Documentation

baddocumentationIf you had to do a critical assessment of your daily chart notes, how would you rate them?  Do you record all the necessary components that would aid someone in understanding your patient’s case?  Would you be proud to share your notes with another professional such as a physician, lawyer, or associate?  If the answer to the above questions is “NO” you are not alone.

Since 2000, the CERT and more recently the OIG report have revealed what we already know about chiropractic documentation; it is abysmal.  We were especially weak in recording evaluations, treatment plans, treatment goals, and supporting the necessity for care. These poor grades do not only injure our reputation with insurers and third-party payers, it may also damage our relationship with our patients.

There are many reasons, beyond reimbursement, for keeping an accurate record of your patient’s status as they progress through your care.

  • Improve the quality of your care. In a busy practice it is impossible to keep track of all the minor details about every patient you are seeing.  Excellent note-taking allows you to retrieve this information rapidly and make choices about future care.
  • Improve inter-professional communication. Clear, well thought out notes aid in your credibility and esteem with other professionals you may have to associate with.  An associate doctor, attorney, IME doctor, medical doctor, or an insurance adjuster can all better serve you patient when your notes are of the highest quality.
  • Protect patients from medical legal issues. All visits to your office are part of that patient’s established medical record.  If they were to have an accident at work or in a motor vehicle, your records would be evidence that could be used for or against their claim.  During such instances, proper notes can be the difference between your patients being covered or not.
  • Protect you from medical legal issues. More frequently today doctors are being asked to submit their notes for an audit or an insurance review.  Many doctors are being charged with fraud or overutilization due to gaps in their record keeping that leave them vulnerable to an investigation.

Today, it is more important than ever before that we keep better records in our practices.  It is no longer acceptable for doctors of chiropractic to scribble cryptic notes and listings on a travel card and think that will be enough.  We have to realize that we may be headed toward a national healthcare system and with it the need for electronic health records (EHR), which will require us to step up and give more attention to the level of our record keeping.

While EHR systems can be excellent and will make your notes fast and more legible, it is easy to misuse such a system and get lazy.  You must still be diligent, make your notes specific, and be sure to support your findings with objective data that proves necessity for continued care.  Doing this empowers both you and your patient with the certainty needed to confidently follow your recommendations.

When investigating EHR systems, don’t just look for anything that can create a note.  You need to find a system that is customizable to the specific needs of your practice and your own unique style of care.  Also avoid systems that allow you to continually randomize text or that doesn’t let you phrase things in your own syntax as this will become a negative burden sooner or later.  Choosing an EHR can actually enhance your practice in a number of ways by making note-taking less of a chore and more of a system to help you avoid errors.

If you are just beginning the process of investigating software programs and you want to avoid the pain of purchasing a system that may not be able to accommodate your practice as it grows, I would be more than happy to spend some time answering your questions and helping you discover whether ChiroTouch Chiropratic Software is a good fit for your practice.

Dr. Meinhofer is a customer sales representative for Integrated Practice Solutions, the makers of ChiroTouch; a complete practice management software system designed to make your job easier and your patients’ experience better.