Episode 99: The Woes and Wows of Documentation

The goal is to learn , inspire and bring Cardiopulm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to today's episode of Talking All Things Cardiopulm . I am your host , Dr . Rachele Burriesci .

Before jumping into today's episode , I wanted to put a plug in for the Innovative Treatments Effortless Documentation Summit hosted by the Note Ninjas on May 6th , 7th and 8th . It is a three-day free virtual event . You have access to all of the pre-recorded sessions for that day for 24 hours and then you can upgrade for 20 contact hours for either PT or OT .

I'm going to drop the link in the show notes . If you're interested , if you're a PT or OT , or if you are working in a department and you have other PTs and OTs that are there , share that link with them . This is going to be a great event 20 CEUs , 20 contact hours .

I always me and Nikki had a whole conversation about CEUs and contact hours the other day . I feel like you need a whole definition on that . So 20 contact hours is 20 hours of content from 20 experts in PT and OT and the lineup is just pretty awesome . We have high intensity neuro rehab with smart motor learning strategies .

We have documentation and assessments in home modifications . We have strategies to optimize breathing and performance . That's mine . The role of heavy resistance training and rehab and injury prevention for middle age and older adults . Enhancing geriatric evaluations . Integrating caregiver wellness for optimal patient outcomes . Enhancing Geriatric Evaluations .

Integrating Caregiver Wellness for Optimal Patient Outcomes . We have Creative Solutions to Enhance Patient Care and Promote Optimal Independence . An OT Approach to Dementia and Bathing , BPPV Basics and Updates and I am so excited for that one . I feel like I need to do a whole course on BPPV and dizziness .

It's the one thing that I feel like in our programs back in the day didn't spend a ton of time on and it's just such a hot topic in acute care and you know typically get those consults on a daily basis . So need to tap into those skills a little bit more but don't want to read all of them to you . This is going to be an awesome lineup .

It's a free virtual event . You can upgrade for 20 contact hours as well as one year access to all of the recordings . So this is a this is an awesome one . I'm super excited to be a part of this um summit . I'm very thankful for the note ninjas for inviting me to this .

This is , uh , this has been really fun promoting and also just being a part of really fun promoting and also just being a part of .

But that actually is a perfect segue into today's conversation because I wanted to talk a little bit about documentation and so just the summit in general is its purpose is not only to give strategies and intervention ideas , but also to give skilled documentation tips

, right ? I feel like documentation is one of those conversations that you have with every PT and OT and it's just the guttural right Documentation .

And it's true , and I'm going to give both sides of the story and if you're familiar with me , you know you're always going to get the truth and you're always going to get both sides and I think the arduousness of documentation and the time it takes to complete is really the annoying part .

Right , it has to be done and it takes a lot of time and , depending on what setting you're in , depending on what documentation EMR you're using , really can enhance and make it easier and efficient , or the opposite . I have been in this game for a long time now and sometimes when I like reflect back on the beginnings , I'm like , wow , I'm pretty damn old .

I don't know , I have that , you know . Wow , this has been quite the evolution . And I think this is also part of being a millennial in the sense that we have really seen such dramatic change with technology over the years . Right , I'm an 85 baby .

I literally had a TV with the knobby-do that you had to get up and turn it and crank it with the rabbit ears . That was the original TV that we had in our house and that just kept upgrading . And all of a sudden now there's remotes and all of a sudden there's cable . Right , like , cable was a big thing in the 90s , like that wasn't .

You just had , like what ? Five to seven channels , right , and it just keeps going . I had AOL , right . So my mom still calls the internet as like a thing , the internet . She calls it AOL and I , you know , I try to help with some of the verbiage sometimes , but she's not wrong , because when we started with the internet it was AOL Literally we had .

And so for all my millennials out there , right , anyone who's Gen X or millennial , like I'm sure you're just like vibing with this . Right now I feel like I need to start writing down all the things that we had right , free , I don't know seven day trial and you would need the CD to access said internet .

And said internet was on dial-up , like legit , had a phone jack wire , sorry , in the wall and you would have that whole long , you know , sign in time . Right , we saw so much change over the course of however many years . Right Now the change is more minutiae , but we're going to talk about new changes too , because I have my qualms .

