How many times have you been to the doctor and they basically ignore you to type on the computer while you just sit there?
It can be infuriating if it happens every time you have an appointment. Unfortunately, this is a common situation enabled by point of service (POS) documentation.
As occupational therapists, we have been told to do POS documentation more and more to help achieve our productivity standards. I’ve even written about incorporating POS documentation into treatments to improve productivity in one of my earlier articles titled “Practical Advice for Achieving Productivity.”
But the more I practice giving quality occupational therapy treatment to my patients, the more I wonder:
- Is point of service documentation really adding value to our patients?
- Is it just satisfying the needs of our facility’s unrealistic productivity standards?
- Is spending more of our time with the patient documenting leading to poorer treatment plans?
- How can we maintain decent productivity but still give our patients the best care we can?
This post offers a few words of advice to these pressing questions.
What is Point of Service Documentation?
If you haven’t yet heard of this, point of service documentation means that you complete 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 assists your productivity is that it cuts down your documentation time after your treatments.
If you complete most of your documentation during treatments, you will generally be done with your day sooner and thus cost your company less money in wages.
Sadly, it sometimes seems like healthcare companies’ main mission is cutting costs. Because of this, they will encourage you to get as much of your work done during treatments as possible.
Is There a Catch?
The main drawback to point of service documentation is that it takes away from your attention paid to patients. Less attention generally equates to a poorer treatment session.
When you’re writing a note, you can’t fully focus on your patient. When under pressure for high productivity, therapists will give their patients simple exercises like putting them on the UBE/arm bike or NuStep to write their notes.
The patient might need activity tolerance retraining, but instead they’re slowly pedaling away while the therapist is busy writing notes.
Many of our patients need hands-on attention, especially during ADL retraining. If you’re providing a good 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 worrisome during bathing tasks if the patient slips and you were writing notes instead.
Other treatments like hands-on neuro re-ed treatments or transfer training also are not conducive to documenting. As a rule of thumb, if you’re providing good, effective treatment you probably won’t be able to document at the same time.
How to Involve Your Patient During Point of Service Documentation
If you absolutely must spend the last few minutes of your treatment writing your note, you can include your patient in the documenting.
When I do 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. This can lead to increased patient satisfaction in the long run since a lot of therapists don’t necessarily take the time to discuss this.
A good point brought up by an OT in one of my many OT Facebook groups 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.
“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.”
I couldn’t have said it better myself.
When Point of Service Won’t Work
As an example, if you have an impaired neuro patient you should be providing hands-on treatment.
With insurance companies getting more and more strict, the patient likely only has a few days or a few weeks of occupational therapy, so definitely don’t 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.
I say this in the nicest way possible:
Don’t be that therapist that just sticks the patient on whatever piece of equipment or gives the patient a pointless activity and neglect them to do notes.
This is one of my biggest pet peeves as a therapist if you couldn’t tell!
Be Careful 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 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 horrible.
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.”
I hope this post clears up any questions you may have about POS, especially if you’re a new clinician.
I would love to hear if you have any other tips for successful point of service documentation. When has it worked for you? When has it been impossible to complete?