Electronic Physical Therapy Documentation for Flow Sheets
Flow sheets are one form of documentation used by physical therapists in the daily notes for patient care. They provide a format for documenting exercises, repetitions and weights.
In Chart Links’ Rehabilitation Software, flow sheets provide electronic management of clinical data entry and review of patient progress over time. Flow sheets can accommodate multi-disciplinary documentation requirements and may be linked to progress notes and charges.
Visit the Chart Links website for more information about electronic physical therapy documentation.
Implementation Services for Electronic Therapy Documentation
When it comes to implementing an electronic medical record for your outpatient rehab facility, Chart Links provides clinical and work flow expertise.
We employ a team of software development, implementation and support experts that have dealt with the electronic documentation of physical therapy, occupational therapy and speech therapy evaluations for years. Our team can work with your therapists and staff members to determine how best to link an electronic patient chart to each critical resource in your rehab department.
Some of the services Chart Links offers includes:
- Engineering the system and designing the network
- Identifying and coding hospital system interfaces in HL7
- Prepare your therapists and office staff for implementation
- Applying technology to your current workflows with the least disruption to staff
- Writing customer reports that will help you best manage your facility
Contact a Chart Links representative today to learn more about how our rehab software can automate therapy documentation and scheduling for your outpatient rehab facility.
Optimizing Outpatient Rehab Therapy Documentation with Software
The July issue of Rehab Management features an article written by Mark Finn that focuses on Software Solutions for Multisite Therapy Practices.
Mark cites the following areas to automate in a multi-site physical therapy practice for gaining improved efficiencies:
- Workflow Automation
- Manual Documentation
- Claims Processing
- Reporting
- Clinical Documentation
We encourage you to read the full article to learn some tips on how to spend less time dealing with paperwok, documentation and reports — and more time treating a greater number of patients.
If you need help evaluating electronic medical records systems for your multi-site outpatient rehabilitation facility, contact Chart Links.
CCHIT Addresses EHRs for Inpatient Rehabilitation
A task force of the Certification Commission for Healthcare Information Technology (CCHIT) has issued recommendations for a new long term and post acute care electronic health records certification program.
The program would cover EHRs in skilled nursing and nursing facilities, Medicare-certified home health agencies, inpatient rehabilitation facilities and long term acute care hospitals.
Recommendations from the task force include identifying core certification criteria common to the four priority care settings, reusing or adapting existing criteria from other CCHIT programs, identifying additional criteria specific to each care setting, and developing a roadmap indicating when the criteria are expected to be implemented.
A newly appointed CCHIT work group on long term and post acute care will start developing certification criteria in mid-July. The recommendations from the task force are available at cchit.org/about/organization/commission/advisory/ltpac.
[Source: Information taken from HealthData Management, written by Joseph Goedert.]
Features and Benefits of Therapy Documentation Software
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.
Electronic Documentation Software for Rehab
A recent article in Physical Therapy Products, titled “Electronic Efficiency: Using software for business and treatment solutions” and written by Nina Silberstein, covers stories of four therapists that are using electronic therapy documentation software.
Among the therapists featured was Tracie Rodak, PT, who works for Spartanburg Regional, a large not-for-profit hospital in South Carolina that is a customer of Chart Links’ therapy documentation software. Tracie is the manager of the outpatient pediatric rehabilitation program and treats the special needs population that includes childres with cerebral palsy, Down syndrome and autism.
When asked about the software’s capabilities for managers who want to track productivity, Tracie had this to say:
“…when a patient is checked in, our therapists automatically get a notification that says the patient is here. It creates an incomplete note and charge ticket. [The therapists] are constantly working down their lists [of how many notes they have left and how many evals and plans of care are due daily]. Technically, they can’t sign a file unless they’ve done all the parts. The nice thing is that they can’t sign the note and forget to bill. The system won’t let it happen. As a manager, I can see everyone’s incomplete notes, where before, I wouldn’t have any idea unless there was a problem. I’m able to manage better.”
Therapy Documentation Software Return On Investment
When it comes to automating therapy documentation, funding is one of the biggest challenges outpatient rehab facilities face.
If you’re struggling to make a compelling business case for electronic medical records to your hospital board of directors, consider all of the operational areas that will yield quantifiable results. As you build your case, marry up metrics to timeframes as a part of your formula for return on investment.
Efficiency Improvements
When you automate therapy appointments, appointment reminders, referral management, authorization tracking, evaluations, plans of care, progress notes, flow sheets, and more; information can be called up and acted on almost immediately. List out and quantify all of the administrative task time this saves. Consider improvements in communications alone as it relates to time spent on referrals, authorizations and appointment reminders. The staff productivity gained allows for major improvements in therapist work flow which, over time, allows more patients to be seen in the same amount of time.
Cost Savings
One of the greatest cost savings brought by electronic therapy documentation is the elimination of transcription costs. Because therapists enter clinical documentation directly into the system, traditional paper-based methods are greatly reduced, if not eliminated. Determine your current cost per therapist or per page for transcription. Estimate, conservatively, a reduction in transcription costs. This will likely be one of the most significant contributors to your overall cost savings with an electronic therapy documentation system. Don’t forget to consider other paper chart costs in the ROI equation:
- supplies for creating and storing charts (from folders, stickers and dividers to cabinets)
- labor expenses for managing chart pulls, filing and audits
- copying expenses for documentation to attorneys, payers and physicians
Revenue Enhancements
Electronic therapy documentation opens new doors for driving revenue that should be considered as a part of return on investment. Consider how much more compliant, complete and accurate documentation becomes when it has the checks and balances of automation. Coding levels and claim errors correlate directly to documentation of the encounter. When therapy documentation occurs electronically, therapists report greater confidence levels as it pertains to Correct Coding Initiative (CCI) Edits, Medicare time tracking (or the eight minute rule), authorization tracking, and other compliance issues that can help or inhibit proper reimbursement. Consider improvements in billing accuracy as a part of your ROI analysis.
Quality Improvements
Some of the less tangible returns of electronic therapy documentation include quality. In most cases, electronic documentation allows for quicker, more legible, better organized and more comprehensive patient documentation overall. Across the outpatient rehab facility, automation standardizes clinical documentation, reducing inconsistencies in structure, poor handwriting, and lag time in documentation and approvals. Patient education sheets are readily accessible and up to date. Plan of care reports are auto-generated from the evaluation, able to be monitored, electronically signed, and faxed from the desktop. These and many other improvements in quality should be considered in ROI.
Summary
In an outpatient setting, electronic therapy documentation impacts both the therapist and staff productivity. A good business case for return on investment should focus on
- efficiency improvements
- cost savings
- revenue enhancements
- quality improvements
If you need help putting together your Return on Investment business case for an electronic therapy documentation system, please contact us.