of Proper Patient Documentation

Proper Patient Documentation Ensures Quality Patient Care

Like any other field in the healthcare industry, a practitioner PT must ensure that their patient gets the best quality of care possible. With proper patient documentation, they can ensure that patients get the level of care that they need. But how exactly does proper documentation help?

Documenting patient sessions can help a physical therapy team keep track of the treatment provided to the patient. While the ideal outcome of each treatment is for the patient to recover on time as planned, this isn’t always the result. Because of this, the physical therapist will have to look into other available treatment alternatives to help the patient recuperate.

This is where proper patient documentation can help. By accurately recording each session, the clinical team will know each treatment the patient has already undergone. This will allow them to pinpoint what course of action they should follow next to help the patient recover.

As the patient’s health is at stake, it’s vital that documentation errors be minimized as much as possible. As such, it’s highly recommended that physical therapy clinics begin using electronic documentation tools to reduce mistakes in recording patient sessions.

Correct Clinical Documentation Improves Collaboration Between PTs

Proper clinical documentation can also improve collaboration and communication among physical therapists. Accurate documentation assures that every clinical team member is updated on the patient’s status. This can be especially useful if their usual therapist is unavailable for the day and someone else will have to facilitate the session instead.

In addition to improving communication within the team, accurately documenting the patient session can also improve collaboration between physical therapy clinics. In some instances, a patient must switch healthcare facilities because of certain circumstances. When this happens, the new clinical team will need as much information as they can to provide the patient with continuous care.

With proper documentation, the PTs in the new clinic can pick up where the previous providers left off and dispense adequate treatments. This is because, with the previous documentation, they’ll be able to see what treatments the patient already received as well as the recommended medications or next steps. As a result, the new team will be updated on the current plan, preventing redundant treatments.

Proper Documentation Ensures Billing Remains Accurate

Another reason proper PT documentation is important is because it helps ensure accurate billing for the patient. With accurate documentation, the clinic’s accounting department can keep track of whatever treatment or medication was provided. It can even keep track of which equipment was used to aid the patient’s recovery.

Thanks to accurate documentation, the patient will be billed properly with no issues. This is a great advantage for them, especially if they rely on insurance to pay their bills. Furthermore, precise documentation of patient sessions also helps the clinic retain revenue, as the patient will be able to pay the correct amount.

Correct Patient Documentation Prevents Malpractice Lawsuits

Finally, proper clinical documentation is important because it can help prevent medical malpractice lawsuits. Malpractice lawsuits are an issue that clinics will want to avoid as they can hurt the facility’s reputation. Even physical therapists aren’t immune to legal trouble.

As per a 2022 article by the National Library of Medicine, 10-20% of malpractice cases result from inaccurate documentation. This makes accurately recording patient sessions even more important than ever. With the correct and accurate documents, the PT can build a defense in case of a malpractice lawsuit, which can help them have the case forestalled or even dismissed entirely.

II. Best Clinical Documentation Practices to Follow

Invest in Your Team

Physical therapists can follow various best practices to ensure physical therapy documentation remains error-free. One such practice is investing in your team by further educating them about the process.

Documentation is vital to providing healthcare services. As such, your clinical team must be on the same page about it. By giving a regular refresher course on proper documentation, you can ensure that everyone becomes more efficient when recording patient sessions. As a result, they can take notes faster, preventing them from spending too much time on the task.

Apart from helping the team remain efficient, investing in educating your team on recording patient encounters can help them minimize errors. 

Take Complete Notes

Another practice that physical therapists should follow when recording patient sessions is to ensure that their notes are complete to the greatest degree. To accomplish this, PTs should take great care to ensure that any and all communication with the patient is recorded. This includes communications done via email or even phone calls. Additionally, plans for the patient’s treatment should also be noted in the clinical documentation. 

Including your plans in the note will be helpful not only for you in the long run but also for the entire clinical team and even other healthcare facilities as well. By ensuring the clinical note is complete, the patient’s current and future PTs can be more efficient in documenting future sessions while ensuring that the treatment course provided is consistent. As a result, the documentation will not only be accurate but also allow the patient to recover faster.

