Is Point of Service Feasible for Occupational Therapists?
How many times have you been to the doctor or another healthcare provider and they spend half of your visit typing on the computer while you sit and wait?
This can definitely be frustrating when you really need the provider’s attention. This is a common situation enabled by point of service (POS) documentation.
As occupational therapists, we are often told to do point of service documentation more and more to help achieve our productivity standards. I’ve personally written about this, incorporating POS documentation into treatments to improve your productivity in one of my earlier articles titled “Practical Advice for Achieving Productivity.”
But the longer I’ve been practicing (in inpatient rehab and acute care), and the more I try to focus on hands-on and engaged occupational therapy treatments to my patients, I wonder:
- Is point of service documentation adding value to our patients and their treatments?
- Or is it just satisfying the needs of some facilities’ unrealistic productivity standards?
- Is spending more of our time with the patient documenting leading to poorer treatment plans?
- How can we maintain our required productivity but still give our patients the best care we can?
I hope that this post will provide some thought and insight to these questions.
What is Point of Service Documentation?
Point of service documentation means that you complete or work on your documentation while you are treating your patient. In other words, you document at the same time that you treat a patient.
The reason why this helps your productivity is that it cuts down your documentation time after your treatments.
If you complete all or most of your documentation during treatments, you will generally be done with your day sooner which will cost your company less money in wages.
In our modern healthcare system, it sometimes seems like healthcare companies, especially for-profit ones, have a big incentive to cut costs and increase profits. Because of this, they will sometimes encourage you to get as much of your work done during treatments (billable time) as often as possible.
Is There a Catch?
The main drawback to point of service documentation is that it does take away from your attention paid to your patients. Less attention can equate to a poorer treatment session. I can verify this firsthand from personal experiences with other providers as I mentioned earlier.
When you’re writing a note, you can’t fully focus on your patient. When under pressure for high productivity, therapists may give their patients simple exercises like putting them on the UBE/arm bike or NuStep to write their notes, for long periods of the treatment session.
The patient might need activity tolerance retraining, but instead they’re slowly pedaling away while the therapist is busy writing their notes for the day.
Many of our patients do benefit from hands-on attention, especially during ADL retraining. If you’re providing a quality ADL retraining session, you probably won’t be able to really get into your documentation.
One exception that does sometimes work is during showering with a higher level patient as long as you’re still within arm’s reach if needed. Even then, it can still be stressful with the thought of the patient slipping while you were writing notes instead.
Other treatments like hands-on neuro re-ed treatments, manual therapy or transfer training also are not conducive to documenting. As a rule of thumb, if you’re providing fully focused and hands-on intervention you probably won’t be able to document at the same time.
Can You Involve Your Patient During Point of Service Documentation?
If you do need to spend the last few minutes of your treatment session writing your note, you can include your patient in the documenting.
I’m not 100% opposed to point of service because it can be helpful at times, and I do personally complete point of service myself at times, when appropriate. When I work on a note during my treatment, I will oftentimes discuss with my patient what I’m writing and inform them of their progress thus far.
It’s also a good opportunity to educate them on why they’re doing the intervention you’ve chosen and a good time to discuss any other obstacles they would like to work on. This will lead to increased patient satisfaction in the long run since therapists don’t always take the time to discuss this.
A good point brought up by another occupational therapist in an OT Facebook group was this:
If your patient is significantly cognitively impaired, reviewing your notes with them might not be a good tactic. The patient could be engaged in something more therapeutic than listening to a recitation of their goals as you document.
I generally don’t spend more than five minutes discussing goals and progress while documenting during the treatment unless the patient is safe and engaged in their appropriate intervention.
Another point made from Advance Healthcare Network’s Physical Therapy Medicare Advisor in the article “Point of Service Documentation” is that…
“Discussing progress with the patient, teaching the patient about the disease process, obtaining information from them that relates to our treatment that day, as well as performing observation and assessment is skilled therapy and should be included in the time billed. However, having the patient just sit there while you are reading what you are typing is not skilled treatment.”
When Point of Service is Not a Good Option
As an example, if you have an impaired neuro patient, or a medically complex patient in general, it is best for them to provide hands-on treatment.
With insurance companies getting more and more strict with rehab length of stays, the patient likely only has a few days or a few weeks of occupational therapy (if they’re lucky), so we don’t want to short-change them on their minutes. Consider saving the documentation for these patients for after the treatment is over.
While your productivity might be affected, it’s not worth skipping on giving your patient the best treatment they can get in the very short therapy time frame they have.
Be Thoughtful About Using POS Documentation
The general takeaway I want to give is that if you’re going to attempt point-of-service documentation, make sure it is appropriate to do so.
Ensure your patient is safe and that you are incorporating them in the documentation process. As you gain experience, you’ll quickly be able to recognize when it is actually appropriate to use point of service.
When I have a day of hands-on patient care and have no time to do point of service, I honestly don’t let myself stress about it even if my productivity is below the requirement.
We all got into this career to provide our patients with the best care we can give them. This is something to remind yourself on those bad days when you’re worried about the “numbers.”
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I hope this post clears up any questions you may have about point of service documentation in occupational therapy, especially if you’re a student or new OT practitioner.
I would love to hear if you have any thoughts on this matter, or any other tips for successful point of service documentation in OT. When has it worked for you? When do you find that it is not appropriate? Thank you for sharing your thoughts!
