We all know that proper clinical documentation is important in our practice. Many critical aspects of our business rely on it. As providers, we are also active participants in the recording of each one of our patients’ medical histories. Patient history is a vital record used not only by us, but by a wide range of associated parties who rely on our notes to determine next steps and a proper course of action for our patients.
Documentation reflects on us directly and relays to others how thorough, professional, and serious we are about chiropractic. And sloppy documentation can have much more of an impact than simply causing your notes to be difficult to read. Our documentation, regardless of how hastily or diligently we record it, touches a wide range of areas that directly affect our practice, including:
• Legal—It is often used by attorneys and courts to justify the chiropractic care of a patient. In legal matters, the completeness of a patient’s history can make or break a case.
• Insurance—Accurate documentation also affects your ability to get paid by insurers, and to defend yourself against audits and insurance reviews.
• Treatment—Notes are a vital player in our ability to analyze, investigate, test, and verify a patient’s progress. Good documentation allows you to make educated decisions about a patient’s care and modify their treatment plan accordingly.
• Reputation—Your notes are reviewed by practitioners outside of your office, and ultimately reflect on the chiropractic profession and public image.
But the amount of effort required to host fully compliant and bullet-proof documentation can be a daunting and tedious daily task. Many doctors find themselves spending more time on their documentation than they do on their patients. This disparity continues to take our focus away from treating our patients and offering better care. And with new and more stringent standards ever-evolving, chiropractors have been put under the looking glass like never before. So how do we create complete, compliant, and evidence-based chart notes?
• Know the definition of medical necessity
Original goals, outcomes assessments and complete SOAP notes are invaluable to proving the effects of a patient’s care.
• Use standard abbreviations
Other people must be able to interpret your notes in order for them to be effective.
• Record information about the patient’s care by other providers
Is the patient seeing other medical professionals concurrently?
• Sign your chart notes
Medicare requires a valid, Medicare-accepted signature, either handwritten or in electronic signature format.
• Record all findings, normal or otherwise
Thorough assessment and documentation necessitates recording all findings, regardless of whether they are normal or abnormal.
• Create unique notes
Do not simply copy over the same note from visit to visit. Make sure your notes are unique to the visit at hand.
• Document patient cooperation
Is the patient following their treatment? This affects the patient’s outcome and is an important part of their progress record.
• Record problem-oriented medical records
Remember to include the chief complaint, history of illness, physical examination, assessment and plan.
All of these requirements can be streamlined by considering a move to an electronic system that allows you flexibility and automation. These systems immediately eliminate issues like legibility, messy corrections, and consistency. Automated notes allow you to save and re-use common text to ensure you remain consistent, use a standard set of abbreviations, track your referrals, and manage patient phone calls and in-person conversations.
Regardless of how you manage your documentation, the bottom line remains the same. Good documentation sets a precedent for our profession. It helps us avoid errors, review treatment history, and get reimbursed for our services. It also helps our patients get the most out of care from other providers, feel secure through legal matters, and have faith in the importance we place on their health and wellness.
Dr. Michael Failla is the CEO and Co-owner of Integrated Practice Solutions, the makers of ChiroTouch. Dr. Failla graduated from Life University College of Chiropractic in Atlanta, GA, and went on to run a highly successful chiropractic office in Seattle, WA, for 25 years. He sold his practice in 2007 and continues to promote health and wellness by helping chiropractors run streamlined and successful practices with more time for their patients and less time with their paperwork. Go to www.chirotouch.com for more information.