And there's benefit to technology

right , it makes you more efficient in some ways and in other ways , it also changes your capacity for good and bad . Right , we're more distracted . We have more notifications than ever before . We're also more immediate and I think that is , you know , just something that we're going to continue to see and expect . But you know , those dopamine hits are real .

It was actually really interesting being in academia just with grading , right , like getting a grade to your student . Now we had Canva , canvas , canvas Sorry , the two names are so close it's hard to get them right .

So Canvas was the basically platform where you would host exams , powerpoints , like all your stuff , all your data , and if you had a multiple choice type test , as soon as they hit enter , they get their grade . That's really fast Now , when we were in school we didn't have when I was in grad school . We're going to go back to back in the day .

Apparently , we're going to talk about this today . When I was in grad school , I had a flip phone cell phone . It was my second cell phone and there was no texting . Texting was just coming out . And so I'm talking from timeframe wise , 2006 to 2009, . Right , I had a Verizon Razr flip phone . Again , my millennials probably had the same damn phone .

And in grad school , in my DPT program , people were starting to text , and so I was getting these messages on my phone and I was like I don't know what kind of plan you have , but I pay by the character . I don't know what kind of plan you have , but I pay by the character .

No , I just want to for all my youngins out there who have unlimited data , unlimited text , unlimited phone , all the unlimiteds . Texting was so new that you paid by the character , so you would text . If you did text at the time in , like you know , abbreviated as abbreviated as abbreviated as you can get to consolidate the number of characters .

Then that it progressed to how many texts you could send right . So all of a sudden I'm having text invoice on the phone bill . I'm like all right , we need to get this under control . Also , google was very new , if it even existed yet . So when we were in grad school , I wasn't Googling range of motion . Right , show me how to .

There was no YouTube showing me how to do an anterior glide or how to take a blood pressure or what's that breathing exercise . That did not exist , didn't exist . Right , pros and cons . Right , we have so much access to things now . We have so much information at our fingertips , but it's also overload right Back to documentation .

But it's also overload right Back to documentation . When I started my first job 2009 , and actually before that , I was working in an outpatient PT clinic we had paper documentation . My first job actually I'm going back my first job and my first secretary job in a PT outpatient world was paper documentation . Like , the outpatient clinic had a folder .

We printed paper , we're faxing insurance off , all that stuff , right Hand handwriting these things . Now , that was always a problem . My first job in a hospital setting was

paper documentation . We would go see the patient . We would go to the nurse's station to go get the binder , find the patient's name , go to their binder , chart review right , because you also have to chart review these patients prior to seeing them . So you weren't chart reviewing 20 patients you know prior to seeing them .

You were going , you had your list , you go to that person , you read the chart in real time , you decipher everyone's handwriting , which was just awful and then you would document , hand , write a soap note in the hospital setting in the binder and go see your next patient . Not too long after starting at the hospital , we switched to an EMR .

I don't even remember the name of that EMR , but that was actually one of my favorite EMRs in hospital setting . It was kind of a combination of click and text tool , so there were a couple of click options very few , it was very bare bones . Same for chart review like very bare bones , but like you had everything you needed in one place , which was great .

And then we switched to Epic . I don't know how many years later Now . Epic's purpose is to be more efficient . Its purpose is to collect more data , right , and so this is part of documentation , but this is kind of like the back end part of it .

The problem with using EMRs to collect data is that it becomes a really it's a giant pain in the ass from a documentation perspective . Even though the clicking might be more efficient in some ways , the ability to show your note after is awful .

I mean , in my opinion , if anyone's using Epic out there and you document in said cells , right , and you have all these click box options , when you actually turn it into a note , it is so unreadable and so that's very annoying because you spend all this time documenting to show what you have done with the patient and the document is , I don't know , it's really

unreadable in my opinion . So I literally go in and like make sure that there's breaks in different sections , that it is more readable than it is , because it kind of just jams everything together and has semicolons everywhere , like it's just not .

It's not how we read , which is not great for other professions reading our notes , right , it's not good handoff between physicians , nurses , rts , whoever is reading each other's notes . It's just you know it's got it .