Always Reduce Shorthand and Review Prior Notes

When recording patient sessions, another practice to consider is reducing the use of shorthand. Not everyone can understand the shorthand writing style. Similarly, not everyone performs shorthand writing in the same way. This can prevent other PTs from understanding the documentation. Therefore, it is beneficial for the team if notes are written in normal handwriting instead of shorthand.

In addition to reducing the use of shorthand, reviewing prior clinical notes is another practice that PTs should implement. By reviewing the patient documentation from the previous session, the PT will be refreshed on the situation. This, in turn, prevents mistakes in the treatment and redundancies in the following documentation.

Additionally, should the upcoming treatment session require the attention of a different physical therapist, reviewing prior notes can keep them updated regarding the patient’s current situation.

Take Advantage of Clinical Documentation Tools

Finally, physical therapists should also use electronic documentation tools in their daily operations. According to a 2019 study by the Advisory Board, healthcare providers spend only 27% of their office day actually interacting with patients, while 49.2% is spent on tedious tasks such as documentation. This results in reduced patient engagement, which can lead to patient dissatisfaction and physical therapist burnout.

With AI scribe tools, documenting each session can be streamlined and accomplished much faster. Additionally, increased accuracy in recording patient sessions can also be achieved. Thanks to these advanced tools, physical therapists will no longer have to spend too much time documenting the current session or fixing mistakes in previous documentation. As a result, they can be more efficient in recording patient encounters.

III. Common Problems of Clinical Documentation

Clinical Documentation Can Be Time-Consuming

Recording patient sessions is an important part of the healthcare process. However, it does come with its own set of problems and challenges. One of the common issues of the documentation process is that it consumes a significant amount of time.

In a 2018 National Library of Medicine study, physicians spend 35% of their time taking down patient data. As such, healthcare providers are often faced with the choice of reducing time spent with patients to focus more on documentation or reducing time on clinical documentation at the cost of note quality.

Thankfully, there is a solution to this particular problem. Physical therapists can easily save time on documentation by training their staff to become more efficient in the task. Using tools that leverage artificial intelligence can also help streamline the documentation process.

Patient Documentation Lacks Standardization

Another problem often associated with documentation is that some clinics lack standardization. While there’s nothing wrong with each physical therapist having their own method of recording patient sessions, the lack of standardization can often result in communication gaps, documentation errors, and even bottlenecks in the PT team’s workflow.

To solve this problem, it’s highly recommended that PT teams adopt a standardized documentation process. That way, the physical therapy documentation process can be consistent and uniform. By doing so, the patient note can remain as accurate as possible, minimizing confusion and improving communication between physical therapists.

Documentation Raises Privacy and Security Concerns

It may sound hard to believe but privacy and security concerns among the most common problems in documentation. The reason for this is because without the proper security measures, patient records are vulnerable to HIPAA violations and security breaches. This is especially true if the clinic still uses pen and paper to record patient sessions.

HIPAA violations and data breaches are issues that physical therapy clinics will want to avoid as much as possible. Otherwise, the clinic can be held legally liable for negligence, which can damage the practice’s reputation and even cause it to lose revenue. 

To prevent such privacy and security concerns, consider giving your staff regular refresher training on HIPAA and other methods that can help them protect patient data. That way, the risks of accidental data leaks or breaches from your staff can be reduced. Apart from that, you can also research and implement the most robust data security measures to address any potential security flaws in your clinic’s EHR.

Clinical Documentation Can Be Difficult to Keep Accurate

Maintaining accuracy is a must in patient documentation. With accurate patient records, clinics can ensure that the patient is receiving the quality of care that they need to recover properly and on time. If a clinical note is inaccurate, on the other hand, it could lead to various problems. These include miscommunication among the team and mistakes in the treatment, which could result in a malpractice lawsuit.

