Paper medical records are quickly becoming a thing of the past. Electronic Health Records (EHR), also known as Electronic Medical Records (EMR), are required by the ACA and provide an efficient method for members of a diverse healthcare team to track patients’ treatments and progress. Still, the transition from paper charting to electronic charting can be challenging as healthcare professionals need to master an entirely new system. The following suggestions can facilitate documentation best practices among your staff.

Three Valuable Documentation Tools

Create the following tools to help your employees sail through implementation. These include:

  • Documentation In-service and Stand Up Meetings. To make sure everyone is on the same page, provide introductory trainings for new employees that show what electronic documentation should look like. If you can, have your facility’s media department videotape your training session for therapists who can’t make the meeting in person. Follow up your introductory training with weekly 15 minute stand up meetings where your therapists can ask documentation questions and get new information in a group setting. These meetings are absolutely necessary to help your staff understand and comply with your documentation expectations. These non-billable hours pay for themselves in uncontested reimbursements!
  • Documentation flow chart. To help speed up your therapist’s productivity during the electronic charting process, you can create a flowchart of steps. Provide a printed copy of the flow chart to new therapists at orientation and post them near charting stations. Therapists should be able to follow these steps for the fastest route through the software requirements. This will improve efficiency and serve as a back-up reference to your in-services.
  • Software cheat sheet. Every documentation software product requires the repeated entering of patient information in a certain order. A cheat sheet reminds therapists what information to gather and where to click to speed through the steps of each module. This reminder sheet can serve as a quick reference for therapists until they have memorized the steps of your particular EMR system.
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Make the most of your “Expert Users.”

Which of your team members is the most efficient at electronic documentation? What methods do they use to enter medical records into the system? Most likely they’ve developed their own unique short cuts that could be shared with the whole team. Utilize your staff members who are naturally gifted at electronic communication to train and answer other team member’s questions.

Additional documentation resources from myPTsolutions

For more information on using documentation best practices in your facility, you can check out our past blog posts on managing productivity, screening job applicants and preparing for ICD-10 implementation.

Do you need to supplement your workforce?

To round out your staff with physical or occupational therapists or speech language pathologists, check out myPTsolutions. We’ll work with you to place exactly the healthcare staff you need for your facility. Contact one of our experienced Therapy Consultants today to learn more!

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Increase Your EHR Efficiency – Documentation Best Practices was last modified: by



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