It has its faults , but one of the things that I have noticed over the span of time of treating , is how documentation has changed , right , we've changed literally from handwriting to computerized , to more of like this epic sort of click box situation . I'm all about efficiency , truly I am .

I mean , I'm sure if people read my notes they're probably like she's not about efficiency , but I do think , as much as we hate documenting , we have , I mean , it's what shows your skill , right , it also shows the person's needs and I think and it's a great handoff right , like when I get a note that gives me no information outside of , like the facts , you

know , contact that I'm like I don't actually , besides the fact that this person moves relatively well , I don't really know much about what happened . And so one of the things

I really have always emphasized to my students and mentees is to make sure that you are telling the story , make sure that you are showing the skill in what you're doing , number one and also showing the needs of the patient right , because this is like a two-part need here .

As a clinician , I need to know what my counterpart has done or the prior PT the day before , like I need to have that handoff and I need that information to like know what AI need to progress . Next , what to be aware of , what to expect . All of those like heads up things From a patient perspective .

They need that note to show their impairments , their abilities , whatever .

It is right If we're talking about the hospital setting right now , if the person is , you know , between going home versus skilled nursing , for instance , or acute rehab , right , like we'll put all three on the table and let's say , for instance , because this , this , you know , just happens quite a bit like patients ambulating 200 feet contact guard , but the

recommendation is acute rehab . We could have all sorts of conversation about that sentence . In general , I would argue that 200 feet , I mean 200 feet , I mean it's a decent distance . There's not a lot of assist being provided . But why does that person need acute rehab ? Is it their decision-making ? Is it their dynamic balance ? Is it their aerobic capacity ?

Is it that they're tanking their blood pressure ? Is it because they need significant up titration with the 200 feet ? Right , it's a different story . I just told you a whole different story If I told you the person walked 200 feet , rolling walker , contact guard , and I'm asking for acute rehab . Your first question's why .

I think sometimes we get so hung up on , you know , just walking distances , that sometimes we forget about the other important things that allow people to become more independent Dynamic balance , for instance , right , or maybe we get too hung up on the number .

I remember being in an orthopedic hospital back in New York and there was like a number game , right , if you said the patient walked 300 feet , that's the magic number to go home . It's like could a patient technically walk less than 300 feet and go home ? Yeah , I mean , think about your house .

Like how far do you need to go from your front door to the kitchen , to the bathroom , to the bedroom ? It's probably not 300 feet , it's probably a lot less than that . Could I argue that 300 feet doesn't mean that the person's independent ? Totally Right , like I can give you the other side of that coin .

The other side of that coin is , yeah , they can go a distance , but how much assistance do they need ? How much queuing do they need ? Are they a falls risk ? Right ? The documentation is what helps determine all of that .

If you just give again 200 feet contact guard , rolling walker , that doesn't tell me the whole story , it only gives me a little piece of that information .

So the way I've always described documenting to students , mentees , is to create an ESPN snapshot , right , like we're all coming off March Madness , right , if you were to watch the next morning right , there were 20 games on in the beginning of March Madness you could watch ESPN and get a good feeling of what happened .

Who played who , who dominated , what were the faults , who won , who are the star players , what changed the outcome of the game right , you're going to get all those big highlights . That's what documentation is .

Documentation is giving those highlights and , in my opinion , it's your ability to show off the skill , the skill of what you did , the impairment of the patient , the improvement of the patient , the decline of the patient right , that's the time that you get to highlight why this person needs to have increased assistance , why this person needs to go to an inpatient

setting , post acute care . It gives the why , right , not just the what and the what is important , right , like , the objective piece of all of this is important , but the skill comes in . What you're doing , how you're cuing , what you're assessing right For me , what you're assessing right For me vital signs is such a huge part of this right .

If , for instance , I don't know patient day before was able to sit edge of bed , maybe they stood and that was all they could tolerate and they laid back down . Well , my next question is like well , what was the limiting factor ? Was it their blood pressure ? Was it dizziness ? Was it pain ? Was it fatigue ?

Was it the patient's not into it and they just said I'm good , I'm done right . Without that conversational piece , you're not telling the whole story . So I really think that , number one , we should be identifying said impairments . We should be giving the snapshot of the session . What went well , what didn't go well ? What was the vital sign response ?