Unfortunately, difficulty maintaining accuracy is a problem that’s too common when recording patient sessions. To ensure that your physical therapy team remains as accurate as possible while taking down clinical notes, consider creating a comprehensive guideline that can assist them in documentation. It’s also recommended that AI tools be implemented into the clinic’s workflow to minimize errors and ensure a high degree of accuracy when recording patient sessions.

Patient Documentation Can Be Difficult to Access

The final problem often faced in documentation for physical therapy is the difficulty in accessing the clinical notes. While this is especially true for clinics that still use pen-and-paper documentation, clinics with outdated EMRs or EHRs can still face this problem. This can be a problem in a field where speed is often the key to ensuring patients the treatment they need to recover properly.

The best way to get around this problem is to implement an EHR/EMR system that’s simple and easy to use and understand. That way, the physical therapy staff can use it seamlessly even with minimal training. With an easy-to-use EHR/EMR, the patient's medical records can be stored securely and easily accessed should the need arise.

IV. Improper Patient Documentation: The Common Causes

Poor Documentation is Caused by Time Constraints

Time constraints are one of the common causes of poor PT documentation. Every day, physical therapy clinics have to cater to a significant amount of patients. These numbers can even double on certain days, such as the weekends when people have more free time. Because of this influx of patients, they’ll have to spend more time on administrative tasks like documentation. In fact, according to a 2018 study by the National Library of Medicine, healthcare providers already spend 35% of their time on documentation.

Because of the number of patients and demand for healthcare services, it’s inevitable that some healthcare providers would rush the documentation process. Unfortunately, this often results in some important information being omitted fromthe patient record, leading to poor documentation.

To combat the dilemma of poor documentation due to time constraints, physical therapy clinics must adopt technologies that can reduce documentation time. These include AI documentation tools or updated EHRs/EMRs.

Improper Documentation Can Be Caused by Technological Limitations

It may sound hard to believe in today’s digital age, but there are still some technological limitations that can result in poor clinical documentation. For instance, such limitations in a clinic’s EMR or EHR may result in documentation errors. These errors, in turn, might make it challenging to understand the clinical note.

Inadequate Clinical Documentation is Caused by Human Error and Lack of Training

The final common cause of inadequate documentation is simply human error. When documenting patient sessions, there’s a high chance that PTs can make a mistake in taking down the relevant health information. This is especially true if the physical therapist is recording everything using pen and paper instead of using an AI documentation tool.

Additionally, a lack of proper training can lead to poor documentation. Because the PT isn’t adequately trained to record patient sessions, errors in the health record are more likely. This can affect not only the patient’s treatment and recovery but also the physical therapists themselves, as they’ll have to spend more time fixing the errors in previous notes instead of directly interacting with their patients.

V. Signs of Poor Documentation

Missing Treatment Rationales

One of the signs indicating a poorly made clinical note is missing treatment rationales. Missing treatment rationales in documentation occur when physical therapists rush to create the clinical note, which sometimes causes them to completely forget to include them in the first place. They may also occur when PTs falsely assume that their colleagues will be able to figure out the rationales for themselves.

When creating physical therapy documentation, the treatment rationale must be as clear as possible. That way, the clinical team won’t struggle to interpret the note and they’ll be able to understand the treatment that has already been provided to the patient. By doing so, treatment duplication can be avoided and the patient can recover faster.

Incomplete Patient History

When recording patient sessions, it’s vital that healthcare providers start with the patient’s medical history. These include the patient’s medical conditions, past and current treatments and medication, lifestyle, and even their family’s medical history if needed. By including these in the note, the clinical team will have a better understanding of the patient’s needs and prepare the appropriate treatment course.

Incomplete patient history is a common sign of poor documentation. Often, it is caused by rushing the documentation process, forms missing the necessary data gathering fields, or even the patient sometimes forgetting their medical history. This could lead to poor diagnosis and the wrong treatment courses, preventing the patient from recovering properly.