This post was originally published on November 28, 2016 and updated on December 7, 2023.
Point of service documentation is truly difficult if you’ve based your career on providing your patient with the best opportunity to succeed towards regaining their mobility. I have practiced for nearly 30 years and I am so grateful for the period of time in which I was blessed to practice. I am truly challenged by this current practice of point of service documentation in which you are expected basically neglect the true needs of the patient to assure your documentation is done during the time your hands should be on your patient. I’ve witnessed so many patient’s hanging on UE exercisers, hand grippers, pegs and pegboards while their potential to gain stability is neglected because the therapist is preoccupied with documenting. POS also delays patient progress because more aggressive treatments are not able to be attempted. It is even more frustrating, because these managers would never even fathom that there is anything wrong with this practice.
I agree, but even the managers are under the pressure of the companies.
Point of service is rarely possible if you are providing truly “skilled” therapy. Putting a patient on a bike (stationary/arm) is NOT skilled therapy because anyone can do it. With more involved patients, hands on is a must for safety and instruction. Per Medicare, documentation is NOT a billable service (although it takes skill) so purely speaking, POS is fraud. Most rehab companies believe that if you are with a patient, whether he/she is engaged POS is legitimate but this is not true. Most of the time patients are not engaged because our attention is on our documentation and not them. It takes me longer to try and document while I am with a patient, then waiting after when I am not distracted to complete a good note. One of my supervisors told me I could take a charts into patients’ rooms during an evaluation and bill for chart review time because the patient is present. Char review is NOT billable whether it’s done outside or inside the patient’s room. These rehab companies are crossing the line into fraudulent and unethical practices/
Carol,
I totally agree with you. I am so frustrated by my companies mandate to document at point of service. Yesterday, I was told to go as far as to bring a patient with me to the nurses station if I needed to file a communication form or to stand in the patients doorway until I can flag down a nurse or CNA. This way, I am in the presence of the Pt which makes it billable. I am so disgusted with the practice of their unethical POS documentation, and lack of concern on the quality of service. I work in a intermediate facility, so my patients require hands on 98% of the time, and this is just infuriating to me. Our productivity requirement as a COTA or PTA is 90%, our young DOR, yesterday informed us that she wants to review our billing and notes daily and if we do not hit the mark they want a written explanation. No time between patients for therapist to discuss patient concerns, use the bathroom, or take a 5 min break.
It’s gotten truly awful, making it more stressful for the patients as well as the therapists. How did we, the therapists, allow productivity percentages to keep climbing? When is it going to stop? It seems, only to increase each year, making it exceedingly more difficult to provide valuable therapy?
I think POS documentation is only sometimes appropriate for a daily note. for a weekly note or an updated plan of care you can’t be treating and on the computer at the same time. To do so Nd huge inurance for minutes of treatment when the minutes were spent documenting is fraud in my opinion. I was asked to do this on my first and perhaps my last traveling PT assignment. I verbally refused to do it.. for my ethics my pay was docked. What has happened to my profession.
I completely agree and find it really frustrating/unethical that therapists are being pushed to bill weekly notes as treatment time in some settings, particularly SNF settings (although there are still ethical ones out there!) I’m so sorry you had this experience and that it soured your travel therapy experience. What I’ve personally found is that working for non-profit hospitals, particularly in acute care, there can be less pressure on productivity and point of service. If you would be open to a travel acute care position, I would recommend trying that out!
I’ve been a therapist for 32 years. POS documentation is the worst thing that has ever happened to this profession. On the days that I’ve given my best therapeutic interventions and went home feeling like a “real” therapist and good about what I was doing, were the days that my productivity percentages were horrible. On the days that I managed POS documentation and went home feeling like I’d “done good” for the company, were the days that I felt like I’d given mediocre therapy. There are very few circumstances where the documentation is actually therapeutic. How are you to educate a patient while typing? Therapy is hands on. You cannot merely tell a patient what they should be doing while typing on a computer. You need to be showing them. Sorry to say, I’m becoming increasingly disgusted with this practice and find it very unnerving that therapists are being lulled into believing this is billable therapy. Everyone is so afraid of losing their jobs that they’ll compromise what is right with what makes the most profit for the company. I’m tired of upper management’s attempts at brainwashing me into believing that this is okay. I know better. I was practicing OT when some of these upper management individuals were still in diapers. New grads don’t know better because this is how they’re being trained. I find it disgusting that management doesn’t even seem to care about retention of good therapists. They’d rather use them, burn them out and move on to the next new hire. Now they’re talking about artificial intelligence providing therapy with the therapist remotely controlling several sessions at one time. Are you kidding me? I’m so glad that I’m closer to retirement than just beginning my career.
I am a new grad and very frustrated with POC documentation. If I am lower than 85 percent productive (even 84.9%) I get written up and if that happens 3x I am fired. I do not feel like I am giving my patient’s the care and attention that they need when I am following POC documentation, but I am either forced to clock out early to complete notes or document while I am with a patient and basically have them do activities that are not skilled. I am already “burnt out” and I haven’t even been practicing for a year.
I hate to see that you’re going through this! I know it’s so hard to find a job as a new grad, but now that you’re getting some experience, I recommend applying to non-profit OT jobs (like hospitals; either acute care or inpatient rehab as a few examples). From personal experience, these settings are often much more laid back about productivity standards and will have lower percentages as well.