Point-of-service documentation: does it work?
A common suggestion for therapists behind on notes, and where it holds up.
Point-of-service documentation, writing your therapy note during the session instead of after it, works for some sessions and not for others. It can recover documentation time, and it can also take your attention away from the patient.
It's a common suggestion for therapists who are behind on notes or behind target. Whether it works for you depends on the patient, the session and your documentation system more than on how hard you try.
The case for point-of-service documentation
The time saving can be large. A note written in the room removes a task that would otherwise sit at the end of your day. Take an example: 60 minutes of notes a day, five days a week. Moving half of that into sessions recovers 30 × 5 = 150 minutes, or 2.5 hours a week. Across 46 working weeks, an assumption that allows for leave and holidays, that is 2.5 × 46 = 115 hours a year. The documentation time calculator runs the same sums with your own figures.
Accuracy can improve too. A note written at 5:40pm about a 9:15am session is written from memory. By then it's easy to lose the specific details, such as reps, assist levels or the patient's own words. Those are the details that show skilled care. A note written in the room records them while they're in front of you.
Your employer or payer may also have its own rules on when a note must be completed. Check them before you change how you document.
Where point-of-service documentation works well
A workable rule is to document while the patient rests or exercises alone, and to stop while you're talking with them. Typing while a patient tells you how their week went splits your attention at the moment they're speaking to you.
Patients who need rest breaks. Cardiopulmonary, post-surgical and deconditioned patients already have recovery periods built into the session. Writing during them doesn't take time away from the patient.
Independent exercise portions. If the patient is safely working through a set, that's documentation time you don't have to find elsewhere.
Established patients on stable programs, where the note mostly confirms the plan and the session doesn't need continuous hands-on attention.
Settings with a computer or tablet already in the room, so you don't have to fetch and set up equipment before you can write anything.
Where it doesn't
Evaluations. A first session is where you build rapport and where the patient decides whether therapy is worth their time. Splitting your attention between the person and the screen at that moment is a poor trade, whatever it does to your numbers.
Cognitive, behavioral and pediatric work. With children, distressed patients and anyone with cognitive impairment, the intervention usually needs your full engagement. Documenting during those sessions changes the session.
Complex transfers and any task with a falls risk. Don't document during these tasks, even on a day when the schedule is tight.
Patients who find it rude. Some patients find it rude, with reason. A patient who feels documented rather than treated may tell you less, and you learn less from the session.
A split approach to therapist note taking
Between full notes in the room and full notes at 6pm, you can capture data in the room and write prose between patients.
Numbers, reps, distances, assist levels, blood pressure and the patient's own words are quick to record. They also need to be accurate, and they're the details most easily lost by the evening. Clinical reasoning, skilled justification and the plan can be written between patients, for example in a four-minute gap, or in a protected documentation block.
How much time the split saves depends on your setting and your documentation system.
How to trial it properly
Pick one week and one category of patient. Established patients on stable programs are a sensible starting point. Track two things: the minutes of documentation left at the end of each day, and anything you noticed about the sessions themselves.
At the end of the week, compare. If your documentation time dropped and the sessions didn't feel compromised, extend it to another category. If sessions felt worse, stop, and say so if anyone asks why you aren't doing it.
Here is an example of how to report the result: "I tried it for a week with my stable outpatient caseload. Documentation time dropped by 20 minutes a day. I'm keeping it there but not extending it to evaluations." That is a specific position based on your own week's figures. The guide on how to track therapy minutes yourself covers the daily record.
When the target is the problem
Point-of-service documentation is sometimes offered as the answer to a productivity target that is too high for the work involved. It is a real efficiency. It can also leave each clinician to make up for a target that is too high by changing their own habits.
If your department answers every productivity conversation with a documentation tip, look at the arithmetic instead. Measure your documentation load, then check what the target assumes about your available time in the therapist productivity calculator. If the same minutes have to cover a larger caseload, the caseload calculator shows how many patients your available time supports. To raise it with a supervisor, start from the guide to the supervision conversation when you're below target.
The EMR question underneath it
Point-of-service documentation is far easier in some electronic medical record (EMR) systems than in others.
A system with fast templates, sensible defaults, a usable tablet interface and few mandatory fields makes point-of-service documentation quick. Now take a system that needs eleven clicks to open a note. It times out when you put the tablet down and asks for the same information in three places. In that system, clinician technique can't make point-of-service documentation quick.
If your department is pushing point-of-service documentation on an EMR that fights you, say so plainly and specifically. An example: "It takes 90 seconds to open a note and the session is 30 minutes." EMR configuration may be adjustable even when the software can't be replaced.