Defensible Documentation Best Practices

Defensible documentation—what a buzz word (er, phrase). But it’s not just hot air; there’s a good reason why it’s so trendy. According to the APTA, creating “documentation throughout the episode of care is a professional responsibility and a legal requirement.” As a “tool to ensure safety and the provision of high-quality care,” defensible documentation serves to:

  • Communicate information about a patient’s care, status, and treatment outcome among providers.
  • Tell others about the unique—and valuable—services you provide as a therapist.
  • Demonstrate compliance with local, state, federal, and payer regulations.
  • Help third-party payers determine appropriate payments.
  • Act as a historical account of patient encounters for legal purposes.
  • Provide a resource for policy or research purposes (e.g., outcomes).

So, for your physical therapy documentation to be defensible, it must be able to justify and support your diagnosis and plan of care—and thus, your payments. But, how do you know if your documentation is thorough enough to stand up to scrutiny? Start by taking a few moments to ask yourself these questions (as adapted from this WebPT blog post):

  • Would your documentation provide enough information to recall a particular encounter—and protect you against any questions or possible legal claims—months or even years after the fact?
  • Does your documentation support and justify your diagnosis, treatment, number of visits, and charges?
  • Is your documentation clear and legible to a non-clinician?
  • Does your documentation accurately describe the patient’s course of treatment?

If you can’t answer “yes” to any of these questions—or if you frequently spend time on the phone or writing letters trying to appeal or explain your documentation to a reviewer—then you’re not only losing payments; you’re also losing your rightful place in the continuum of care.

Basically, creating defensible documentation comes down to proving the medical necessity of your treatment. As Deborah Alexander from the PT Compliance Group discussed during her presentation at Ascend 2015, “Your documented services must be at a certain level of complexity and sophistication, or show that the patient’s condition requires services that can only be delivered by a therapist.” That means you must demonstrate that you provided skilled care. To that end, the APTA offers these recommendations to improve your documentation:

  • Provide a brief assessment of the patient’s/client’s response to the intervention(s) at every visit or event.
  • Document your clinical decision-making process (like explaining why you changed the patient’s/client’s exercise program, added or discontinued a modality, or progressed a functional activity).
  • Make sure your documentation is not repetitive (i.e., don’t write the same thing every time).
  • Make sure your documentation leaves no room for doubt that only a skilled physical therapist could have provided the treatment.

Additionally, here are a few more tips for creating defensible documentation from the University of Scranton’s DTP program:

  • Avoid using abbreviations or vague phrases like “patient tolerated treatment well” or “as above.”
  • Date and sign all entries.
  • Complete progress reports, as necessary.
  • Document during the visit, whenever possible.
  • Clearly identify note types.
  • Include all related communication and missed/cancelled visits.
  • Incorporate valid and reliable —and standardized—tests and measures.
  • Produce legible documentation—or risk having your claim delayed or outright denied

One last tip: use a physical therapy EMR.

Not only can electronic medical record-keeping make sure payers don’t have to decipher your notes, but it also can keep you compliant with all defensible documentation regulations. Alerts, measures, and reminders are built into your documentation, note types are easy to identify, and you can conveniently document during (or immediately after) a visit—you know, when you can easily remember what happened and can paint an accurate picture of the patient’s condition and treatment.


Think of it this way (and bear with me): you know how castles have moats? Well, as a physical therapist, your practice is your castle, and defensible documentation is your moat. And like a moat, your documentation is more defensible when it’s full—of crucial information, that is. So, follow these tips to ensure your documentation—and your practice—is safe and sound.

Want more tips and examples of defensible documentation?
Download this chart for defensible documentation tips.

5 Reasons Why PTs Love Their Cloud-Based EMRs

Some physical therapy clinics seem to have it all together: documentation gets done in a flash, claims are processed—and reimbursed—with ease, and everyone’s up-to-speed on all the latest regulatory changes. Maybe they’re born with it—or maybe it’s their EMR. Great cloud-based EMRs are designed with PTs in mind; these systems help make running a clinic seem like a breeze. Here are the top five reasons why PTs love working with a cloud-based EMR:

1. Affordability

Thanks to the cloud, PTs no longer have to shell out big bucks upfront—or cover the recurring costs associated with manual updates and IT staff—to use server-based EMR systems. Plus, software-as-a-service (SaaS) EMR vendors typically offer month-to-month payment models, making a cloud-based EMR an even less risky investment—an especially crucial selling point for smaller practices. Plus, users of these systems can switch to another EMR at any time. Vendors know this, which means they’re dedicated to providing customers with the highest-quality products and support.

