Burnout is an epidemic amongst clinicians, and while there are several contributing factors, documentation burden is not only one of the most significant culprits—it’s also an unnecessary one. WebPT reported in its annual "State of Rehab Therapy" that rehab therapists average 13.5 hours per week in non-clinical work, and 85% of clinicians document at home in some capacity.
Similarly, Prompt EMR asked 215 rehab therapists who are members of The Clinician Transition, an online community for rehab therapists (PTs, OTs, SLPs) who are either considering a nontraditional role or have already taken one, why they are considering leaving traditional patient care. 79% of respondents under age 30 reported excessive workload as their reason for leaving, and 68% of total respondents said emotional burnout was a top reason.
AI solutions have entered the healthcare scene and are here to stay. They offer clinicians a way to document better, code more accurately, and help improve organizational outcomes while reclaiming the other parts of their lives that bring them joy and fulfillment. This means engaging with family at home without the distraction or pressure of catching up on notes. It's also the time and energy to pursue hobbies and goals outside clinic hours without the weight of long sign-off times and open charts looming.
While documentation styles aren't one-size-fits-all, there are some common behavior patterns in how rehab therapists approach their documentation to complete their notes along with the rest of the clinic responsibilities. PredictionHealth analyzed documentation and sign-off times across its user base to identify common documentation behaviors and understand how they might impact a clinician’s daily workflow.
What do all of these documentation personalities have in common? They all have inherent strengths and risks. Each documentation personality has found some rhythm to help them provide great patient care and complete the administrative tasks of being a provider. Still, even the Methodical Organizer can be prone to over-documentation in an effort to be thorough in documenting patient care. And over-documentation doesn't equal better compliance and can sometimes even hinder it.
Documentation patterns that take place consistently after hours or even over several days introduce a higher risk of mistakes and errors as it becomes increasingly difficult to remember the details of a patient's visit, background, injury, and parts of the assessment with increased time between patient care and completing the documentation.
AI scribing solutions are relatively new but are growing in adoption quickly. Designed to alleviate the documentation burden and help clinicians reclaim their time, this technology uses ambient listening powered with AI to distinguish who is speaking, add context, and deliver clinical documentation from the provider-patient conversation. While the basics of various AI scribing solutions are similar, several factors differentiate them, including:
We cover each of these in more detail below in “Getting Started: What to Ask Every AI Scribing Vendor & Why It’s Important.”
In Rehab Therapy, AI scribing solutions vary in how specific they are to the industry and whether or not compliance and CPT coding help are built into the solution. These are important distinctions because PredictionHealth analyzed data points across its Sidekick user base, PredictionHealth’s AI scribing solution, evaluated changes in sign-off times, time-to-sign-off, compliance scores, and use of functional CPT codes. These reflect significant outcomes for rehab therapy organizations as they impact not only burnout but also reimbursement rates and audit risk.
Without AI scribing, 50% of rehab therapy groups average more than 48 hours to sign off on patient charts, some seeing outliers that take over a week to sign off. Long sign-off times and after-hours charting contribute to more than burnout; they drive lower compliance scores, too. When organizations used AI scribing (Sidekick) to document patient visits, the average hours to sign off dropped by 62% within one month.
Documentation compliance and CPT coding are critical aspects of healthcare, but they’re often viewed as tedious and complex. AI solves this by providing real-time insights and recommendations so clinicians can adjust their documentation behaviors without a learning curve or added burden.
For example, therapists may default to general codes like TherEx, even when interventions justify more specific functional activity codes. An AI scribing solution tailored to this use case identifies these opportunities at the point of care, helping therapists code more accurately while adhering to compliance standards.
The results are clear:
These changes reduce audit risks and support better patient outcomes by emphasizing functional progress.
If AI scribing is new to you, getting started and finding the right partner can often be enough to keep you from getting started—but don’t let it. Regardless of size or structure of your rehab therapy organization, the payoff of AI scribing is too great to pass up or sleep on. And navigating the market of options doesn’t have to be overwhelming, we’ve outlined some differentiating factors and what you should look for below.
While many AI scribing options on the market promise similar functionality, some will have features that set them apart. Some organizations offer a scribing solution only, while others have a much broader solution, and scribing is either a feature of their larger product or an add-on product to their primary offering. And while there are pros and cons to both of those scenarios, it can be hard to understand how an organization will or won’t meet your organization’s needs just by the information on their website.
A demo or sales call is a great opportunity to learn more about an AI scribing solution if you know what questions to ask and what to look for in the answers. Below are some categories and questions that should tell you a lot about how an organization prioritizes product development and improvement, accuracy, compliance, integration, and more.
An AI scribing solution tailored to physical therapy offers distinct advantages, including a deep understanding of PT-specific terminology, workflows, and compliance requirements. This specialization enables more accurate and relevant documentation, reducing the time therapists spend editing and ensuring better alignment with payer and regulatory standards. Additionally, it can integrate with physical therapy EMRs and provide insights unique to the field, such as functional outcome measures and progress tracking. And while a tailored solution may be less versatile, its generalized nature may lead to less precise documentation for physical therapists, necessitating more manual adjustments and potentially falling short of capturing the nuances of PT workflows. If you’re considering a generic scribing solution, be sure to ask:
How a scribing solution communicates and passes data back and forth from your EMR is critical to your success with the solution. At the same time, nearly all scribing solutions are Chrome extensions that sit on top of your chosen EMR, but not all function or interact with your EMR similarly. Be wary of solutions that promise many integrations but don’t have formal partnership announcements or boast that they can work on “any” or “every” EMR. This is a strong signal that their integration is really more “copy/paste” functionality, which can lead to slower workflows and a frustrating documentation process. Many of these will also highlight their “one-click entry” as a key component of their EMR integration, which is a better workflow than copying and pasting from one to the other manually but leaves a lot of room for errors and doesn’t account for the natural disruption of clinic life. When you are talking with the sales team, be sure to ask:
CPT coding is one of the most significant learning curves for new and experienced providers. Because CPT coding can be overwhelming to therapists, it’s common for them to pick a broad code like therapeutic exercise (97110) and use it consistently and, in some cases, even exclusively. This practice is not only risky in that it can trigger an audit, but it also robs a clinic of being able to bill for the level of care that was actually provided to the patient. The AI scribing solution you choose should help you account for these challenges and aid therapists in selecting the appropriate CPT codes at the point of care. When effectively built into the scribing solution, it shortens the learning curve, saves the therapist time, and improves the accuracy of your organization's coding (and, in theory, billing). Ask every vendor:
While the time savings AI scribing solutions provide are well documented and an enormous help to clinicians who have historically been overwhelmed and burdened by hours of documentation time at home, on nights, weekends, and over their lunch hours—rehab therapists need more than just fast notes. The outputs from an AI scribe should also improve a therapist’s compliance, accounting for the components in the documentation that regulators and payers require. Still, discerning what an organization means when it tells you its AI scribe has compliance built-in takes a little digging. Be sure to ask:
The best technology solutions are built with the collaboration, validation, and quality assurance of clinicians who understand real-life workflows in a rehab therapy clinic. To choose the AI scribe that will serve your rehab therapy organization best, you should be asking, “Where are PTs and OTs?” In other words,
AI is reshaping how therapists approach their work and solving big challenges that previously strategies either couldn’t or were too resource-intense to sustain. Tools like AI scribing demonstrate how powerful an ally technology can be to providers and leaders alike, reducing administrative burdens while improving compliance and coding accuracy.