Hottest 5: Our Tips On Point Of Service Documentation

Jenn Ruoff, MS, OTR/L, BCG: Hey, Rachel, did you see these two bozos’ Hotter 5 video on what apps to use?

Rachel Read, MS, ORT/L, BCG, CAPS: Yeah, they…

Dr. Will Dieter, PT, DPT, GCS, FSOAE: I mean everybody saw it.

Rachel: They tried really hard.

Jenn: No, I’m pretty sure we had more views.

Rachel: They can’t touch us. We got more likes, right?

Jenn: Yes, right. Everyone goes back to the originals. But we thought we would spice it up a little bit and bring you guys our Hottest 5 series by adding a new member. So my name is Jennifer Ruoff. I’m the director of occupational therapy clinical services and our newest member…

Dr. Megan Valenzano, PT, DPT, GCS: I’m Megan Valenzano, our director of documentation review and Regulatory Affairs.

Jonross Neptune, MS, CCC-SLP: Jonross Neptune

Jenn: That’s fun.

Megan: Yeah that is a fun. It’s totally fun. Yeah that was fun ever.

Jonross: Jonross Neptune, the director of SLP clinical services.

Will: Hey, buddy.

Jonross: How are you doing?

Will: Good to see you again.

Jonross: Yeah, you, too.

Will: Will Dieter, director of PT clinical services.

Rachel: And I’m Rachel Read, EHR clinical director.

Jenn: And we’re here today to bring you the Hottest 5 on point service documentation. So do you want to get started?

Rachel: Yeah. So one of the, I think, the most crucial tips for when you start point of service documentation is just getting it started and scheduling it in your day. So building that documentation time within your client care-time as well.

So if you’re seeing clients from eight to four, having that hour window afterwards from four to five to do your documentation.

I prefer not to go home because I get easily distracted when I get home, so I may set up at a local coffee shop and finish up my documentation for the day so I don’t have to do it later at night because I find that it just that makes your day never feel like you’ve ended it. You’re just constantly working even if you have to do documentation at night.

Jenn: You think you’re getting on early, but you’re really not because you’re doing it at night.

Rachel: And then also building that time between your clients. So if you have five minutes even, just five minutes, you can get a lot of documentation in. And so just, you know, building that time and open up the laptop while you’re sitting in your car, do your documentation and then head out to your next client so that you, again, you’re just finishing up as much documentation as you can before the end of your day.

Jenn: Good one.

Will: It’s great way to look at it and a different way to look at it: spend extra time when you efficiency building your day.

So one of the things we talk a lot about and I think for anyone on an EHR system is to make sure that when you go to see that patient or client you get a note opened, you get the correct date put in, and you get the note saved at the very least. At least then, you’ve got a note opened for every day to service. You have the right date on it. That’s sort of the starting point.

And then from there you start to put in your vital signs. You start to do your visit verification. And when you do this consistently, the patients and clients start to understand and they start to expect it. They can remind you if you forget to do one of these things.

It just really sets you up nicely so that once all that is done. you’re There working with the person. You’re putting a little pieces of information in and, and you’re ready to go and you’ve got a framework that you can continually work with and always go back to and you’re never going to get stuck in a really bad spot — not remembering when I saw that person. What was the day? What did we do?

You’ve got something there.

Jenn: And if people are looking up your apps or your video, they would have their computer with them.

Will: So everyone’s going to have that up.

Jonross: Exactly.

Jenn: Right.

Will: Absolutely.

Rachel: Looking at you two.

Will: Of course.

Jonross: Tremendous points. One thing that I like to do in my daily documentation and…

There’s a fly.

Jenn: We have a sixth member.

Jonross: Is actually explaining the activity when I’m opening up in the system. So instead of just explaining the activity to the person without being in my electronic health records system, I’ll actually bring up that activity and key it in as I’m explaining it to the client of what we are about to do or what we’re about to accomplish in our treatment session. And then after the activity is completed and you’re going to put your trials in or your queuing methods that you use, you can really incorporate your caregiver education within that time, too, and get that put in and have the activity completed, signed, and move on to the next. And it’s something that really has helped speed up my documentation time and actually get more relevant information into the chart as well.

Jenn: Life changing.

Megan: The really important thing about that is when you’re documenting what you did is just really try and keep it simple, you know. Especially in my world of documentation, the thing that we’re we really want is to see the skilled care that he did that day.

And you don’t have to write big paragraphs to do it. You can simply write: Increased weight by 3 pounds because of muscle fatigue or changed from a compliant to a non-compliant surface. And those are all easy things such as you know a couple of little keys in there and you got your skilled care and you don’t have to worry about that later in the day.

Jenn: And the skill is the why.

Megan: The skill is the why.

Will: That’s what people are thinking of. It’s going through their heads. It’s just if they don’t write it down right then and there it’s hard to go back six hours later or two days later and try to remember all that.

Jonross: You might remember but it’s going to take you to three times longer to do that when you would just do it in and point of service, it would make a big difference.

Rachel: And you always say, Megan, to put what you’re doing not what a client is doing. And so I think that’s really valuable: it’s like what was your skill that day?

Jenn: Absolutely. It’s so much easier to do when you’re actually…

Megan: When you are actually doing it. Like, the big thing that they’re really looking for documentation is not necessarily what did the client do, but why did you have to be there to do it. You know, so that’s really really the key.

Jenn: So with all these great tips, mine is to talk about setting expectations with your clients.

That day one, talk to them about the need to provide time to do the documentation, to document everything that you’re doing in their interventions.

And if you’re not doing point of service, next week try starting with one client that you have currently that you seeing and try to incorporate all of these tips regarding scheduling, setting the date of service, educating and providing documentation on the activity, and then making sure that you’re keeping it simple and really justifying the why and the skill that you are providing.

So those are the Hottest 5 Tips on point of service documentation. If you want to look at our Hot 5 video, you can go on the FOX website and see it there, and their’s will be directly under ours.

Megan: Just remember, it took me for the hottest 5.

Jenn: Yeah.

Jonross: Yeah.

Will: Yep.

Rachel: Thanks, Megan, for taking us to that level.

Megan: Yeah.

Will: Bringing the fire.

Rachel: awesome

Liam McKenna: Done.

Will: Boom!