2. Support

Speaking of support, like your best friend (or a pint of ice cream), a good EMR vendor is there when you need it with top-notch customer service. Think you have to bust out a user manual or comb through compiled help files if you have issues during setup or implementation? Not with a cloud-based EMR that’s ready to assist you with how-to guides, extensive knowledge bases, and an expert support staff.

3. Ease-of-use

A great cloud-based EMR is simple, user-friendly, easily scalable, and flexible. PTs love that cloud-based EMR vendors provide constant software and compliance updates to improve the user experience. Some vendors even develop enhancements based on user suggestions. With cloud-based EMR systems, PTs never have to lift a finger to access the newest version of an application or waste time worrying about—or fixing—notes or claims that aren’t up to payers’ standards.

4. Security

When it comes to keeping your patient data safe and secure, never fear—cloud-based EMR is here. With bank-level security encryption, tough password guidelines, automatic data backups, audit trails, super-secure data centers, and specialized staff, cloud-based EMRs have your back (and your front, and your sides, and—you get the picture).

5. Accessibility

PTs enjoy the convenience of working with a truly cloud-based EMR, which can be accessed anytime, anywhere, from any browser, and on any Internet-enabled device (unlike those bulky server-based EMRs, which sit in your office like a bump on a log—and require downloads, installations, and manual upgrades).


Cloud-based EMR vendors work hard behind the scenes to make documentation, billing, compliance, and practice management less of a hassle—and less of a hit to a clinic’s budget. But it’s not just about saving time and money (or wearing long-lasting makeup). A truly great EMR makes PTs feel all of the feels. Why? Because these features give PTs the freedom to get back to doing what they love most: helping patients.

One-Size-Fits-All Software Zaps Productivity

Have you ever worn one-size-fits-all clothing? If not, let me give you a word of advice: it’s not actually made to fit everyone. If you wear it, you’ll likely spend half your day tugging, twisting, and jerry-rigging your outfit so it works for your body. Sounds pretty annoying, right? Now imagine applying that same one-size-fits-all approach to EMR software. As a 2010 UC Davis study discovered, implementing that kind of technology could spell disaster for your practice.

This four-year study focused on roughly 100 physicians—specializing in either internal medicine, pediatrics, or family practice—from six primary care offices, all of which were part of a large primary care physician network affiliated with an academic medical center. These offices had implemented a multimillion-dollar information technology system that “digitized patient records and allowed for electronic prescriptions and messaging.” The three researchers collected data on work hours and output levels from before and after implementation to analyze the impact the EMR had on productivity.

The research findings suggest that the one-size-fits-all approach doesn’t work. After an initial—and expected—drop in productivity post-implementation, researchers found that the internal medicine physicians and their staff were able to adjust to the new technology. And once they did, they rebounded to a slightly higher level of productivity. However, the pediatric and family practices involved in the study never returned to their original productivity levels.

Why? According to Heman Bhargava, associate dean and professor of management and computer science at the UC Davis Graduate School of Management, this kind of software can’t accommodate the needs of every practitioner. In fact, there’s a “‘mismatch between technology design and the work-flow requirements and health administration expectations for individual care units.’” Bhargava affirms that “‘the ideal technology design should vary by physicians’ requirements and work-flow demands.’”

Would you settle for a shirt made to fit what an industry has deemed “average” in size and shape? Certainly not. (And who wants to be considered average, anyhow?) So why would you settle for an EMR that isn’t tailored to your physical therapy practice? A therapy-specific EMR is designed to mimic the workflow of your clinic, meaning the documentation, scheduling, practice management, billing, and compliance features are built for the way you work. And that allows you to document efficiently, maintain full HIPAA compliance, decrease patient no-shows, save time and hard-earned dollars, and grow your business.

One-size-fits-all software can’t offer the kind of specialization your industry requires, and spending precious time adjusting a non-therapy specific software to fit your clinic’s unique workflows and documentation needs isn’t simply a mild irritation; it’s a serious problem that affects your clinic’s overall productivity—and, ultimately, your bottom line. You chose to specialize in physical therapy; you deserve to work with a software company that chose to specialize in PT, too. Still not sure what the big deal is? See for yourself.

