How to Create Efficient Documentation for Physical Therapist

Travel Therapy Tips from a Physical Therapist

Tim Fraticelli is a Physical Therapist, Certified Financial Planner™, and founder of PTProgress.com. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your physical and financial health.

Writing therapy documentation is one of the most time-consuming aspects of our job as health care professionals. Add clunky EMR setups, and it can be a recipe for frustration at work. But the documentation doesn’t have to be the worst part of your day. With a few tips, you can improve the quality of your notes while reducing the time spent writing each day. Below are three tips for becoming more efficient with your documentation in the clinic.

1. Build The Story

There’s a reason why Disney films are so effective: they all follow a particular storytelling structure. It’s hard to argue with the success of Disney’s Aladdin or Soul—just two of hundreds of films that follow their near-foolproof storytelling. We can learn from these award-winning films by weaving in a few of the key themes of the Disney storytelling formula. Every patient you encounter has a story to tell. The next time you go to write the subjective portion of your therapy evaluation or treatment note, ask yourself:

“What is the patient’s story here?”

“What do they want that they cannot have right now?”

“What will it take to get them there?”

“How will they change or grow because of this treatment?”

As you identify these key elements and build the patient’s story, it’ll become easier to highlight their progress in your notes. While everyone has a story, not everyone has the gift of gab. So, it’s part of our job as therapists to learn the patient’s story during their visit. I like to begin each patient’s visit with questions such as these:

• What kinds of activities are getting easier to do?
• What kinds of things are still difficult to do at home or at work?

Leading questions help draw out answers that I can use in my subjective note to highlight the functional deficits (or improvements) they’re experiencing for example, “the patient reports having difficulty climbing up basement stairs in order to perform laundry tasks.” Once you’ve set the scene with the beginning of the story, now it’s time to design the treatment around ways to meet those goals.

2. Highlight Your Intent

Your patient’s story helped you write your subjective note and identify functional tasks to justify the treatment you provide. Now, as you write the objective and assessment portions of your notes, you can continue the story of your patient’s progression.

You started the session by building the patient’s story next you want to highlight your intention for the patient. To highlight your intent, simply note how the treatments you’ve chosen can help them overcome their personal obstacles and make progress towards their goals.

Within every good therapy treatment, you should be able to identify your intention for the patient that day. Is your goal to improve the patient’s quad strength so that they can better navigate stairs? Do you intend to work on dynamic balance activities that will help the patient feel more stable as they descend a narrow stairwell?

Writing your intention for the patient will not only provide context for the exercises and treatments, it will also help answer the question, “Why is this skilled therapy?” The treatments you’ve selected for your patient are not arbitrary but reflect your expertise as a therapist. Be sure to highlight this in your story!

3. Create Your Own Therapy Documentation Templates

Note-writing can get monotonous. And following the standard SOAP-note formula—without telling the patient’s story—could get you in a rut of using the same phrases and treatment descriptions over and over. 

One of the reasons I created my own therapy documentation templates was to overcome the monotony of note-writing. These prewritten phrases helped me describe treatments with consistent accuracy, so that I could focus more on the creative aspect of writing without getting bogged down in details. By simply following a template and telling a story, my documentation notes began to write themselves.

So instead of “reinventing the documentation wheel” with each new evaluation or treatment note, why not start with a better formula? A documentation template can help you tell your patient’s story with even more compelling detail. Well-structured phrases make it easier to highlight your intention behind each treatment and can reduce time spent writing documentation, by 3–5 minutes per patient. With 8–10 patients per day, this can easily add up to 30 minutes of time saved each day.

There’s nothing wrong with using a formula, as long as you tailor it to each patient’s particular situation. You’ll find that, just like Disney/Pixar, once you’ve established a good story-writing formula, you can generate high-quality notes in much less time and with much less effort.

Final Thoughts on Improving Documentation

Once you adopt a storytelling framework for your notes, you’ll find it easier to tie in the patient’s functional limitations into the treatments you provided that day. With a little extra effort, you can even come up with some example documentation statements that will help you describe the treatment sessions with even more detail and in less time.

Are you a therapist interested in exploring the country and taking on new challenges in your career? Learn more about the exciting travel therapy opportunities Med Travelers has to offer nationwide.