physical therapy documentation

The average therapist spends approximately 6 hours per week on documentation (eval, treatment planning, daily notes, status notes, etc.).

That comes out to about $1,260 per month and over $15k per year! It’s costly (not to mention it takes you away from more important tasks that could bring a return).

We need to document but does it need to take this long?

We asked physicians if they read our reports and they said, “NO.”  We asked auditors/insurances if the notes and reports they audit typically have the necessary info required to justify payment and they said, “NO.” So then what are we doing?

If all the info we write isn’t being read by physicians (find out why below), and it’s not helping us in case of audit, what are we doing?

Stop wasting time and money.

Here are a few things you can do to start cutting your documentation time immediately.

  1. Remove the generic phrases such as, “Patient tolerated tx well.”, “Continue as indicated.”, “Independence with a home exercise program.”, etc. These statements don’t have any meaning whatsoever. They can actually hurt you in an audit.
  2. Stop wasting time on Short Term Goals (STG). You should be focusing on the Primary Functional Limitation. Track it. Measure it. Work towards it. Everything else becomes noise.
  3. Stop listing ALL your objective testing. Physicians don’t understand it. Auditors don’t understand it. Instead make quick statements justifying your assessment and medical necessity. It’s faster and means more to physicians and auditors.

DISCLAIMER: This is only an informative article. It’s not intended to be a complete Tutorial on Documentation. Full guidelines can be learned at an IndeFree course near you.

Reasons Why Physicians Don’t Read Our Reports

  • “It’s too long.”
  • “Don’t understand it.” (Too much jargon)
  • “Can’t decipher the checkmarks.”

Physicians judge you by the reports/status notes you send. If it’s more than one-page and has jargon or fluff that is not needed, they will ignore it (you). They will either like working with you or not based on your reports. If they are not reading them, it’s hurting you. And if they are reading them, they will send you more patients. See what Fort Worth Physical Therapy has to say,

When we started using IndeNOTES, several doctors in the first week made it a point to tell me how much they loved our reports. I am convinced after 3 years that using IndeNOTES has brought us more referrals. Doctors love it. I have 12 therapists who love IndeNOTES also, which is very important to me. They like that it is easy and quick to use. They like the other features like MD/Physician Requests. IndeNOTES has been an unexpected marketing tool for us. It sells itself! One Neurologist recently told me he started referring to us because of our reports.” -Weldon Russo, Owner FortWorth PT

DISCLAIMER: This is only an informative article. It’s not intended to be a Tutorial on Documentation. Full guidelines can be learned at an IndeFree course near you.

Learn how to cut documentation time, audit-proof, save over $600 per month, per therapist, and spend more time on growing! Click here.

About the Author James Ko

James Ko is the lead instructor and founder of IndeFree. He's a physical therapist of over 20 years and have owned 7 private practices and is launching a national chain. He's worked with some of the world's most celebrated athletes, actresses, and X-Game competitors. More importantly, he knows what it's like to fail and succeed. He enjoys reading James Patterson and Nicolas Sparks, and likes to golf, play the guitar and practice martial arts. He loves playing with my Mac and Cozy most of all!

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