What was the improvements that they showed today ? What was maybe a backtrack ? Why are you recommending whatever place you're recommending ? I think that's kind of the . That's the whole piece , right , and I think when we start using different EMRs , it sort of affects how you are able to portray what is happening . I don't know much about Cerner .

I have never used Cerner . I just know that they're the competitor to Epic , so I don't really know what their layout looks like . If anyone does use Cerner , I would love to hear kind of how that works as well .

Epic's kind of been the primary EMR that I have used literally across the country , and I think the fascinating part is like we've watched it come into each facility we have ever worked in .

I think Nikki and I could technically be like the epic gurus and all these places and it's actually really interesting to see this the same software be utilized differently in different institutions ,

different institutions . It's just actually quite phenomenal how different like the doc flow sheets look , even what they call it right Like there's just a whole bunch of stuff with that , but we have literally seen a epic essentially takeover across the country and also how documentation has very much changed over time .

In my opinion , I think it's great to have increased efficiency . I love the ability to do like smart phrases right , like the things that you say a lot , the things that you document , frequently throw it into a dot phrase and you , you know , save a few minutes of time .

Where I start to lose the efficiency part , right , everyone thinks that click boxes are efficient . I think when I was writing more text format versus Epic , I feel like my documentation time is damn near the same and that text format is much more readable to the person who's , you know , either interdisciplinary or your colleague that needs to check in .

So I really think just being able to articulate what you did , describe your interventions describe . The result is so important in documentation From outpatient slash , home health slash , mobile PT . I'm going to talk from the mobile PT side . I use Jane . I think Jane is a great software . It's very user-friendly , it's very plug and play .

It has the ability to integrate with insurance . It has the ability to integrate with Medicare . There are third-party software connection things that you have to use in order to do such things .

I don't use that side of Jane so I'm not as familiar , but if you did want to know more , I have videos on YouTube where I talk with a Jane representative showing some of that back end stuff and it's been really nice to actually be able to customize how I want to document , which has been great .

So , like from a mobile perspective , my primary population is Cardiopulm . That is not a very common niche across the PT world , even across like EMR type stuff , right , jane is awesome because it has all these like built-in templates that you can basically download and customize yourself . Cardiopalm isn't one of them .

So it's nice for me to know what I want and be able to literally create documentation so I can easily plug and play and that saves me a ton of time . I've also played with the idea of trying to use voice to text either while I'm driving or after my session or during my session to sort of speed it up . I don't really do that .

I usually keep my documentation open while I'm working with the patient and I'll just kind of jot some you know trigger words while we're working together , just so that I have the memory and I'll clean it up when I get home . Everyone's got their things .

I think if I have a higher patient caseload I'll probably start documenting in the car , maybe utilize voice to text to kind of speed things up . So just having some of that conversation is really nice too , just to see how you can like create a little more efficiency and take some of the woe out of documenting .

Because you know it's probably the number close to number one complaint across PTs , across settings . My home health colleagues I got I don't , that is not my domain .

I was talking to a recent former student of mine who went into home health and you know reiterated the cumbersome , arduousness of the documentation that is required for home health and you know that's the hard part . It's what is required for insurance .

Insurance is getting even more , you know , aggressive with declines , the things I'm seeing just kind of across PT , even physicians , like what physicians are dealing with to get approval for medication , a surgery , a procedure , whatever it is . It's just .

It's a little bit disheartening in some ways , and so those are the times where documentation is even more important , right . So really showcasing your skills , showcasing what has improved , what has declined , using your objective ability and ability to articulate what has happened in your session , to show the need for either continued PT or what , what have you ?

One thing I haven't even touched dove into , and so if anyone is using AI for documentation and you want to talk about it , how are you using it ? I would love to have you on the podcast . I know there's a few softwares out . I can't pull the name right now . I actually saw it the other day .

I , you know , I have my um , my guard up a little bit with AI , and so same thing , right . Like we watched technology happen , we watched the progression , and so AI is the next progression . I'm a little nervous about how it's being utilized , how easily it is accessed , how I don't know . I just have a little concern about it .

I'm actually glad I'm not in academia right now , because the ability to use AI to write a paper , create

anything is so easy , right , like I was on a meeting recently with a tech company and they were using AI to . I mean this person had AI to collect emails across any profession , just like dial it in . She had AI to basically create all sorts of templates .

