Therapist completing EMR documentation

Why It’s Important to Systemize Your Therapy Treatment Documentation

As a therapist, you may feel like you’re drowning in documentation. You often have to finish up treatment notes and evaluations from home after a long day. If you’re completing them piecemeal — a bit at a time all day or all week long — you’re not going to be as efficient or accurate as you would if you had a regimented method. 

We’re fans of the flexibility that therapist life offers, but we also believe in creating predictable order when it comes to your professional processes. Following best practices in this area can save you time, protect you from issues that arise in an audit, and allow you to manage a full caseload while devoting your energy to quality time with your patients. Instead of letting documentation frazzle or exhaust you, we suggest systemizing.

What Does Systemizing Documentation Look Like?

First of all, it means creating habits around each documentation type. One example is to complete treatment notes at the same time of day (a free lunch hour or just after dinner) every work day. Another is to always fill in the fields on an evaluation or reevaluation in the same order. Presumably this way, you won’t forget any. Tasks that become habits are those you can stick with long-term.

Think ahead by reviewing patient charts, making a note of which patients have upcoming reevaluations far in advance (30 days) of the plan of care end date, and scheduling those appointments well before said date. Bonus: when you engage in this practice regardless of your clinic’s policies, you set an example for fellow therapists and show your clinic owner that you’re conscientious.

Systemizing also looks like anticipating any holes in your documentation. Especially if you have a supervisor, send an explanation via email before they need to sign the document. Perhaps it’s a new goal you’ve added to a plan of care that may not be aligned with previous goals. Thinking ahead of your supervisor could prevent a delay and a lot of unnecessary time spent on back-and-forth communication should they need you to clarify something. In this case, you’d be better safe than sorry.

Advantages of Doing All Documentation the Same Way

In most cases in life, routine leaves little room for error. Therapy documentation is no exception. You’re less likely to forget to complete something, or compromise on quality, if you do it the same way every time. Even though every insurance company and state provider has different standards, none of them will have a problem with you being overly thorough with the way you fill things out.

Billing delays also won’t be on you when you’re taking a bit of extra time on the front end to be detail-oriented. As long as your billing is being done the right away, you should get paid faster than you would if you had to make corrections or took too long to sign documents. When you maintain continuity of care for each patient, your claims are more likely to be submitted and paid on time.

Trust us…you’ll also be your clinic owner/admin/supervisor’s best friend if you follow our advice! Or at the very least, you’ll build a solid relationship because they know you’re trustworthy and care about the details. Systemizing on your part, at the patient touch point, makes everyone else’s job easier.

How Using TheraPlan Can Help Standardize Therapy Documentation

We believe so strongly in completing documentation in an orderly fashion that we built easy, organized templates into our web-based EMR. Not only can you complete a treatment note in under five minutes* with our application, but it’ll be difficult to make mistakes because you can see what you filled in last time! TheraPlan is here to support systems for therapists like you because we know how hectic your job can be! Check out all the features of our EMR here.

Like our advice? Share this post with fellow therapists who need a bit of organizational inspiration.


*After approximately three weeks of training inside TheraPlan, our average therapist completes a treatment note in five minutes or less.