Point of Service (POS) Documentation. To use or not to use: that is the question. It’s a hotly debated topic with polarizing viewpoints. Here, I will simply state the pros and cons of incorporating POS documentation based on perspectives held from both sides.

What is it?

Point of Service Documentation basically means that you are documenting at the time of care while you are treating your client. More and more, therapists are encouraged, at times pressured, to use POS documentation to improve productivity. For those of you who aren’t familiar,  productivity is a term used in healthcare to refer to the amount of time providing direct patient care, also known as “billable time.” The drive for productivity is often what boosts the bottom line for rehab companies, even at the cost of increased burnout, ethical dilemmas, decreased job satisfaction and high staff turn-over. In our current healthcare climate where productivity and profits seem to be the driving force, it’s no surprise that POS documentation is becoming more and more common. But is it the right thing to do and can it be done ethically and safely?

Critics of POS documentation may assert that POS is not client-centered because it hinders the process of active listening, attention and observation. After all, so much of what we do as therapists require skilled observation and active hands-on treatment. How can we provide the kind of attention that the client needs and deserves while taking notes? The unfortunate result may be poor quality outcomes, resulting in neglect or harm to clients.

Proponents, however, may reason that POS documentation can be a meaningful part of the treatment session that benefits both the therapist and the client. If done properly with the client involved, POS documentation can be an opportunity for the therapist to educate the client and reinforce the exercises, while ensuring all the important data is captured accurately. In that way, incorporating POS into your session may actually help to improve the quality of your documentation, while also alleviating the therapists’ burden to work off-the-clock to meet productivity standards. It will certainly take practice and it will have to be incorporated in a way that is safe, meaningful and beneficial for the client.

For example, the therapist may spend this time reviewing the notes with the client and discussing the progress, client goals and strategies to attain those goals. By actively engaging the client in a dialogue about their progress and plan of care, the therapist can help to enhance better carry-over and motivation. In that way, Point of Service documentation can be an effective part of collaboratively engaging the client, even as you’re taking notes. To ensure your session is client-centered, here are a few things to keep in mind:

Safety First

Point of Service documentation may not work with every client and you will have to use your clinical judgment to ensure you always have your client’s best interest and safety in mind. For example, if your client is significantly cognitively impaired, discussing their progress with them may not be meaningful so it would not be in the best interest of your client to do POS. 

While Point of Service documentation can greatly improve your overall productivity and efficiency, productivity should not be the primary driving factor. Instead, the client’s safety and well-being should guide every clinical and practical decision.

Meaningful Engagement

If you plan to incorporate Point of Service documentation, be sure to first inform your client that you will be taking notes during the session. Reassure them that this is a way for you to capture all their important needs, goals and progress for future records. Remember that this should be a collaborative process with the client engaged in what you’re writing, discussing and documenting. If you are unable to engage the client in a meaningful way while taking notes, you should probably consider other options or processes for completing your documentation. 

Tip: Consider allocating the first and the last 5 minutes of the session to capture all the important data. This may feel less intrusive and more streamlined than taking notes throughout the session. When you’re wrapping up, you can review your notes together with the client.