30 Seconds Of Therapy: Smarter Documentation With AI

START

1. Using dictation tools at the point of care

   1. Typing notes at the end of the day leads to fatigue and forgotten details. Dictation lets you “speak” your charting in real time, saving time and improving accuracy.

      1. Download a tool like Dragon Medical One or check if your EMR has a built-in dictation feature. https://www.installdragon.com/dragon-medical-one

         1. Open your EMR – Go into the note field where you’d normally type.

         2. Turn on Dragon – Activate the dictation tool (microphone icon).

         3. Speak your note – Talk naturally, as if explaining the session to a colleague. Example: “Patient completed sit-to-stand x10 with standby assist. Needed two verbal cues for posture. No dizziness reported after activity.”

         4. Review & Edit – Scan the text for accuracy, correct any small errors, and save.

      2. Right after treatment, dictate SOAP notes or assessments while everything is fresh.

      3. When using Dragon, you can complete your documentation in just 2–3 minutes.

      4. Free trial available: Clinicians can sign up for a 7-day free trial of Dragon Medical One here—Dragon Medical One USA

         
         

2.  Creating smart phrases in your EMR

   1. PTs often type the same instructions or education multiple times. Smart phrases (shortcuts that expand into full text) save you from repetitive typing.

      1. Dragon Medical One (Dictation + Auto-Text)

         1. Works directly in TherapySync’s typing fields.

         2. You create custom “auto-text” commands in Dragon.

         3. Example: Shortcut: “Insert HEP1” 

         4. Output in TherapySync: “Patient instructed in seated knee extensions, 2 sets of 10, with caregiver assisting for safety.”

         5. Every time you say “Insert HEP1,” Dragon will instantly type the full phrase into TherapySync.

            
            

3. Building AI-Assisted Templates in TherapySync as EMR

   1. Templates reduce “blank page syndrome” and help keep your notes compliant, consistent, and less stressful. While TherapySync doesn’t have a built-in AI documentation tool, you can still use its default templates as a foundation and layer in AI support (like Dragon Medical One) to speed up documentation. This means you don’t have to start every note from scratch — AI can generate draft text based on your keywords, and you simply edit with your professional judgment.

      1. Use TherapySync’s Built-In Templates

         1. Open TherapySync and select a documentation template (e.g., PT Evaluation, Progress Note, or Discharge Summary).

         2. Customize it by adding common static fields you always use, such as “Therapeutic Exercises,” “Home Exercise Program (HEP),” or “Patient/Caregiver Education.”

      2. Pair with Dragon Medical One for AI Drafting

         1. Install Dragon Medical One Download from Nuance Healthcare. Follow the installation steps (you’ll need your license or trial account).

         2. Log into Dragon Medical One Open the Dragon application on your computer.

         3. Open TherapySync: Launch TherapySync in your browser or desktop application. Go to a patient’s chart and open the documentation form you want to complete.

         4. Test Dictation: Place your cursor inside a TherapySync note field (e.g., Objective, Interventions, or Assessment).

         5. Start speaking:  “Patient performed sit-to-stand transfers x5 reps with minimal assist, verbal cues for forward lean provided.” Dragon will transcribe your voice directly into the TherapySync note.

      3. Create Custom Shortcuts (Optional)

         1. Within Dragon, create “auto-text” for common PT interventions.Example: Save the phrase “Insert HEP” → expands into:  “Patient educated and demonstrated home exercise program, including ankle pumps, seated marches, and quad sets, with caregiver supervision recommended.”

      4. Final Step: Review & Save

         1. Always review for accuracy and compliance.

         2. Save the note in TherapySync.

STOP

1. Waiting until the end of the day to chart

   1. Documenting hours later increases errors and adds stress to your evenings.

      1. Use dictation tools or smart phrases to complete notes during or immediately after visits.

2. Retyping repetitive education

   1. Rewriting the same fall prevention or transfer training note in every chart wastes time.

      1.  Use smart phrases or AI-generated text. Add only patient-specific modifications (e.g., “patient lives in a 2-story home, instructed to use rail for stairs”).

3. Assuming technology is “too complicated”

   1. Many PTs hesitate to adopt AI because it feels overwhelming. The truth? Learning one feature at a time builds confidence and efficiency.

      1. Set aside 10 minutes a week to explore one new tool — such as dictation or shortcuts — until it becomes second nature.

WHY

1. Why it improves patient care

   1. When documentation is efficient, PTs can focus more on clinical reasoning instead of rushing through notes. Real-time dictation and AI-assisted templates reduce the chance of errors or missing details, which strengthens communication with the care team. Accurate, timely notes mean safer and more effective treatment plans for patients.

2. Why it reduces burnout for clinicians

   1. Documentation overload is one of the leading causes of burnout in home health. AI tools cut down repetitive tasks and allow PTs to finish notes at the point of care, freeing evenings for recovery and personal time. This balance keeps clinicians energized and sustainable in a demanding field like home health.

3. Why Dictate Out Loud

   1. While you are resting I’m going to write down what we did so I can inform your Physician and he or she can see your progress.  Then pick up you phone and talk into it.   Let them hear your dictation that way if there is an error you address it right there. Then put your phone away, so they can see they have your attention. Its much better than typing because they can’t see your face your eyes, and they have to just sit there in the quite… THAT is what makes patients mad.