Point-of-care documentation (also known as point-of-service documentation) is not always appropriate, and there are some billing considerations to keep in mind (see "When Can Pediatric Therapists Bill for Documentation Time?"). But overall, point-of-care documentation is a great way to improve productivity at your pediatric therapy clinic.
If you're ready to give it a shot, here are five quick tips you can use to optimize your point-of-care documentation workflow:
1. Dictation Software
Dictation software can be a lifesaver! Tools like Dragon NaturallySpeaking can increase your productivity by allowing you to record notes hands-free. If you’re on a budget, Apple Dictation, Windows Speech Recognition Windows Speech Recognition, and Google Docs Voice Typing are free options.
This sort of software is great for people who are slow typists, or for times when you’re working with a patient who requires a more hands-on approach.
2. Plan Ahead
Take a look at your planned activities and try to map out the times you’ll be able to document. By going in with a specific game plan, you’ll be more likely to make the most of every minute during a session.
3. Find the Right EMR for You
If you’re going to be doing point-of-care documentation, you’ll definitely want therapy software that doesn’t require a desktop. Then it just comes down to whether you prefer to work with a laptop or a tablet. This will depend on how you work and how your clinic is set up.
Since speech-language pathologists are generally able to be more stationary, a laptop is probably a good fit for that discipline. (Then again, you may have so many materials for your kiddo that there isn't enough on the table!) For physical therapists, the hands-on nature of most treatment might make a tablet a better fit (you might want to look into a dictation app if that’s the case).
Whichever you prefer, just make sure that the therapy notes software you choose works on the device that works best for you!
4. Know Your EMR
To work efficiently, you’ll need to be one with your EMR. So learn your way around! Be familiar with your EMR’s format so you can breeze through documentation without having to stumble around looking for the right place to put things.
That means you’ll need to be familiar with how your EMR structures the template, and be sure to take advantage of any features that make point-of-care documentation easier (e.g., Fusion’s Quick Phrases).
5. Find a Pediatric-Specific EMR
Find an EMR that is focused on pediatrics first. Many EMR’s have pediatric “add-ons” but there can be big differences between an “add-on” and tools specifically designed for pediatrics first. If you’re a pediatric therapist, you should find an EMR that was designed with you in mind. That way you won’t have to spend time scrolling past irrelevant fields, or manually formatting test results.
A pediatric-specific EMR will make you more efficient by providing a pediatric format for notes and including pediatric content. By using an EMR that’s specifically designed for pediatric therapy, you can rely on pediatric goal banks, assessment content, and standardized tests to help you speed up your workflow.
Point-of-care documentation may take some getting used to, but the sooner you start, the sooner it will become second nature to you. Eventually you won’t believe there was a time when you spent so many hours outside of work on documentation!
But Wait! There's More
For even more help optimizing your documentation process, we've created a Pediatric Therapy SOAP Note Kit that you can download below. It includes four resources to help you document more efficiently. Combine these resources with point-of-care documentation and you'll be breezing through your notes in no time!
Pediatric Therapy SOAP Note Kit
This kit includes:
SOAP Note Template
7 Tips to Improve Your Pediatric Documentation Handout
SOAP Note Checklist Handout
SOAP Note Examples
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