Evidence-Based Analysis: Does Point-of-Care (POC) Documentation Result in Lower Patient Outcomes?
We’ve all heard both sides of this discussion:
- Therapists need to document at point of care. Real-time documentation enables the therapist to stay on track throughout the day, leave work on time, and avoid documenting from home
Vs.
- Spending time “hands on the computer” instead of “hands on the patient” is wrong. We didn’t go to P.T. school to be “keyboard jockeys.” Treatment is the only thing at improves progression – as such, we need to maximize our treatment time with the patient – and document later
Putting emotion and opinion aside, Systems 4PT settled this discussion by conducting a landmark, evidence-based analysis of 776 therapists over the span of 663,000 patient visits. All therapists involved were documenting on Systems 4PT EMR. The therapists involved followed their normal approach to treatment and documentation and did not know they were being measured.
During the research project, Systems 4PT analysts tracked a variety of data points for each therapist. For this discussion, we will focus solely on our point-of-care documentation research, which identified:
- Whether or not the therapist documented at point of care during daily visits
- And if the therapist did document at point of care, what percentage of the daily note was completed during the patient’s visit
Likewise, Systems 4PT analysts tracked progression for each patient being treated. Our analysists identified, by patient:
- The percent of patient progression (eval to discharge) based on improvements in functional outcome test scores
- The number visits required to yield that progression
Findings
Therapists who documented 75% (or more) of their daily notes at point of care had EXACTLY the same patient progression as therapists who documented their daily notes later.
__________________________________% Patient Progression # of Visits Required
>75% of Patients Documented at POC: 53% 14.0
0% of Patients Documented at POC: 53% 15.0
And therapists who documented most of their daily notes at point of care averaged a 6.7% lower visit rate (14 days vs. 15) as opposed to those who documented later.
Not all patients can be documented at point of care. Complexities in diagnoses and schedule abnormalities sometimes interrupt the process. Even so, signing the daily note before 75% (or more) of your patients leave your facility would a have a significantly positive impact on your lifestyle.
Workflow is the Key:
Therapists who successfully document at point of care have learned to “develop the note in their head,” while treating. Then, during a modality, or while observing therex or during patient transitions, the therapist updates the daily note. On average, documenting the note and the flow sheet/treatment plan within Systems 4PT takes 2 minutes. This workflow does not reduce hands-on treatment time.
Note: All of the 663,000 visits analyzed were documented on Systems 4PT’s EMR. These results may or may not hold true with other EMR software. In particular, slower checklist approaches to EMR would likely yield different results.
We live in a world of science and evidence. It is appropriate for therapists to be fair to themselves and apply the same evidence-based thinking to how they document.
The Numbers Tell the Story:
Therapists who document most of their daily notes at point of care:
- Deliver the highest progression of functional deficits
- Equal progression with those therapists who documented 0% at point of care
- In 6.7% fewer visits vs therapists who document nothing at point of care
And no doubt, these therapists:
- Go home earlier than those who documented 0% at point of care, and
- Spend less time catching up on notes at home vs. therapists who documented 0% at point of care
Prove it to yourself with a no-charge, no-obligation, hands-on Systems 4PT EMR trial on your own computer.
Be fair to yourself. Maximize patient outcomes – and take your life back!