I mean she had an AI software for every single thing and you see it all over Instagram or Facebook or write all the commercials . For all these AI softwares to edit everything , all the deep fake videos . It's getting harder and harder to distinguish from a . What I have used it for purpose .

I play around in chat , chat , gpt a little bit for like outlines , some um titles , for like podcasts or blog things . The problem I have just across the board is it feels very AI .

So , like I use Buzzsprout as my podcast software to basically host it , and when I plug the video into Buzzsprout I have the option for like AI generated show notes and all kinds of things , and I'll have it . Show it to me . It just feels very AI and I know this is going to get better , which is a little scarier to me too .

But like I don't know , I can't . I personally can't use something that's not mine . It just doesn't feel right . Oh , I definitely froze . Okay , I'm going to let that . I'm just going to let that blip come out there . I just can't . I don't have . I don't know if it's an integrity thing , like I can't put something out that I didn't create .

I like it for ideas . It kind of gives you some ideas on verbiage , but it feels very AI and I I can pull an AI title . There's just very specific words that they like to use and it just feels not genuine . I don't know if that's the right word , but if we're using it for documentation , I'm curious how that's going to look right .

Is it going to be listening during your session and then basically compile the information ? Is it going to just basically create a soap note based on the things that you lay out ? I don't know . I'm kind of curious to see how these work .

It just makes me a little nervous because as you start doing this and using this , you become less in tune with what's being put out , and are you actually proofreading it right and addressing it and editing it ? So I don't know . I kind of went a little bit right on this , but I'm just curious how that's gonna look right .

I just I'm a millennial , I've seen all these things happen . I'm a little nervous about AI and its functionality and I will add one more piece here . The less and less we do , the less and less we create , the less and less we articulate , the less you're able to . I'm all about using it as a tool .

I'm even hearing a lot of people using it as a alert , like to teach you how to do things . I feel okay about that . Things . I feel okay about that . Where it's pulling information from is kind of endless , right . So is the information accurate ? And what happens when you start relying on something that isn't I don't know fact-checked across the board ?

Right , it's different from reading an article yourself and being able to pin it to that specific article . It's just giving you the information . It doesn't tell you where it got it from and from being in academia and just kind of seeing the change in generations .

And I even think about , like my niece , like she's had a phone , a tablet in her hand since she was way young . I mean , she was using all these , you know , flipping through TikTok at whatever age , right . And she's like texting Texting is like very common right . What happens when you text ?

You get autocorrected , right , and so I feel like the ability to actually spell right . I'm just going to break it down as honest as it is , spelling is a problem and because everyone has autocorrect or grammarly on their computer , if you ask someone to , you know , write this out .

The grammar is not great , the spelling is not great and the more and more we depend on and utilize other information , I just kind of question our intellectual abilities across it . So I know I went a little bit right , but it's kind of been a concern . I even think about GPS right Again .

Another thing that we saw change over time , back in my day , I mean when we were kids , we had maps . We had maps in the car like legit maps to get . I remember like Hershey Park , we're driving to Hershey Park in Pennsylvania and there's like a map , like a legit map , navigating it from New York .

When we played I played basketball and was travel basketball we had MapQuest . That was like a big deal . You put in the address to and from and you had the printout of where to go . Now you come in the jump in the car . It knows that I'm like going to work . It tells me okay , go to work .

You click it , even though you know how to get there and you just start relying more and more on technology to kind of do all the things . That makes me a little technology to kind of do all the things . That makes me a little I'm a little worried about it .

But with that being said , I feel like we really need to take ownership of our documentation , make sure that we are showing skill , not that we're just clicking the box and getting it done . Trust me when I say I would love to just say bing bang , boom , send it off . I just I can't do it because I think it's probably a little integrity thing .

I don't know , I just have to like this is what we did . I want to showcase it . The good , the bad , the ugly , the pros , the cons , the highlights got Gotta let them know . So if you are interested in having some more documentation tips , even some intervention ideas , get a different take , check out that three-day virtual event hosted by the Note Ninja .

