Patient Documentation Workflows - MEG blog

Build Better Patient Documentation Workflows for Your Private Practice

Does paperwork follow you outside the office? Without the proper patient documentation processes and workflows in place, it’s easy for this aspect of your business to get out of control. 

In order to keep your focus ON the business rather than IN it, we have organized some practice management solutions to help reduce the after-hours work for you and your team.

How to Improve Patient Documentation at Your Private Practice

Regularly Train on Patient Documentation

Ensuring your team is well trained on physical therapy patient documentation prevents beginner mistakes that may cost a considerable amount of time to correct. Going back to the basics can help ensure you get it right.

Best Practices of Good Patient Documentation:

  • Communicates patient’s health to other providers
  • Provides legal protection
  • Justifies your services

By thoroughly documenting the care you provide, you may be able to include additional billable units, helping improve your bottom line per patient.

Document at Point of Service

Nearly every physician takes notes during your visit or has someone there to assist them. Documenting during the exam helps ensure nothing is left to memory, is precise and complete by the end of the visit.

Patients are conditioned to seeing other providers take notes while working with them, so incorporating this process respectfully shouldn’t cause much, if any, friction at your practice.

Stop Fighting Your EMR

Sure, your EMR may be clunky and something that gives you visions of Office Space levels of revenge on your electronics. It doesn’t have to be a nightmare, though.

Most EMRs are customizable, and companies are usually more than happy to provide additional training and resources to ensure you stay with them. 

Figure out who your in-office power user is as well. There’s always someone who can make the most of any system – identifying the person who actually likes the EMR and making them the office trainer will do your team a world of good. You’ll probably even learn shortcuts you didn’t know were possible!

Best Practices on Customization:

  • Identify and eliminate duplicate processes, like entering duplicate data in multiple places
  • Create templates based on patient documentation workflows to streamline data entry
  • Explore tools in the system that aren’t currently used and look for time-saving steps that may have seemed too complicated to adopt when you implemented the system

Eliminate Unnecessary Documentation

Simply put, you must ensure everything that goes into your EMR serves a critical purpose for insurance, legal or care. If you’re documenting unnecessary items, it’s time better spent elsewhere.

Use Ancillary Staff to Streamline Communication

Aides, students and volunteers can help streamline your documentation workflow while acting as a scribe during appointments. For instance, looking at a physician’s office workflow, the medical assistant can take notes, clean and set up treatments. In PT, it’s no different – your ancillary staff can help with basic steps as well to give better care and increase your efficiency.

Use Technology to Improve Your Documentation Efficiency

Adding in additional technology such as AI-assisted tech to turn recordings into documentation is a done-for-you solution that can save hours of work when your workflows are already as tight as they can be. Emerging technology will continue to propel the PT trade and open up time for providers that wasn’t previously thought possible.

Other options include autofill or text expander tools that can help turn a typed shortcut into expanded text. Use these tools for common phrases and treatment plans to save time and keystrokes.


Delegate! Delegate! Delegate!

Sometimes we just don’t let our support staff support us enough, and in the end, that’s the main cause for the breakdown and high workload. Trusting your staff and passing off work to the appropriate parties may seem like a given, but it might be hard for some of your PTs and is worth taking a look at now and then. Leaders who can delegate will get more done.

Let MEG Help with Patient Documentation Workflows

MEG Business has physical therapy practice management solutions to improve every aspect of your clinic. Our clients are the top 10% of the industry because they know how to do what they do best and outsource the rest. 

Join our team and get the certifications, programs and coaching you need to launch or scale your private practice in 2022 and start living the owner’s life you’ve always dreamed of.

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