5 PT Industry Predictions for 2015

I’m no fortune teller; I don’t have a crystal ball, and I can’t see into the future. But like a good sports analyst or meteorologist, I can make some educated hypotheses. And while I definitely couldn’t tell you who’s going to win the Super Bowl next month—or what the weather will be like at kick-off—I’m pretty confident about these five predictions of the topics and trends that will have the biggest impact on the physical therapy community in 2015:

1. Outcomes

The healthcare industry is changing, and in the never-ending quest to control costs while simultaneously elevating the quality of care patients receive, outcomes have emerged as a vital component of the pay-for-performance reimbursement models many payers are embracing.

For physical therapists, outcomes have traditionally provided a mechanism for staying ahead of the game—for gaining a competitive edge in insurance contract negotiations and referral marketing efforts. As we enter 2015, however, outcomes are fast becoming necessary to merely stay in the game. To truly capitalize on our strengths—and own our roles—as healthcare providers in the current medical landscape, PTs must be able to objectively demonstrate the effectiveness of their care.

You all know how amazing you are; you witness incredible outcomes in your clinics every day. But physicians and insurance companies can’t see those results firsthand; they can’t experience the human impact of what you do. What they can see, though, are the numbers representing those results, and in our increasingly data-driven society, that information holds a lot of weight. Additionally, outcomes tracking allows practices to assess clinical team performance through benchmarking. Practice owners and directors can then use that data to make informed business decisions, enabling them to better manage their therapists and their practices as a whole. After all, you can’t manage what you don’t measure.

2. Consolidation

The therapy industry has changed a lot in the last couple of decades. Back when I first started practicing—almost 20 years ago—it was all about the big dogs. Then the economy did a 180, and things started breaking up. At that point, independent private practice clinics stepped into the spotlight, which did wonders in the patient care department. But now, with ever-increasing regulations and declining reimbursements, consolidation is making a comeback. Faced with shrinking profit margins—but not wanting to close their doors for good—many clinic owners are considering joining forces with larger practices that have the business resources necessary to contend with the market forces working against them. And while, according to this report from Harris Williams & Co., smaller, independently-owned practices still account for about 45% of the physical therapy market, many of those businesses are having a tough time expanding “outside of their local footprint due to underdeveloped referral sources and infrastructure.”

So, while I think we’re probably going to see a swing back to a less-fragmented landscape—a return of the big dogs, if you will—I also believe that this time around, things will be a lot different. Why? Well, most importantly, the people at the helm of these large practices are PTs—rather than hired CEO guns. So unlike the private equity-owned, HMO-driven mega-corporations of the past, these owners don’t see patients as just dollar signs. In 2015, I foresee a lot of PT businesses partnering, consolidating, buying in, and taking on private equity funding. And all of that means that influential, business-minded PTs—specifically, some key heavy-hitters in our industry—will maintain the power.

In my book, change is inevitable, and we here at WebPT support industry changes —so long as PTs have the final say over what happens in our profession, and so long as those in this industry make decisions that increase our clout, respect, and autonomy within the healthcare community.

3. ICD-10

Try as they might, ICD-10 resistors aren’t gaining any ground in their efforts to further delay the implementation of these diagnosis codes. And while we may see some additional efforts to put off the inevitable—particularly in conjunction with the SGR fix legislation that likely will come around (again) in March—I truly believe that the switch to ICD-10 will occur October 1, 2015. What does that mean for you and your practice? If you haven’t already started preparing for the transition, then now’s the time to get going. I recommend checking out the resources on There’s a good deal that goes into getting ICD-10-ready, from learning the new code structure and ensuring the readiness of your vendors to evaluating your staffing needs and preparing for reimbursement delays.

4. EMR Switches

According to Robocop, Back to the Future 2, and The 6th Day, the year 2015 was supposed to feature cyborg police officers, hoverboards, and successful human cloning. Disappointingly, many of us in the healthcare industry instead will start this year with a strong desire to turn our backs on technology—and throw our computers out the window. Why? Well, the majority of our industry has switched from paper charting to EMR documentation, and while we certainly aren’t living in a Robocop-esque dystopian society, many PTs’ EMRs make them feel like they are. That’s why I envision 2015 to be the year of EMR-switching. Ultimately, there’s no reason for any PT to stay stuck in time with his or her lemon of an EMR, because believe it or not, there actually are great EMR systems out there—and there’s nothing fictitious about that science. And in 2015, PTs will go out and find them.

