Point of Service Documentation Tips for Your Pediatric Practice

As you work with the parents of your patients, it’s vital to create great relationships with them so they trust you to use your time, judgment, and expertise expertly. Then if you need to change your documentation procedure, they will already trust that you would always use your time, energy and expertise efficiently. With that rapport established, they will have confidence in you. They will literally love you and agree with your approach so this documentation change can go smoothly. 

You’ve also got to train your other therapists on how to establish this rapport, especially the newer and younger staff who don’t have children. It may not be as easy for them to relate to parents if they don’t have kids themselves. You’re going to have to do your best to train that ability into your staff, so they can also make smooth transitions in treatment or documentation.

Once that rapport, relationship and trust are established, then you can get the parent’s agreement on changes in your documentation procedure. I’ll show you how this can be done with a little bit of role play. 

Introducing Parents to Point of Care Documentation  

To introduce a change like point of service documentation, I’d walk the parents through an explanation like this one below. Here, I am speaking to a fictitious mom named “Holly.”

Point #1: Describe the Documentation Problem You Are Solving

I’d come in with my computer and I’d go, “Hey, Holly. So lovely to see you and your daughter today. I am so excited about our session today and what we’re going to work on, but I want to share with you, I’m going to have a new approach in 2025. I really have to make sure that I get all my documentation done on your cutie here every single time I see her, because what I’m finding is I’m getting backed up in my documentation. I have so many kids scheduled back to back and I want to help all of them.” 

Point #2: Explain How Point of Service Documentation Is Beneficial

Next I’d explain the advantages of POS documentation like this:

“I love talking to you and I love working with your daughter so much that I forget to write her story and keep detailed treatment notes. Her story is what I need to write to make sure your claims are paid. That story is what your insurance company sees, so the story needs to show what we did, the progress she’s making, and how consistently you’re coming for her appointments. 

“You and I believe in this therapy and she’s making such good progress. The insurance company can see that in my treatment notes. Now, if I don’t write these notes during your session and I see four kiddos back to back, sometimes I forget how many seconds she stood on the right foot versus the left foot.

“So some details may be lost if I wait until my lunch hour to get all of these notes written. If I’m taking the time during the session to jot notes on a piece of paper, I might as well add that information to my documentation. I’m just sharing with you that our treatment sessions might look a little different because I’m going to be documenting your daughter’s treatment during our session to make sure my notes are as accurate as they can be.” 

Step #3: Describe How Therapy Sessions Will Change

Finally, I’d describe how our treatment sessions will look:

“Now, during that documentation time, I want to approach it in a couple of ways. One, we’re going to give your cutie some time to make her own choices on what she wants to play with. Everything here is therapeutic. Everything here is going to make her better as a little one. Then I also want her practicing the skills that we’re learning here so I can give feedback both to her and to you as mom and caregiver. I want you to practice skills with her so that I can guide and instruct you to make sure you can carry over her therapy at home. 

“Therefore, I’m going to remind myself to be less hands-on during her visit. Actually, I would want my hands on her all the time because I want to help so much. But we’re going to spend a little bit less time on that and more time on her practicing and on you helping her practice so you can easily continue this care when you get home. I want you to have all my tips and tricks while you’re helping her at home.” 

Notify Parents of Point of Service Documentation in Advance

What you’re really doing is developing the relationship and having a conversation in which you’re giving yourself permission to complete the documentation for the visit. At the same time, you’re explaining to the mom what that documentation is going to look like during the visit and why it’s so important. By explaining in advance how you’re going to be documenting their child’s care, the parent understands that it’s not wasted time. You’re showing the mom or dad why this change is going to be beneficial for everyone involved in this session.

Get More Great Tips, Any Time of Day

You’ll find plenty more helpful tips on streamlining documentation in the videos in our Lemonade Library. Get registered with us and look for Lemonades that help you manage your parent relationships with ease. 

About Diane Crecelius

Diane Crecelius is a physical therapist and founder of a multi-million-dollar, multi-location practice with well over 3,000 visits per week and 200 staff! In the past several years, Diane has worked tirelessly to support Peds-A-Palooza™ Community & Conferences and the success of Private Practice Owners. Diane has presented at nearly every Peds-A-Palooza™ live and virtual conference since the first sold-out conference in 2018. Her extensive knowledge derives from her decades in practice and from being trained and consulted by Survival Strategies, Inc. She uses this training to help Private Practice Owners learn how to thrive and expand while keeping their stress low.