Jun 24, 2012
3
0
Status
DPT / OTD
Hey guys i am foreign trained physical therapist and just got a job in SNF/Rehab center. I am really worried about my documentation skills as i have near no experience with US documentation.

Any important points or guidance on how to deal with it or any suggestions on what and how to keep your job for new PT?
 

NewTestament

7+ Year Member
Nov 4, 2010
1,323
416
Itinerant
Status
DPT / OTD
1) Take your time
2) Double-check everything you do
3) Get as much feedback as possible
4) triple-check everything you do
5) make sure they actually train you to use the system

Documentation isn't easy for anyone and learning a new EMR is always a challenge.
 
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OP
D
Jun 24, 2012
3
0
Status
DPT / OTD
1) Take your time
2) Double-check everything you do
3) Get as much feedback as possible
4) triple-check everything you do
5) make sure they actually train you to use the system



Documentation isn't easy for anyone and learning a new EMR is always a challenge.
Thanks!! Yes i will definitely double check everything. Do you know what happens if your clients insurance gets denied bcoz of improper documentation?
 

starrsgirl

7+ Year Member
Oct 5, 2010
1,021
556
Status
Physical Therapist
Every documentation system is a little different. And every place has different things they expect in their notes. So even for a US trained DPT, the documentation process changes a lot. What is your training timeline? Will you have a mentor for the first few days? I would just ask another PT to walk you through how they do notes (maybe even 2 PTs). Ask them to show you a few notes they did that day. Also, when you are charting on a patient, you can certainly bring up their previous session's notes to review and use them for ideas on what is generally included.
 

webcrest

2+ Year Member
Aug 19, 2016
4
1
Status
Pre-Health (Field Undecided)
  • taking the patient / client history,
  • conducting a systems review, and
  • performing tests and measures to identify potential and existing problems.