There are 4 goals for physical therapy documentation if you want to perform at a high level:
Goal #1: help you get better results in session
Goal #2. improve decision making in your plan of care and in reflection on a specific case
Goal #3: improve team results, strategies, and decision making in the future
Goal #4: reduce documentation burden and practitioner burnout
You may think, ‘bull, I have documented my entire career and you are speaking nonsense. I love being a physical therapist. I hate documenting. Its worthless.’
But it’s not.
It can be the tool that unleashes your skill set.
Better results in session
Have you ever been in a session and got lost in the weeds?
The patient, who scheduled the appointment, can’t coherently discuss their pain. Or maybe nothing can recreate their symptoms. Maybe nothing can make the patient feel better. Maybe you get to the end of the session and don’t know where to go with the home plan.
The note can be the tool that pulls you out of the weeds, or even better, cuts the weeds, leaving you with a better understanding of the patient and their issue.
Improve decision making in your plan of care and in reflection on a specific case
The difficulties with one patient highlight our next path to improvement for a clinician and for the team.
The obstacle can refine strategy, help you figure out how to apply a clear methodology in new situations, and ultimately improve tactics. If documentation is lacking, reflection on the case is limited. This is the truth even though it is not fun to hear. Pulling a report is useless when we only go off of your memory and feelings.
This is not to discount how valuable your memory about a case, but the documentation can help us support your memory and uncover opportunities.
Improve team results, strategies, and decision making in the future
By aggregating all of your documentation, from the patient responses to the data you input on your note, a team can look at what actually happens with scheduling, the duration of treatment and investigate regressions, progressions, and recurrence at a macro level.
This can be put into reports and help us understand what decision is most supported in specific situations that your team sees over and over again. You bring this together in quarterly improvement sessions with the entire team. All of the data you gathered can be analyzed, discussed, and ultimately make your team better.
It will lead to changes in strategies and methods that would never occur without a well defined and structured improvement process based on your experience.
Reduce documentation burden and practitioner burnout
We need documentation that supports the clinician’s experience.
The documentation must be interpreted by the clinician as useful in the moment or it will always be an irritating, post hoc activity. This is why documentation typically gets done at the end of the session instead of during – because it is not a useful tool but a necessary evil. Making the data you need to collect at each section easy and useful while inputting your strategy decisions is critical. It cannot distract from the patient or practitioner’s experience.
But you must have collection silo that makes documentation easier and more efficient for the practitioner.
