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Proper Electronic Medical Documentation: Why It’s Important

Sarah Lara

Dec 12, 2023
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Medical documentation is a vital step in healthcare. Often done manually or with an electronic medical documentation software, medical documentation keeps track of the patient’s medical history. It also helps track the kind of treatment provided to them every session. For this reason alone, proper patient documentation is a task that should not be taken lightly.

Apart from keeping track of the patient’s history and treatment, there are other reasons why physical therapists need to take great care to ensure patient sessions are properly documented. Below are the various reasons why proper medical documentation is essential and the consequences of improper medical documentation.

Proper Medical Documentation: Why is it Important?

Ensures Everyone on the Team is Updated on Patient Status

When patients return for their next PT session, their usual therapist might be unavailable to assist them for the day. In this case, a different physical therapist will have to jump in and attend to the patient for the session.

Since electronic medical documentation programs note the patient’s health information and the treatment they receive each session, the attending physical therapist can remain updated on these developments. As a result, they can understand the patient’s medical history, even if it is their first time meeting them.

 By knowing their medical history and treatments, patients can receive continuous treatment, which can help put them on the road to recovery much faster.

Prevents Successful Malpractice Lawsuits

Even a highly trained physical therapist is not immune to a malpractice lawsuit if there is a good reason to call for one. According to a study by the National Library of Medicine, improper medical documentation is the reason for 10-20% of medical malpractice cases. Naturally, a medical malpractice lawsuit can easily hurt the reputation of the therapist and the clinic. Proper medical documentation, however, can prevent a lawsuit from occurring.

With proper medical documentation, physical therapists accused of poor medical practices will have what they need to prevent lawyers from aggressively pursuing the claim. This is because the document will prove that the physical therapist conducted the treatment according to the patient’s needs. As a result, the lawsuit can be forestalled or even dismissed entirely.

Since no healthcare professional wants to face malpractice lawsuits, it’s highly recommended that clinics take advantage of medical documentation services. That way, they can easily avoid mistakes leading to inaccurate medical documentation.

Makes Billing More Accurate

Whether it’s for physical therapy or other forms of healthcare, medical documentation plays an essential role in billing a patient. By properly documenting every patient session, a clinic’s accounting can track the treatment, care, or medication the patient was given. As a result, the clinic can bill the patient more accurately. This, in turn, will prevent the patient from experiencing any payment issues, especially if they're relying on their insurance.

Ensures Proper Patient Care

One of the primary duties of a physical therapist is to ensure that their patient gets the best medical care possible. It may sound hard to believe, but proper medical documentation can assist therapists in doing just that. But how can note-taking assist in ensuring proper patient care?

Medical documentation helps therapists and healthcare providers keep track of the patient’s treatment. Ideally, the initial treatment should be able to help them resolve their health problems with time, and usually, it does. However, sometimes, the initial treatment may fail to work. As such, the physical therapist will have to look into other kinds of treatment to relieve the patient of their symptoms.

This is where proper patient documentation comes in. With the proper medical documentation, physical therapists will have a record of what treatments the patient has already undergone. This can be helpful if there is a change in therapists as it will prevent them from recommending the same treatment twice. Apart from that, it can also help clinics improve the patient’s future care and provide them with high-quality service.

Additionally, there are also instances when a patient must switch healthcare facilities. Proper medical documentation helps improve patient care even in the new clinic. If the medical documentation is clear and accurate, the new clinic will see every treatment that the patient has undergone. With this, they won’t miss out on the details of the current treatment plan, the proposed next steps, or medication that the previous PT recommends to help the patient recover.

With the patient’s care and health at stake, physical therapists need to minimize errors in patient documentation as much as possible. Therefore, it’s highly recommended that clinics begin using electronic medical documentation software. Doing so could prevent medical documentation mistakes, ensuring that the patient’s health and safety are preserved.

The Consequences of Poor Medical Documentation

Physical Therapist Burnout

According to a study by the Advisory Board, 49.2% of healthcare providers spend their time documenting patient sessions instead of interacting with patients. Additionally, an American Physical Therapy Association study claims that 86.3% of PTs agree that administrative work like medical documentation causes burnout. This means that physical therapy burnout directly results from excessive focus on patient documentation.

Physical therapists often spend an excessive amount of time on medical documentation due to outdated manual systems still used by some clinics. When patient documentation is done by hand, it could lead to errors that could cause confusion in the patient’s treatment plan. Some reports may even be poorly written and almost incoherent due to time constraints. 

As a result, physical therapists would have to spend extra time rectifying these mistakes instead of communicating with and treating their next patients. This could eventually lead to physical therapist burnout, preventing the clinic from running efficiently. To avoid the mistakes that lead to burnout, take advantage of medical scribe services to streamline your clinic’s medical documentation process.

Poor Team Communication, Inferior Patient Care, and Improper Billing

Medical documentation can result in better team communication. As stated before, medical documentation notifies the whole team about a patient’s medical history. It also ensures transparency and understanding for all parties on the treatment plan outlined for their care. This means if done properly, the team can avoid poor communication and errors in the patient’s treatment plan.

Poor medical documentation has the opposite effect. If a patient interaction isn’t recorded correctly, it can confuse the physical therapy team members. The communication error it will cause can result in a physical therapist recommending a treatment or medication that didn’t work before. These mistakes can be detrimental to the patient’s health, preventing them from recovering as planned.

The redundancy in treatments and medications can also lead to improper billing charges at the end of the patient’s treatment. This can not only negatively affect the patient’s finances, but overcharging can also ruin the clinic’s reputation. As a result, new patients could become reluctant to turn to the clinic for their medical needs, affecting its bottom line in the process.

As the aforementioned issues are mistakes that should be avoided, it’s highly recommended that clinics implement electronic medical documentation. By doing so, the task of patient documentation will be much easier and simpler for physical therapists.

License Revocation

Finally, poor medical documentation can also result in the revocation of a physical therapist’s license by the country’s medical board. Remember, the mistakes that result in poor patient documentation aren’t minor problems. Often, they lead to drastic problems for the patient, both financially, mentally, and physically. 

If a patient feels slighted enough that they received poor care as a result of inadequate medical documentation, they’re well within their rights to file a medical malpractice lawsuit. Once the examinations find that poor medical documentation is indeed the reason for the poor care that the patient received, the suit can be pursued aggressively by the patient’s lawyer. This will likely result in the revocation of the physical therapist or physician’s license.

In the healthcare industry, mistakes in medical documentation should be avoided at all costs. As such, if you’re running a clinic, move on from manual documentation by implementing electronic medical documentation software like ScribePT. 

ScribePT is a revolutionary tool that aims to make the task of medical documentation easier for physical therapists. With features such as personalized pre-note generation, hands free recording, one click transfer to EMR tools, and even real time human scribe support, documenting each patient session is sure to run faster and smoother than ever. Contact us today to learn more about ScribePT and its clinical documentation services!

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