Physical Therapy Documentation And How To keep Them Safe

Physical therapists are required to keep accurate medical charts for each patient. Though these charts may be on paper, many physical therapists are switching to fully computerized charts. Physical therapy documentation may be necessary for the referring doctor, lawyers, or employers if the patient was injured on the job.

Physical therapy involves the treatment of disabilities and injuries. Many times, the causes of these injuries are from accidents like car accidents, falls, or lifting heavy objects. If the patient received an injury at work, the employer might need to see some documentation. A lawyer might require physical therapy documentation if the patient’s injury was caused by another person’s negligence or willful act.

If a clinic is using paper physical therapy documentation, the storage of the files can end up being a significant concern. Also, if a copy of part of the chart is needed, the staff must be able to go search for the file and make copies of the needed information. In a busy office, the staff don’t always have time to retrieve a chart from a separate area of the clinic.

Unlike physical therapy forms which can be pre-printed, physical therapy documentation stored on the computer can make finding and printing the necessary information faster and easier. A physical therapist can easily access the patient’s records from the computer and add notes or document more treatment. Some physical therapy documentation software contains templates for different types of injuries or impairments that are treated with physical therapy. These templates make it easier for the physical therapist to add the information about the diagnostic tests and treatments administered.

A physical therapy documentation software can let the physical therapist know if something is missing or incomplete. This prevents the records from being incomplete or for the physical therapist to have to struggle to figure out how to fill in the blanks. At the end of the day, the physical therapist simply can check for any incomplete notices on the dashboard of the physical therapy documentation program.

Some software programs like this also allow the therapist to write a treatment plan for the patient. This way, the physical therapy documentation is kept in the computer file with the completed treatment and diagnostic tests. The therapist can add text notes in addition to template fields.

Physical therapists may be concerned that they would lose their documentation that is kept on the computer. A physical therapy documentation software program installed on the office’s computer network could be susceptible to data loss if the computers would become inoperable due to a natural disaster or virus. It is equally important that while digital storage is available that physical therapy documentation has a backup storage.

Typical web-based software keeps the patient data in secure files that can be accessed through an internet connection by the clinic staff. Before using any kind of physical therapy documentation software for patient records, the physical therapist should consider how the patients’ data will be safeguarded.


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