5. The Rise of the Patient

Back in the old days, getting more patients meant you had to get more physician referrals. And while doctors are still an important source of new business for physical therapists, patients are increasingly taking their health into their own hands. Because in this day and age, researching symptoms and vetting treatment options is as easy as hitting your Enter key. With that kind of power, patients no longer have to consult with their primary care providers to learn how physical therapy can help them. And with direct access to therapy services rapidly shifting from being the exception to being the rule—thanks to legislation passed last year, some form of direct access to physical therapy now exists in all 50 states—I predict that in 2015, we will really start to see a deviation from the traditional patient path to PT.

As physical therapists, we’re all about progress—and based on my predictions for 2015, we’re going to see plenty of progress in our industry over the next 12 months. Of course, there will be plenty of challenges, too. But although we might have to break a few tackles, if we keep playing tough—if we can we continue to move the ball down the field—we’ll score some major points this year.

4 Reasons Your EMR is Bad for Business

Your clinic already has an EMR, but it’s less than ideal. In fact, you frequently wonder whether it might bring you more satisfaction if you threw the whole computer off the roof of your building. But don’t despair. There are actually good ones out there. Here are four reasons why your current EMR is bad for business and it’s time to make a switch:

1. It’s designed for physicians.

While they share a doctoral title and a love for caring for people, physical therapists and physicians certainly don’t share the same documentation needs. If your EMR is designed for an MD instead of a PT, you’re probably having a heck of a time developing Band-Aid fixes and workarounds to ensure you can complete your documentation compliantly and thus, get paid. So ditch that bad-for-business EMR and switch to one that’s designed for therapists. After all, you want an EMR that’s tailored to your needs. Just think: functional limitation reporting, 8-minute rule monitoring, and therapy cap tracking all built right in. Plus, you’ll have a system that follows your workflow, which’ll save you oodles of time.

2. It’s server-based.

If your EMR is running on a server, you’re shelling out way more money and time than you should be. Not only do you have to worry about securing your patients’ protected health information (PHI), but you’re also responsible for updating the system to ensure you have the latest compliance features—if your server-based EMR vendor upgrades its technology at all. Who’s got time for that? Toss your server-based EMR in the trash heap and adopt a web-based one instead. You’ll be able to securely access your documentation anywhere you have an Internet connection. And because most web-based EMR vendors store all their data with top-tier security firms, you can be sure your patients’ PHI is safe. As if that weren’t enough, you’ll also gain the benefit of never having to perform a manual upgrade again. Instead, your EMR vendor will automatically update the system for you, so you’ll always have the latest technological advancements and relevant compliance features at your fingertips.

3. It costs an arm and a leg—and a chart.

Your EMR should increase your cash flow, not deplete it. So if you’re using a system that charges you per chart or per visit, where’s your incentive to grow? The more patients you add, the more you’re paying your software vendor. That doesn’t sound right. Good thing there’s another payment model available. Move to an EMR that offers you a monthly, membership-style payment structure so your technology can grow with you, not cap your growth. Plus, look for a solution that doesn’t lock you into long-term contracts or hold your data hostage. That way, you’ll never again feel stuck with an EMR that’s bad for business.

4. It doesn’t include free training and support.

If you’re paying extra for support and training—or worse yet, there’s no one available to answer your calls—your EMR is definitely bad for business. Sure, your system should be intuitive and easy to use, but good training should be a given and support should always be available just in case you need it. The last thing you want is to have an urgent question and either not be able to reach someone or have to shell out your hard-earned dollars just so you can get back to work. Instead, opt for an EMR vendor that prides itself on providing exceptional customer support and training—for free.

If any of the above rings true about your current EMR, then there’s no denying it: your system is bad for business. Replace it with a better option—namely,
WebPT. For more information on how WebPT blows your current EMR out of the water, schedule a free demo today.