It's going to be awesome . In my presentation I do all sorts of examples of documentations with my strategies that I use . Right , I pretty much go through my four primary strategies I use on a day to day basis . To be honest , I use all of them today .

I really think it's important that you have like words to put behind things and sometimes Nikki and I kind of go back and forth about it too , like how would , how would you say this ? And just being able to articulate what you did , how you did it , what the outcome was , what the you know big event was in that time period , is important .

Right In the world of cardiopulmonary you have like four primary impairments that you see Impairment of gas exchange , impairment of ventilation , impairment of aerobic capacity , impairment of airway clearance . I was trying to think of what my fourth one was . Those are your like primary problems . What does your person have ?

Right , if your person has oxygen needs , they're wearing oxygen , you're up titrating . They have an impairment of gas exchange . If your person has mucus , well then they probably have an impairment of gas exchange and they probably have airway clearance impairment , right . So both are important .

If your person has maybe like a neurologic dysfunction I had a lot of patients post-CVA today one-sided weakness you're probably going to see more impairment of ventilation . Where it's more a mechanical functional strength issue , it's probably one-sided .

Right A person has impairment of ventilation my heart failure population , high prevalence of impairment of aerobic capacity , obvious reasons right . Their overall capacity , their endurance is low . Focus on that . That's the primary impairment . Then you're going to pick your interventions based on those impairments right . Showcase what did you do to help that gas exchange ?

Well , we did inspiratory holds . We did inspiratory holds , we did stacked breathing , we did maybe percussion vibration because they have increased mucus . We were able to do huff , cough , clear it and we improved SpO2 . Maybe we got a ventilation issue , maybe we have mechanical deficits , maybe we're using like things like the sniff technique or diaphragmatic breathing .

I did a lot of pursed personal breathing today . Right , a lot of pain management . What's what are you ? Why are you doing ? This thing Should link back to your impairment and then that should all hook back into your goals , right ? So making the whole story kind of work together is the whole goal of documentation .

I know it's a pain in the ass , like I'm going to be

very honest with you , it takes a lot of time , right , we can become more efficient with different tools to kind of help us along the way , and also , when you have kind of strategies or similar patient populations , you're going to see some ease in all of that .

But at the end of the day , I think we really do need to show off our skills , and I really mean this from a place of as a profession . Showcasing what we do is so important .

I think I have this conversation once a day , once a week where we have so we have such a wide breadth of knowledge in pt and I think we need to do a better job of showcasing what we can do In the acute care setting . I would talk about the example of , you know , walking patients .

It is just something that drives me up the wall when we that's what we go back to it's like oh , are you going to walk my patient today ? There might be walking involved , there might be . We might be doing gait training , we might be ambulating for endurance , we might be . But there's context , right , and I think documentation gives that context .

It also shows your skill . We don't just walk patients Drives me up the absolute wall . Those stereotypes exist in every setting . Part of undoing stereotypes is showing your worth , showing your skill . Documentation is a piece of that puzzle .

So when you're having your documentation woes and this is a giant pain in the ass feeling Remember that this is part of showcasing you , showcasing your patient , right , it's the ESPN snapshot . Show your skill , show the impairments , show the improvements , make the impairments meet the interventions which match your goals right ?

That's the whole big picture of this whole thing . And then having the words to put around it . I think that for me sometimes this is the fun part . It's like how do I want to word this right ? And so , yeah , that all takes time , but the more you do it and the easier it does get .

We're going to continue to see technology be a part of this conversation . Pros and cons of that exist always , right ? So , again , if you are using AI in any sort of way in the world of documentation , I would actually love to hear how you're using it . I would love to hear the pros and cons . Just reach out to me , let me know .

I'm actually really curious . And again , if you're interested , sign up for that three-day virtual event . Link is in the show notes . If you want to upgrade , you get 20 contact hours for both PT and or OT pending your profession and you'll have your access to those recordings , and there's great variety in what's being presented .

So , at minimum , take a look and see what's there . If something sparks your interest , get after it . All , right , I hope you all have a wonderful day . I hope this was helpful for you . I know I kind of went on a little tangent there , but you know , if you have questions , if you have advice , if you have woes with documentation , let me know .

All right , I hope you all have a wonderful day and whatever you have to do again after it .