Inaccurate Billing

Physical therapists can find treatment billing complex. This is because they have to comply with coding specifics, coverage limitations, and insurance requirements, which are regularly updated under HIPAA regulations. This complex process, combined with the PT’s need to multitask, can lead to mistakes in creating clinical documentation. As a result, the billing given to the patient becomes inaccurate.

Inaccurate billing is a mistake that physical therapy clinics will want to avoid as much as possible. Otherwise, not only will the clinic face reduced revenue because of delayed reimbursements, but it can also lead to legal issues from the patient.

Lack of Future Treatment Plans

With the time they spend documenting patient sessions and the number of patients they have to cater to daily, they may not be able to allot any time to have post-treatment discussions with the patient. However, excluding future treatment plans for the patient in the clinical note is a sign that it’s poorly made.

Post-treatment plans are vital in the patient’s overall recovery. Without it, the patient can experience setbacks that may prevent the treatment from working. Not only will this prevent the patient from recovering on time but it could also lead to a malpractice lawsuit from them.

VI. How Patient Documentation Causes Physical Therapist Burnout

Monotony and Repetitiveness

According to a 2022 report created by The American Physical Therapy Association (APTA), 86.3% of PTs strongly agree that administrative tasks such as clinical documentation often lead to burnout in their ranks. One reason for this is that they are too monotonous and tedious.

Remember, physical therapists got into the job to treat and help patients recover from their ailments, not to fill out paperwork all day. As such, if a PT is too focused on documenting patient sessions instead of actually treating patients, the repetitiveness of the job can lead to a lack of satisfaction and, eventually, burnout.

Pressure to Comply with Regulatory Requirements

Another reason taking down clinical notes can cause PT burnout is the immense pressure it puts on them. Physical therapists are expected to remain updated on regulatory requirements such as internal guidelines, legal regulations, and billing codes. Otherwise, the PT and the practice itself could face legal problems.

Unfortunately, the  same pressure can reduce a PT’s morale, which could eventually lead to the dreaded physical therapist burnout and, potentially, turnover.

Time Limits

It may not seem like it but patient documentation is a time-consuming task. Not only must the physical therapist be as detailed as possible in their notes, but sometimes, they also have to spend time fixing their predecessor’s mistakes in previous documentation. As a result, some physical therapists have to take the work home, making work-life balance difficult to achieve.

Because of the amount of time they spend on the task of documentation as well as the tight deadlines they have to face daily, physical therapists experience constant stress, resulting in PT burnout.

Lack of Proper Clinical Documentation Software

Despite advancements in technology and artificial intelligence, some physical therapy clinics have yet to documentation software in their daily operations. On the other hand, some clinics do take advantage of documentation tools as well as EMRs or EHRs but choose unintuitive software with clunky interfaces, glitches, and other limitations.

Lack of proper documentation software or using inefficient ones can make recording clinical sessions a more tedious task than it already is. This can further contribute to a physical therapist’s stress, eventually causing burnout in the process.

Apart from inefficient documentation software, a lack of sufficient training in the use of AI scribe tools can also prevent PTs from maximizing their documentation time, preventing them from becoming even more efficient in the task.

Pressure to Adhere to Documentation Standards

Finally, the need to adhere to the current documentation standards can also cause physical therapist burnout. PTs are expected to include patient assessments, progress notes, treatment plans, and outcome metrics in the documentation. Apart from the amount of things that they need to include, the note must also be as precise as possible.

As PTs always have to keep these two requirements in mind when recording patient sessions, the task of clinical documentation easily becomes physically and mentally taxing, eventually leading to burnout.

VII. Best Methods to Protect Your Team from PT Burnout

Promote Healthy Work-Life Balance

With the long hours and volume of patients that they have to deal with on a daily basis, it’s no wonder that many physical therapists feel physically, mentally, and emotionally exhausted to the point of burnout. According to WebPT’s The State of Rehab Therapy Report in 2021, the COVID-19 pandemic caused a lot of physical therapists to experience burnout. As of WebPT’s 2023 The State of Rehab Therapy Report, these numbers are only getting worse.