Imagine a PT-Designed EMR

Israel Green-Hopkins, MD, recently wrote a pretty interesting article for KevinMD about an imaginary physician-designed electronic medical record (EMR). He begins by saying that the thought alone “should make us all cringe,” because a clinician-designed product “is doomed [to be] limited [in] scope and lack…forward-thinking trajectory. Yet, the concept of integrating and considering the physician point of view and workflow is critical to successful EMR functionality.” While we definitely don’t agree with his first point—that a physician-designed EMR should make us cringe—we do think there is a lot to be said for a clinician-technologist partnership in the creation of a technological tool for clinicians. It just makes sense: two heads—with two specific, perfectly relevant skill sets—are most definitely better than one. And this is true for any specialty-specific technological tool. For our purposes, let’s consider the benefits of a physical therapy EMR (hopefully, imagining a PT-designed system doesn’t make you cringe, because it makes us practically giddy):

Specialty-Specific Workflow

Green-Hopkins writes: “Healthcare is a rapidly changing field and applying a blanket EMR structure to its core function seems impractical at times. Kenneth Mandl, MD, MPH, and Isaac Kohane, MD, described the paradox well in the New England Journal of Medicine in 2012 when they stated that the challenge is fitting EMRs into a ‘dynamic, state-of-the-art, rapidly evolving information infrastructure.’” All of this supports the need for niche, specialty-specific—one day, interoperable—technological tools tailored to meet the needs of each practicing professional. And who knows your needs better than one of your own? No one. And who can bring technology to life to address them? An expert software developer. (It’s a pretty powerful team.) If your EMR fits you like a glove, you won’t have to worry about developing Band-Aid fixes and workarounds. Instead, you can spend your valuable time improving relationships with your patients, building your business, or enjoying your family.

Relevant Compliance Updates

There’s a lot going on in health care right now—ICD-10, the Affordable Care Act, functional limitation reporting, meaningful use, and PQRS, just to name a few. Don’t you want the person (people) who designed your EMR to know which documentation and compliance regulations apply to you—and which don’t? With a PT at the helm of your software solution, you can be sure you’ll have the best—and most relevant—tools and features before you need them. Take functional limitation reporting, for example: only PTs, OTs, and SLPs must complete this type of reporting, so a generalist EMR most likely won’t take the regulation into account. A physical therapy-specific EMR, on the other hand, focuses on the exact regulations and requirements impacting the PT community—which do not include meaningful use—so its users can properly report functional limitations and get paid.

Better Education and Support

Not only does a PT-designed EMR offer the best software for practicing physical therapists; it also offers the best in education and support. Think about it: If your EMR doesn’t come with the expertise of a real-life PT, neither will your support team, your training team, or your content team. And that’s a pretty important piece of the puzzle.

Sure, you want an amazing EMR. As Green-Hopkins points out, “In its simplest form, the EMR is a communication tool. Clinicians from every discipline and at every level use it to communicate with the patient record and, in many cases, with each other.” And this communication is critical because breakdowns can often lead to potentially dangerous medical mistakes. But in order get the most out of your application, you’ve got to know how to use it.  And in order to succeed in your field, you’ve got to know what’s happening in your industry. What better way to achieve all of the above than to choose a 360-degree PT solution led by a PT?

What do you think about a PT-designed EMR? Tell us your thoughts in the comments section below.

Three Things Your Boss Wants to Know About EMR

So, you’ve been bitten by the EMR bug. We don’t blame you. There are so many ways an EMR will make your  work life easier; it’s a wonder it didn’t happen sooner. If you’re not the decision-maker (read: money-spender) in your clinic, though, you might have some convincing to do. But tell your boss the things he or she wants to hear about EMR—all true, of course—and you’ll be well on your way to ditching the pen and paper in favor of some sweet, time-saving technology.

1. It solves a specific problem.

You and I both know that the right EMR (cough, WebPT) has a plethora of amazing benefits—everything from intuitive initial evaluations specifically designed to meet the needs of rehab therapists to seamlessly integrated Medicare compliance alerts, reporting, and tracking. But no one wants to hear them all in one sitting. Unless, of course, they’re having trouble sleeping. Instead, identify your boss’s pain points and tailor your pitch to address those specific issues.

For example, perhaps your boss is concerned that missed appointments are negatively impacting your clinic’s bottom line, but your front office staff just doesn’t have the time or the manpower to call every patient and confirm every appointment. You could point out that an EMR offers automatic appointment reminders (via phone, email, or text), which reduce no-shows and cancellations by as much as 30%. Or maybe your clinic director feels like the practice is missing out on valuable referral opportunities but he or she is maxed out on networking. You could mention the built-in referral tracking report, which provides intel your boss can use to network more effectively by targeting providers who need the most extra attention.

