Clinical documentation only needs to accomplish three essential functions: communicate a clear clinical picture, justify billing, and provide legal protection; anything beyond these three purposes is unnecessary and contributes to professional burnout.
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Deep Dive
Most physical therapists are buried in documentation & nobody told them they didn't have to beAdded:
Bonnie talks about how much documentation [music] Rex new grads. You spent three years in school learning how to be thorough, to document everything.
Then you enter a clinic [music] and maybe you're seeing a higher volume and you try to apply that same standard of documentation. And the gap between what we were trained to do and what the job actually allows is one of the fastest ways to burn out. Your note only needs to do three things. Communicate a clear clinical picture, justify your billing and cover you legally. That's [music] it. If it does all three, then it's good enough. Nothing more.
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