So, how exactly can a physical therapist combat burnout? One way is by promoting proper work-life balance. PTs can achieve this in various ways; for instance, they can avoid working at lunchtime or refrain from taking their work home. They can also focus on a hobby they truly enjoy after work to unwind after a busy day.

One of the best ways PTs can manage burnout is by keeping their work life separate from their personal life. By doing so, they won’t be thinking about the job all the time, helping them avoid the risk of burnout and improving their daily performance simultaneously.

Upgrade Your Clinical Systems

One common reason providers experience burnout is spending more time on physical therapy documentation and other forms of paperwork instead of actually treating patients. Because such tasks are repetitive and monotonous, they lose motivation to continue their work, causing burnout that will eventually lead to their resignation. 

One way they can combat this problem is by upgrading your clinical system. Clinics that conduct such tasks by hand or use technologies with outdated systems are likely to spend more time on tedious desk work. As such, be sure to streamline your clinic’s operations by upgrading the technologies your clinic uses.

Recognize Each Team Member’s Efforts

Boosting your clinical team’s morale can go a long way in preventing burnout. After all, by ensuring that they feel valued and appreciated, you’ll create a positive work environment in your clinic. This allows your physical therapists to remain motivated enough to continue their work, helping them avoid burnout in the process.

To accomplish this, consider celebrating their victories and recognize each PT’s contribution to the practice. You can also hand out awards and bonuses occasionally (e.g., in quarterly reports or weekly catch-ups) to further validate the team’s efforts and boost their morale. Even simple acknowledgments in the line of work can lift your providers’ spirits by a significant amount.

Encourage Open Communication

As we’ve explained, being a physical therapist can be mentally taxing. More often than not, the mental exhaustion that PTs face on the job can quickly cause burnout. To combat the psychological toll that they face, consider encouraging open communication within your clinical team.

By creating an environment that allows people to speak up about their concerns, thoughts, and ideas, you can easily foster collaboration between your team members. You can also allow them to receive support from their fellow PTs or even their managers. 

With this support system, not only will the team build trust in one another but it will also let them see that their superiors are committed to their well-being. Such a gesture can go a long way in preventing burnout amongst your physical therapy team.

Support Your Team

Supporting a physical therapy team can go a long way in preventing burnout among your ranks. Remember, the stress often associated with the job can be difficult to deal with alone. Therefore, it’s essential that a clinic’s manager ensure that their physical therapists are supported by their co-workers and their managers.

One method of providing support to your team to protect them from burnout is by offering mentorship opportunities. According to a 2019 survey conducted by CNBC and SurveyMonkey, people who have mentors to help them along the way are usually more confident and satisfied with their jobs. Coupled with a positive work environment, this can quickly decrease the chances of a physical therapist experiencing burnout.

If providing mentorship opportunities is currently infeasible, managers can hold occasional workshops and training sessions in certain aspects of the job, such as patient documentation. With regular training and workshops, clinical team managers can show that they’re committed to each PT’s improvement, helping them avoid burnout.

Offer Flexible Schedules

Offering scheduling flexibility is another effective way of protecting your PT team from burnout. With a flexible schedule, physical therapists can have greater autonomy over their work, which research has shown often leads to higher job satisfaction

By providing flexible or alternative scheduling options to PTs, you can further protect their work-life balance. This is because flexible schedules gives them more time to rest and recharge to the fullest at their own pace before coming back to their jobskeeping burnout at bay.

Make the Documentation Process Easier

Finally, clinics can also protect their PT team from burnout by making the documentation process easier. To accomplish this, they can begin implementing the use of AI scribe tools in the daily process. With AI tools, they can begin to cut the amount of time they spend on documentation by a significant amount. This, in turn, helps the team avoid as they’ll be spending more time doing what they do best: treating their patients.

Clinical documentation is a vital part of a healthcare provider’s duties. Now that you know everything there is to know about the task, problems such as poor documentation and burnout should now be a problem of the past. By following the tips outlined in this eGuide, you can feel more confident in your documentation skills and be more efficient in recording patient sessions.

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