Whatever the case may be, you’ll be presenting a real solution to a real problem (or several) instead of just an amorphous, disconnected—albeit well-intentioned—idea. This is sure to get you some serious buy-in.

2. It’s a leg-up on the competition.

According to Xerox Healthcare, 80% of primary physicians in the US are using an EMR. And although physical, occupational, and speech therapists aren’t required to make the transition in order to receive Medicare reimbursements, anyone who interacts with doctors or hospitals should be on the same page with them, documentation-wise. It demonstrates a level of professionalism that, according to the American Physical Therapy Association (APTA), referring physicians are coming to expect. And they’re not the only ones. Accenture recently reported that 41% of consumers are willing to switch doctors to gain online access to EMR. For more on why scribbled notes (handwritten documentation) just aren’t going to cut it anymore, check out Heidi Jannenga’s Physiospot article here.

3. It’s worth it.

We’ve all heard a horror story or two about a practice spending tens of thousands of dollars to implement an electronic medical record only to discover that it actually doesn’t meet their needs; and by that point, there’s nothing they can do to fix it. But that doesn’t have to be your experience. In fact, it won’t be—as long as you do your due diligence and choose a cloud-based, therapy-centric EMR (specifically, one with no contracts, no upfront capital investments, and no long-term service or maintenance expenses). Adopting an EMR doesn’t have to be as difficult as some people—or some vendors—make it out to be. In fact, the decision should be easy because the right EMR will pay for itself several times over.

What do you think your boss wants to know about EMR? Tell us in the comments section. We’d be happy to help you develop a custom pitch sure to knock his or her socks off—for which you’ll get all the credit.

The Future of Electronic Medical Record Management (Part 3)

[If you’ve already ready Part 1 or Part 2, jump to the subtitle below.]

The year is 2013, and although we don’t have the technological advancements of say, The Jetsons, we certainly have come a long way. In the last decade, smartphones became omnipresent, Google became a verb, and social networking changed the way we interact with one another. Never before have we had access to so much information—literally—at our fingertips. And although there’s no question that we as a society take full advantage of the newest and neatest technological advances to make our personal lives easier, we don’t always do the same when it comes to our professional ones.

Want an example? When was the last time you hand-wrote three pages of anything in your personal life? I’m guessing—unless it was a sentimental letter in which you chose handwriting to make it more personal—it’s probably been awhile. When was the last time you hand wrote three pages worth of paper charts? Today? This morning? Every day, every hour, every patient visit? Unless your intention is sentimentality here, too, that doesn’t make much sense—especially when you consider that there has been just as much advancement in the world of electronic medical record (EMR) systems as other techy tools. And that’s not going to stop.

Over three consecutive posts, we’re going to share with you what the experts are saying about the future of electronic medical record management. Here is Part 3 (click here to read Part 1 and here to read Part 2):

Integration, integration, inte…interoperability?

The ultimate purpose of widespread EMR adoption is to improve the quality of healthcare across the board. In an article titled, “Electronic Medical Records (EMR) and the Future of Healthcare, the author writes: “…information exchange, sharing, and interoperability represents one of the most compelling EMR benefits that can secure a viable future for healthcare.” Because there will be no one-size-fits-all system, we must work to ensure that the best solutions can talk to one another. After all, in an ideal world, one very complete medical record will follow every patient across his or her lifespan. As a result, every medical professional who sees that patient will have access to a full medical history—everything from immunizations and allergies to rehabilitative plans of care and X-rays. According to the article cited above, this will result in “upgrading the quality and integrity of healthcare intervention to the point of significantly reducing healthcare costs while saving millions of lives annually.”

With this in mind, it’s important to note that just because a system used to work, doesn’t mean it will continue to do so in the constantly evolving healthcare technology environment. As the Office of Standards & Interoperability (OSI) at the U.S. Department of Health and Human Services states, older systems “may not be fully compatible with newer products. Systems that predate current standards may require installation of applications that function as translators.” In other words—and to tie in with the section above—older, legacy (read: server-based) systems just don’t cut it on their own anymore.

Additionally, a siloed system that doesn’t integrate with your billing software, scheduling system, or functional limitation reporting tool, to name a few, will not work well in the long run. In fact, if one main benefit of an EMR is to cut down on errors, you want a fully integrated system with plenty of checks and balances. This way, you’ve minimized the risk of human error as a result of data entry.

