6 Ways To Make Pediatric Physical Therapy Documentation Quick and Easy
Pediatric Physical Therapy Documentation is very different than adult orthopedic and neurological physical therapy documentation because when you’re working with kids, the interventions you are completing are play based, functional, and take more critical analytical skills to produce documentation that is authoritative and skilled. Often in PT school, Student Physical Therapists are taught adult based Physical Therapy Documentation and left to learn Pediatric Physical Therapy Documentation on their own. Here are 6 ways to make pediatric physical therapy documentation quick and easy, along with a resource at the end that will help you enhance your Pediatric Physical Therapy Documentation skills with ease.
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Take notes during your pediatric physical therapy session
Taking notes is a huge time save when you’re completing pediatric physical therapy documentation. Pediatric PT sessions move really quickly and if you are not taking data in real time, it is quite easy to forget which leg lead when going up the stairs and which leg lead when going down the stairs (especially since they’re often opposite).
Taking notes ensures that you have specific data to go back to when you start your SOAP note, Evaluation, Progress Note, or Discharge. It also ensures that it’s as accurate as possible. While taking notes during sessions is helpful from a productivity stand point, it isn’t always realistic, and going off memory is difficult, time-consuming, and generally inaccurate (especially if you check out the data on witness accuracy, I cannot imagine PT accuracy is that much different a few hours after an appointment or even a day later).
When you go to write a SOAP note off of a pre-written note, there is a much higher likelihood of its accuracy, it also works as a cue for your brain to remember more details for the note like the specific exercise the child was doing, the position they were in, and what activity you did before and after the one you jot down.
Create your own shorthand abbreviations for your PT data
Taking down notes for pediatric physical therapy documentation does not have to take that much time, especially if you create your own written language for data points that you use for specific circumstances. Abbrevations used in pediatric documentation that is official such as SOAP notes typically must be either spelled out in advance ie BL (bilateral) then use BL for future sentences in the note or they must be universally recognized by the medical community.
When you write your short hand notes in a small notebook, however, you can write whatever you want down that is quick and easy as long as you know what it means. Personally, that means using abbreviations including arrows up/down for ascending/descending stairs, LLE up arrow if the left leg led while ascending stairs, or LLE down arrow if the left leg led when descending stairs. Other common abbreviations I use are: RGP (recirpocal gait pattern), STGP (step to gait pattern), sit <> st (sit to stand and stand to sit transitions), etc. There is freedom for you to create whatever abbreviations help you, including using fractions for successful trials/total trials ie 4/5 would mean that 4 times the child completed the trial successfully, but you completed it a total of 5 times; therefore the child was unsuccessful 1/5 times.
Time yourself to make pediatric physical therapy documentation quicker.
Writing pediatric physical therapy documentation notes, progress notes, evaluations, discharges, IEPs, etc can take different amount of lengths depending on the child, the circumstance, whether there are on-going legal concerns, and/or depending on the detail required by insurance companies, doctors, bosses, etc. I do find that it is extremely helpful to time myself when typing SOAP notes and other styles of notes.
I find that SOAP notes can take me anywhere from 5 to 15 minutes, depending on my level of detail and length of the session. If you’re just starting out as a PT student, it might take you 30 minutes per SOAP note and multiple hours for an evaluation. It’s important to build a time goal into your documentation skills as this is a specific skill set needed to maintain both productivity and also your sanity. If it takes you 30 minutes to write a SOAP note ever single time you see a patient, your workload will double and you will likely be very unhappy.
Using timers and the Pomodoro principle where you are writing for 25 minutes and then take a 5 minute break can increase your effectiveness and focus. Note also that if you distract yourself by googling something or checking your phone it will take you 15 more minutes to focus, during which time you could have another note written.
Understand what goes where
Learning the differences between subjective, objective, assessment, and plan data and information can be tricky in the pediatric physical therapy documentation world. Ideally, subjective information is information gathered prior to the start of the appointment and history of what happened since the previous visit, usually given via a parent or teacher report. It can also include upcoming concerns, dates, or information.
Objective information is data-driven and activity-focused, it includes specific interventions done in the PT session or evaluation and the data collected. In pediatrics it is a little harder to tease out the objective and assessment data from each other. If you need additional resources including prompts for sentence structure and questions to help you figure out what is objective and what is assessment, the book The Ultimate Guide to Pediatric Physical Therapy Documentation will be a helpful resource for you.
Create key phrases to use for your pediatric documentation
Having specific key phrases that you go back to in order to get your point across and make sure that you are not missing anything can be really helpful to systemize in your brain. Examples include a signs and symptoms (sx) statement in your assessment section to note pediatric physical therapy impairments in the documentation. For example, a child who is struggling with crawling and has a medical diagnosis of developmental delay may have a signs and sx statement that looks like this, “Johnny presents with signs and sx consistent with a medical diagnosis of developmental delay and gross motor concerns that are resulting in delays in crawling including decreased strength in core, hip and shoulder girdle muscles as well as decreased motor planning necessary to attain independent mobility.”
Other examples of key phrases include, “Skilled PT is necessary in order to xxx,” at the end of the assessment paragraph of each SOAP note or a specific phrase in the Plan section that includes, “continue with Plan of Care (POC).”
Buy The Ultimate Guide to Pediatric Physical Therapy Documentation for Student Physical Therapists and PTs Transitioning into Pediatric Practice book.
There are so many specific nuances of documentation in the pediatric world that are required in order to have your interventions sound skilled and authoritative. It is important that documentation shows the expertise that the Pediatric Physical Therapist brings to their interventions and differentiates the intervention from play based activities that the parent is able to do on their own.
If you’d like more information on how to master Pediatric Physical Therapy Documentation, please check out The Ultimate Guide to Pediatric Physical Therapy Documentation for Student Physical Therapists and PTs Transitioning into Pediatric Practice on amazon.
You’ll Learn How To Document:
Pediatric Physical Therapy Evaluations
Progress Notes, Treatment Sessions, and Discharges
In both the school and medical model settings (outpatient and hospital based)
It’ll include examples of:
Understanding PT documentation
Expressing interventions as skilled
Differentiating between objective and assessment data
Simple sentence structures and examples
Includes both medical model (outpatient) and school based documentation (including goals)
Examples of letters of medical necessity, incident reports, IEP, and discharge statements