Features and Benefits of Therapy Documentation Software

March 30, 2009 · Posted in Documentation, Workflow 

By trading in pens, papers, labels and folders for therapy documentation software, therapists can 

  • spend more time with their patients
  • monitor key performance measures
  • report on outcomes
  • save an enormous amount of filing space in their facility

Here are some of the areas that can become automated with the right therapy documentation software:

Patient Arrival Notification. For a busy outpatient facility to maintain its schedule, it’s critical to know exactly when patients arrive.  Look for a complete workflow management system that notifies therapists by pager when a patient has checked-in at the front desk.

Evaluations. A robust therapy documentation system will offer a vast array of discipline-specific evaluation forms.  Look for a system developed by therapists that contains an extensive library of numerous sections.  The system should enable the therapist to to customize the library of sections into sets and forms that meet the guidelines or preferences of his/her documentation approach.

Flow Sheets. A good therapy documentation system will provide electronic management of clinical data entry that allows for review of patient progress over time.  The automation of flow sheets should accommodate multi-disciplinary documentation requirements.  It’s also good practice to link the flow sheets back to a progress note.

Plans of Care. Look for a therapy documentation system that auto-generates plan of care reports directly from the evaluation.  The report should include recommendations, plans and goals for the patient. To help administrators effectively manage multiple clinicians, the system should notify managers of incomplete or overdue plans of care as well as physician approvals.  To save time and further streamline processes, look for a system in which plan of care reports may be electronically signed and faxed directly from the desktop.

Progress Notes. A good benefit of a therapy documentation system is its ability to track patient progress.  The patient shoud be monitored on the system from scheduling and check-in through the evaluation and on to discharge.  By automatically creating a daily progress note for each patient at check-in, the system is able to link documentation to billing and help eliminate lost charges. 

Clinical Messaging and Correspondence. It’s one thing to document INTO a system and another thing to get information OUT.  Make sure that your therapy documentation system can transmit authorized patient-specific information in a secure electronic format.  The system should provide customizable letters, forms and reports that streamline communications related to patient treatment and reimbursement.

Patient Education. Most therapy documentation systems print-on-demand patient handouts (i.e., home programs, exercises) or even interface to third-party electronic formats.  Many offer an ability to scan-in existing sheets as well as to make your own.  Make sure the system includes instructional and educational materials that may be customized prior to distribution. 

Therapist Productivity Management. With automation comes the ability to generate reports.  Reports become an effective tool to manage the facility more effectively.  Check to make sure that your therapy documentation system offers tracking mechanisms for therapist productivity by units, service analysis, billed time, total time spent, and other criteria.

For more features and benefits of a full rehabilitation workflow management system, visit our rehabilitation software website.

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