So what’s the main takeaway? What can we expect the future of electronic record management to look like? Well, for one, EMRs are here to stay—specifically, cloud-based, fully integrated, working-toward-interoperability ones—and the days of paper charting are numbered. Now, the only question left unanswered is: What are you going to do about it? Hold out until the very last minute—until your patients start seeking out a more with-it provider? Or get ahead of the curve and enter the land of EMR? We hope it’s the latter. In the meantime, check out this lighthearted infographic from Dell on the future of EMRs.

5 Things Rehab Therapists Love About EMR

We could sing the praises of EMR until we go hoarse, but luckily, we don’t have to (which is a good thing, because we just weren’t cut out for vocal performance). Instead, we asked a few rehab therapy professionals to explain how their EMR helps them achieve greatness not only as a therapist, but also as a businessperson. Here’s what they had to say:

  1. It streamlines the billing process and cuts down on the time therapists spend filling out their charges.

    “We find that there is far less redundant data entry, and less time that our therapists have to spend filling out charge vouchers, and ensuring they match the notes precisely. This of course eliminates billing errors,” says Kerry Siman-Tov, MS, PT, MTC, of Archer Physical Therapy & Pilates Institute in Aventura, Florida.

  2. It keeps all patient information organized and secure.

    “The fact that data is encrypted and stored in multiple locations around the country to protect against loss and power outages pleased my computer-savvy technical advisor,” says Deborah Stack, PT, DPT, PCS, of Pediatric Therapy Center of Bucks County in Doylestown, Pennsylvania. She also loves that there are “no bulky charts to carry home, store, or get misplaced!”

  3. Built-in alerts give therapists—and clinic managers—peace of mind.

    “I don’t have to worry that a therapist has been treating a patient for eons and not reporting back to the doctor, because the system prompts them to report,” says Andrea Viel, the office manager at Mt. Eden Physical Therapy Center in Castro Valley, California. “I don’t have to worry about going over the number of authorized visits or past the authorization expiration date, because the system does the prompts. To sum up, I don’t have to nag everyone all the time anymore!”

  4. Branded documents and reports appear clean, readable, and professional.

    “Faxing to doctors is done with the push of a button and our records look a lot better and more professional,” says Lauren Hebert, PT, DPT, OCS, of SmartCare Physical Therapy in Dixfield, Maine.

  5. Web-based systems mean therapists can document anytime, anywhere, from any web-enabled device.

    “I’m very mobile. What I like best is that I have access to all my PTs’ phone numbers whenever I need them. I also like that I can email or fax documents with ease through the program,” says Laura Burger, OTR, CHT, of Maui Hand Therapy in Maui, Hawaii.

  6. There you have it—some EMR kudos straight from the people who know firsthand just how beneficial such a system can be in a rehab therapy practice. So, what are you waiting for? It’s time to ditch the pen and paper for good and take your clinic to the next level with EMR.

10 Warning Signs Your Clinic Needs EMR Now

You’ve been toying with the idea of an EMR for a while now, and maybe you’re still trying to figure out if making the transition is really the right decision for your clinic. To help, we’ve put together this list of ten warning signs that your clinic needs an EMR now:

  1. You’re drowning in paper.
  2. Are you swimming in a quagmire of paper chart quicksand? Is your office overflowing with rows upon rows of filing cabinets all jam-packed with loose, dog-eared, and illegible handwritten notes? If you were audited today, would you be able to easily find the notes you made to justify that your services were medically necessary on Sally Joe back in ‘06? If you answered no to any of these questions, you’re officially drowning in paper. Cut the clutter. Free your space. Demand organization. An EMR will allow you to electronically document, store, and access all of your precious patient information safely and securely. This way, everything you need will be at the tips of your fingers for years to come. And the best part? It will always be legible.

  3. You’re losing money on missed appointments and cancellations.
  4. Take a moment to think about how much each missed appointment and cancellation costs your clinic. Now think about how quickly that adds up! With an EMR, you’ll have access to electronic scheduling tools integrated with your documentation, so scheduling will be a breeze. Then, just a few days before your patient’s next scheduled appointment, you’ll be able to send an email, text, or phone call reminder automatically. Simply reminding patients that they have an appointment scheduled can significantly reduce no shows. And just one recouped patient visit per month could cover the cost of your EMR.

