2 Underused Tools for Streamlining Clinical Documentation

The right clinical documentation tools can help you in your quest to streamline your therapy documentation process. Learn how it works, today.
Streamline Your Therapy Clinical Documentation Processes

Did you know that providers spend an average of 4.5 hours daily on patient records? Most of this time goes towards finishing up patient notes and other clinical documentation processes during and after office hours.

Unfortunately, this wastes valuable time that could be put to better use directly attending to patients and, consequently, improving patient experience as well as reimbursements. The good news is that most of this time can be reduced with an excellent electronic medical record (EMR) solution. Here are two tools from Raintree’s all-in-one platform, which can optimize your clinical documentation as well as save time and money for your therapy and rehab practice.

Establish Great Templates in Your Therapy EHR

Raintree’s EHR system offers clinical documentation tools that deliver a suite of features that help streamline your daily workflows. Among them is highly configurable templates that help take provider notes easily and significantly cut clinical documentation time.

Rather than drafting notes from scratch, providers using these templates only have to fill in a few fields. These templates also allow users to create custom entry fields, templates for specific issue types, configurations for goals values, and normal values. Therefore, providers only have to document fields outside the set parameters.

Raintree’s EMR templates are also specialty-specific, allowing you to customize your notes according to your particular practice. For example, you get built-in templates tailored to remote therapeutic monitoring (RTM) patients, pediatric cases, physical therapy, occupational therapy, and more.

Our practice management software also thoughtfully helps overcome common challenges plaguing providers. Case in point: therapists, especially applied behavioral analysts (ABA), often have to juggle multiple templates. This problem is more evident when the therapist moves from one practice environment to another, such as when they have to meet a child in the office and at their school.

Here at Raintree, we overcome this challenge by providing a straightforward yet powerful cloud-based practice management system, with the option of a single note alongside multiple templates and dashboards. This way, therapists don’t have to keep switching between notes or charts and can keep an eye on the patient data right in front of them. They also get more time to focus on the patient, which improves productivity and optimizes care delivery.

Most importantly, our global templates can be used for multiple note types and are designed to pre-populate multiple fields within the note according to factors such as diagnosis or common complaints.

Here are some other advantages to expect from our global templates:

  • Significant reduction of clinical documentation time, especially during the first visit.
  • Access configurability, so that the template can be made visible to specific users depending on the security.
  • Ability to set typical values, so only parameters that fall outside the set standards have to be documented.

Our other template categories include “Picklist Line Defaults” and “Picklist Templates,” which allow you to load a group of items together or pre-define subsequent choices after the initial item in a column is selected. For instance, once a specific activity is selected, fields for the sets, reps, CPT, and time can all be completed automatically without additional clicks. Moreover, these templates can also be made discreetly visible to specific users.

Abbreviations Manager Tool

Raintree’s abbreviation manager tool allows users to set up custom abbreviations that can autofill in their notes. By auto-populating specific terms or phrases, providers keep documentation quality up and reduce time spent on notes.

For example, Raintree provides an interactive rich text (RTF) editor with a built-in spell checker and abbreviation manager. With our abbreviations, providers easily enter complete phrases or other letters and narratives into their notes without errors or having to search for spellings.

Automatic spell-check is enabled by default, meaning words not found in our global dictionary are underlined and can be autocorrected, ignored, or added to the ignore list with a click. Still, you can edit the global dictionary to include some custom abbreviations and phrases as well. Other options enjoyed by Raintree’s users include:

  • Enabling or disabling abbreviations
  • Setting it to ignore exceptional cases, such as words with uppercase, numbers, markup languages (HTML, XML, etc.), internet addresses, or quoted lines
  • The ability to create or replace custom abbreviations with text you specify or substitute it with other items entirely.

Additionally, merge tags allow our users to create other customized and dynamic content for narratives, such as pulling in context-based data. Common merge tags can also pull information like age, date of birth, etc., allowing our users to autofill such fields where the information is already available within the system.

Final Thoughts on Streamlining the Clinical Documentation Process in Your Therapy EMR

Much of the time that goes into daily clinical documentation workflows can be eliminated with the help of comprehensive practice management software, allowing providers to focus on the quality of care and increasing revenue. 

Here at Raintree, we are dedicated to providing our users with high-level automation software that we continually update to save time and money as well as improve productivity. Learn more about the Raintree way with a demo of our all-in-one EHR today by clicking here.

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Blogs are created for educational and informational purposes only.  The information provided does not constitute or, is not intended to constitute, legal or medical advice. When you read this information, visit our website, or access our materials, you are not forming an attorney-client, provider-patient, or other relationship with us.

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