Supporting Your Providers With Medical Record Documentation: Challenges and Strategies

Joseph Elevado

Jul 10, 2023
Physical therapist conducting medical record documentation

In a 2015 study on physical therapists’ perceptions of electronic patient records, 36% of providers reported that “reporting and administration takes too much time.”

Besides time, energy and focus are also factors that are slowly depleted over time. This can affect not only the quality of the documentation but also the overall quality of the services of your providers.

If you want your providers to perform at their best on a consistent basis, you need to actively support them throughout every aspect of their workflow — this includes medical record documentation.

To help you with this, here are the challenges of medical record documentation and strategies you can use to resolve them.

What Are The Challenges Of Medical Record Documentation?

The most significant challenge of medical record documentation is that it consumes a lot of time and energy and can lead to burnout. However, it also has other hurdles that involve quality, consistency, and security, which are crucial in a physical therapy practice.

These other challenges include:

  1. Compliance requirements - Medical records must comply stringently with HIPAA, or your practice may undergo litigation
  2. Technical obstacles - PTs face hurdles such as data entry consuming a lot of time, and integrating data from various sources of information like medical history and test results
  3. Quality of care - Medical record documentation can consume a lot of time and energy, which may affect provider performance over time

Strategies For Supporting Your PTs With Medical Documentation

Train And Refresh Your PTs Regularly

Your providers may be struggling to keep up with documentation or compliance guidelines or need training in documentation overall. Holding regular training sessions is an effective way to improve their documentation skills.

A few examples of aspects you can train your PTs on are:

  • Regulatory requirements
  • Accuracy and consistency
  • Note-taking techniques

Establish Documentation Protocols and Guidelines

Every provider has a unique documentation style based on their work ethic. However, not every style is productive or compatible with your internal workflow. Otherwise, a provider’s notes will be hard to understand by anyone else, which makes it difficult for another provider to proceed with a patient appointment.

Besides training your providers, you should implement strict regulations to ensure that medical documentation records and notes follow established standards.

The kinds of guidelines and protocols you’ll implement will depend on the workflow and structure of your team. Generally, it’s best to convene with your entire healthcare staff to determine which regulations are the most effective without being too burdensome for your providers to comply with.

Encourage Collaboration Among PTs

Some physical therapists may have specific skills or experience that allow them to document appointments efficiently. Other times, your providers may just need to share their woes or frustrations with their work.

Fostering an environment where PTs can share their experiences with each other can establish rapport and even allow providers to improve their documentation skills.

Assign Administrative Tasks To Other Staff

Another effective strategy for supporting your providers is to delegate their administrative responsibilities to other staff. For instance, you can assign the following tasks to employees from the back or front office:

  • Appointment scheduling
  • Insurance verification
  • Payment collection
  • Data entry

This removes some of the burden off the shoulders of your providers and allows them to have more time and energy to document their appointments accurately.

Consider Software Solutions

Your providers may lack the equipment that would help them expedite the documentation process. A software solution such as ScribePT may help them with medical record documentation by outsourcing the task to trusted experts.

Why You Should Support Your PTs With Their Documentation

Physical therapists are the stars of your clinic, so they will need all the support they can get to ensure that they can perform properly, especially when medical record documentation is concerned.

Helping your PTs lead to:

  • Reduced stress - 57% of burnout incidents among physicians are due to “excessive documentation.” Supporting your providers can substantially reduce the likelihood of stress and burnout
  • Increased efficiency and productivity - Providers may be able to complete their documentation more quickly, allowing them to focus more on appointments
  • Enhanced patient satisfaction - Flawed documentation techniques may lead to providers spending more time correcting their notes than focusing on the quality of their appointments
  • HIPAA compliance - Documentation guidelines and other strategies help providers comply and stay on top of changes in HIPAA regulations consistently

Whatever strategy you employ, always keep in mind that medical record documentation is a recurring obstacle in the workflow of your providers. Supporting them through their documentation not only improves their performance but also decreases stress, enhances patient satisfaction, and boosts morale among your providers.

If you’ve tried every method to support your PTs with little success, consider using a software solution. ScribePT is a voice-to-EMR solution that helps physical therapists with their medical documentation by providing expert transcribers and automated software to expedite the note-taking process and allow providers to do what they do best. Contact us and learn more about ScribePT today!

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