  5. You’re spending too many late nights finishing your notes.
  6. You got into therapy to help people. But instead, you’re spending most of your days—and nights—completing cumbersome paper documentation. Where’s the fun in that? And don’t forget about the dreaded writer’s cramp! Get back to what really matters—your patients—and ditch the pen and paper. With an EMR, you’ll have all your SOAP notes perfectly organized to fit your workflow. And, with just a few simple clicks, you can expand or collapse sections, create custom evaluation profiles, and finalize your notes. Plus, with an EMR, you can access your documentation safely and securely from any web-enabled device. So, if you choose to document outside of the office, you can—and you’ll still be fully HIPAA compliant. Talk about freedom.

  7. You’re tracking important clinic data manually—or not at all.
  8. How many patients are you seeing on average each day? What about the other therapists in your clinic? Do you know how many patients simply dropped off your radar? Or how close your Medicare patients are to hitting the therapy cap? If you can’t answer these questions without pulling out your TI-89, you’re not totally in the know about what’s going on in your clinic—and that can be a serious issue. Stay current on all things relevant to your clinic with an EMR’s integrated reporting functionality. You see, an EMR uses the data you’re already providing during documentation and scheduling to generate all the relevant reports you could ever want, including how productive each staff member is; how many inactive patients you should contact to bring back to therapy; and how close each Medicare patient is to reaching the therapy cap. This built-in reporting functionality will also alert you if one of your patient records is missing important information or if you forgot to complete a piece of required documentation.

  9. You’re spending a bundle on dictation services.
  10. One of the largest expenses many clinics face is the cost of sending out dictation for transcription. The good news is that it doesn’t have to be. Adopt EMR, and you can use a free dictation application—Dragon, for example—to complete any free-form section of your notes. It’s the best of both worlds—for those who feel most comfortable dictating and for those who prefer typing. Just think of what you could do to improve your clinic with the money you used to spend on dictation!

  11. You’re overwhelmed by the recent changes in documentation regulations.
  12. We don’t blame you. Between PQRS, the therapy cap, MPPR, and functional limitation reporting, there’s a whole lot to know if you’re treating Medicare beneficiaries and you want to get paid. Don’t worry, though. With an EMR, compliance is easy because you won’t have to do any of the heavy lifting. Just make a few more selections during your normal documentation, and the system will compile—and often submit—all that’s required to CMS. Plus, the best EMRs also offer a ton of great educational content so that you have all the information you need to feel confident about existing and upcoming requirements.

  13. You’re pretty sure you misplaced at least one patient record in the last seven years.
  14. It’s bound to happen—especially if you’re lugging stacks of paper charts to and from the office—but it’s definitely not okay. A HIPAA breach can cost you and your clinic big time—not to mention ruin the trusted patient-provider relationship. So what’s the best way to avoid a breach? Stop paper charting and start using an EMR—specifically, one that offers unique password protected entry and stores your patient’s protected health information safely and securely in the cloud.

  15. You’re not attracting top-tier talent.
  16. You’re looking to hire—and not just anybody. You want to bring on the best and brightest from the new generation of rehab therapists. But for some reason they don’t seem interested in working for you. Maybe that’s because this new generation is one of the digital age, and chances are they’ve spent at least one graduate-level course learning to document with EMR. The idea of going back to paper charting probably feels like going back to the days before smartphones and the Internet—not a happy thought. Plus, many appreciate paperless clinics—for going digital and green. Don’t resist change; embrace it. It will be good for attracting talent and patients alike.

  17. You’re missing out on opportunities to increase referrals.
  18. Do you know who your top referrers are? What about the ones who maybe need a reminder about your awesome services? If not, you’re missing out on generating a ton of new business. With an EMR, you’ll be able to track referring physicians so you can see who’s doing a fantastic job of promoting your clinic and who needs a little more attention. Plus, with an EMR, you’ll be able to brand your notes with your clinic’s logo so anything you send to a referring physician will demonstrate your professionalism and keep you top of mind. It’s marketing built right in.

  19. You’re falling behind your competitors.
  20. The leading EMR on the market right now has more than 21,000 customers and 5,000 therapy clinics. If you’re not already an EMR user, you’re falling behind your competitors who are. After all, the right EMR helps therapists save time and money, allowing them to be better in business. So don’t let your competitors pass you by.

    If any of these warning signs feel a bit too familiar, it’s time to do more than just toy with the idea of an EMR; it’s time to start demoing, today.