As we work with PTs across the country, we’re often asked about the pros and cons of charting while you treat. Those against say it takes away from your focus on the patient. Those in favor point to increased accuracy and time savings. Mediware has always argued in favor of bringing your rehab EMR system into the treatment room. In fact that’s a key design consideration of our DocuPRO Rehab Documentation System.
Declining reimbursements make it essential that you save as much time as possible and capture every billable treatment you provide. And the best way to meet those requirements is by incorporating your tablet, laptop or workstation into treatment.
Gain More Time for Patients
By completing your documentation as you treat the patient, you finish your paperwork faster and have more time for patient care. This might lead to an extra 30 minutes of billable time each day. It also leads to more referrals in the case of Dean Bessas, PT, Director of Natomas Physical Therapy:
“We can take the tablet with us during treatment, open the appropriate template and click through the case as we work with a patient. In most cases, the report is faxed to the referring physician as the patient leaves our office. This responsiveness has helped us build a loyal referral network, which is a big reason for our fast growth.”
When you document as you treat, even if you don’t fully complete a note as the patient leaves, you’ve finished the bulk of the work. Then a web-based EMR (or Windows system with syncing feature) allows you to clean up your paperwork any time it’s most convenient for you. And time-savings isn’t the only reason to incorporate your EMR into your patient encounter…
Enhance Your Care
A template-based documentation system can facilitate a systemic flow of the exam. So if you start down one path of inquiry, the template will remind you to go down the other paths required for a complete, thorough examination. Every time you come to a special test –- and with an orthopedic presentation there may be 20-30 different such tests — your EMR can reliably pull up a list of all those tests and speed entry of your findings. Templates also keep you on flow with those afflictions you only see occasionally. (So you don’t have to wrack your brain trying to recall that course you took on TMJ 10 years ago!)
Start with the right technology
If you have balked at charting during treatment up to now, here are two ways to make the switch easier. First, consider the treatment environment when evaluating a new EMR solution. Some interfaces are simply easier to use during the patient encounter.
Speed and performance also become more critical. If your system can’t keep up with you, you’re in trouble. Some web-based systems can be very slow, especially during peak usage times. One PT described a web-based EMR (not SpectraSoft) this way: “Sometimes it takes up to 2 minutes to load an eval, so I usually resort to taking paper notes then putting in the system later, which defeats the purpose for me.”
Talk to your vendor and find out what they have done to ensure fast performance of your web-based solution.
Practice your technique
Second, make sure you have a tabletop or other workspace strategically placed in your treatment area. Some PTs install shelves or workstations to streamline the documentation process.
Skip to 1:20 for a demonstration of how to
incorporate your EMR during treatment.
Once you have your workspace configured properly, practice with it. It may be a little frustrating at first, but you will quickly get the hang of it. In fact many PTs find their iPad is a great conversation-starter to build rapport with the patient.
The video at left shows how Todd Cadby of Rebound Physical Therapy smoothly incorporates his EMR into the eval.