Keeping the right physical therapy documentation is one of the most crucial parts of running a physical therapy practice. As a healthcare provider, it is your professional, ethical, and legal obligation to ensure that each patient’s notes and other documents are organized and accurate. In this article, we have a range of tips to help physical therapists make sure that they have a solid physical therapy documentation system that ticks all the boxes.

Healthie is an all-in-one practice management platform and mobile app designed to help nutrition and wellness professionals manage their business and build relationships with clients.

What is physical therapy documentation?

The law dictates that every time you have contact with a patient, you need to collect details about the encounter and store it in their clinical record. This clinical record is made up of notes and supporting documents that contain information about the patient’s assessment, treatment, progress, and plan. As the record may be used by other healthcare providers, office staff, or even in a court of law, it’s vital that all information in your physical therapy documentation is clear, accurate, and complete.

Why is high quality physical therapy documentation important?

Keeping clear and complete physical therapy records can help you to: 

• Provide the best care to patients. Keeping a record of your patient’s initial condition and their journey towards recovery will allow them to receive better care, whether it’s from you or another healthcare provider. On the other hand, inaccurate notes can lead to unintended, or even dangerous, outcomes.
• Ensure continuity of care. If your patient starts working with a new healthcare provider, accurate medical records will make it easy for them to create an effective treatment plan.
• Bill correctly. Your records will help you to create accurate bills and insurance claims for your services, and prove which services you performed if a bill gets queried.
• Avoid malpractice. Documentation is legally admissible in a court of law. If you’re ever facing a lawsuit, having full and complete physical therapy documentation will support your argument that you met or exceeded the standard of care.

What are some physical therapy assessment documentation examples?

The main type of documentation you’ll be keeping about a patient is likely to be in the form of SOAP notes. However, clinical records can contain a wide variety of documents. You may have other supporting information relating to contact you’ve had with a patient. Some physical therapy documentation examples to keep are::

• Loose paper, including journal entries that patients have filled out about their progress, letters, or even post-it notes.
• Electronic communications, such as emails and messages.
• Video and audio recordings of an appointment with a patient.
• Test results, such as X-rays or MRI scans.

How to keep good physical therapy documentation: Soap Notes

When writing assessment notes, it’s best to stick to the SOAP format. This acronym stands for Subjective, Objective, Assessment and Plan. As a standardized medical note-taking system, physical therapy SOAP notes will help you to ensure that your records will be complete, and easy for any other professionals to understand.

Always date, time, and sign every entry you make into a patient’s record. Include patient identification, such as their name, date of birth, and file number. Make sure you consecutively number your pages, and avoid any unnecessary industry jargon or abbreviations that could result in misunderstanding.

Never destroy or delete any physical therapy documentation or records relating to contact you’ve had with a patient. If in doubt, it’s always safest to keep it. Remember that all records must be stored in a safe and secure location, but also be easy to retrieve when needed.

The Centers for Medicare & Medicaid Services has a range of resources available to help healthcare providers ensure that their physical therapy soap notes and documentation complies with all federal policies.

Using Electronic Health Records (EHR) software

Like many industries, healthcare is becoming increasingly digital. Most modern PT  practices now use a physical therapy documentation software. EHR software is used for documentation and record-keeping, and  comes with many benefits. Research indicates that practices that use EHR software often see increased revenue, fewer malpractice claims, and better patient outcomes than those who don’t.

If you’re looking for the right physical therapy documentation software for your practice, consider choosing an all-in-one option that you can also use for billing, making insurance claims, setting appointments, and communicating with your patients. And, of course, check that your physical therapy EHR software is completely HIPAA-compliant. 

If you’re struggling to find a trusted EHR platform, consider trying Healthie’s free starter plan to test our extensive features for $0.

Managing documentation with Healthie

Healthie offers comprehensive EHR software, where you can securely store all data and information relating to your patients. Healthie offers:

• Cloud-based EHR, so you can securely access and update your notes from anywhere.
• Client Engagement Portal access, with features tailored for physical therapists including messenger, video sharing, and intuitive ways for your patients to track their progress.
• Complete HIPAA-compliance - all your data is stored on top-grade servers.
• Compatibility with all major devices.
• Integration with the key tools you need to run your business - such as charting, telehealth, treatment plans, payment processing, and insurance billing.
  

Healthie offers a free seven day trial - try it for yourself.