Bulletproofing Your Documentation

The new HIPAA compliance regulations coming into effect this year have left a lot of chiropractors scrambling. Nobody wants to do more documentation, but with the threat of fines and jail time hanging over your head if you fail an audit, it seems like there's no way out of it. And to some degree that's true—you are going to have to modify the way in which you note, store, and access your chiropractic documentation. However, there are good methods and tools out there to keep your life from becoming an endless cycle of chiropractic soap notes, and as you might expect, a lot of it has to do with EHR.

The Basics—Why Your Documentation Must Be Bulletproof

Though most chiropractors are aware of the basic rules and regulations related to the HITECH Act of 2009 as well as the new HIPAA compliance standards, it's easy to lose sight of how important maintaining that compliance is. For instance, did you know that under the HITECH Act, HIPAA audits for chiropractors are now mandatory? That means that any hope of your documentation going under the radar is pretty much shot.

Also, it has become extraordinarily easy for a patient, the family member of a patient, or even the friend of a patient to make a complaint about your practice on the Department of Health and Human Services (HHS) web site. Anyone can file a complaint at any time, and it only takes one complaint to bring the full force of an unexpected HIPAA audit down on your practice.

That's why it's essential to make your practice completely compliant as soon as possible. It can be a pain to change methods of documentation, and you may worry about the expense of updating your chiropractic software, but just consider that HIPAA violations can cost up to $50,000 per violation—that makes spending a few hundred dollars to update your software positively negligible.

First Steps

The very first thing you need to do, if you haven't already, is to make yourself aware of the new HITECH and HIPAA regulations, and make sure that your staff is aware of them too. Little mess-ups can really cause a problem in keeping your documentation compliant, so your staff needs to be aware of what's going on.

The next, and second most important thing to do is transfer each and every one of your SOAP notes, miscellaneous chiropractic documentation, billing histories, and any other data you have over into a chiropractic EHR system. If you have done this already, good for you—you're already taking steps to protect your practice from litigation and bring it up to peak efficiency.

Your chiropractic software and your EHR system is going to be your best ally in making your documentation compliant without driving yourself crazy. Many of the newer softwares on the market are specifically designed to produce HIPAA-compliant documentation, but it's important when buying one to make sure that it is compliant under the new HIPAA standards, not just the old ones.

If you're updating your EHR system, or choosing your first HIPAA-compliant chiropractic software, there are a few things to bear in mind. First, you must make sure that the system has a HIPAA-compliant encryption system for sending and receiving sensitive private health information, and a password protected storage server for your documentation, and a log-in application that protects your patient's privacy and also helps you stay compliant. One common pitfall to avoid is one-sided log-in—make sure that your software not only requires you and your staff to log in to the server or application, but that it also requires any of your BAs to log in. It's important to remember that under the new HIPAA regulations, BAs, or Business Associates, include billing specialists, transcriptionists, accountants, and any other non-employees that have access to your information.

With these safeguards in place, it's actually pretty easy to make HIPAA-compliant SOAP notes. Many chiropractic softwares offer one-step templates that allow you to easily input and modify patient information with a few clicks of a mouse. It's worth investing in a small netbook or laptop to take your notes with during each visit.

If you're not already using software to take down your chiropractic documentation, you should begin to do so immediately. This can make your life so much easier and save literally thousands of hours that could be spent scanning or otherwise inputting patient information.

You should also make your patients aware of the regulations, and what measures you take to protect their confidential information. Besides fulfilling an important role by informing them of their rights, this is an excellent way to make sure that your patients are aware of how hard you work to protect their rights and information, and also puts one more check in place for yourself—if you know that your patients know their rights, you're less tempted to try and cut corners.

Staying Compliant Long-Term

A lot of this comes down to common sense, but as with any new system, it's easy to start backsliding when the immediate threat of an audit is off. Though there's no need to live every day like it's an audit day, it is critical to keep your system up to date, and to not allow yourself to fall behind in any of your documentation. Keeping your documentation notation and storage standards up to par is critical in keeping your practice safe come audit-time.

Also, make sure that you run an eye over the HIPAA regulations from time to time, just to make sure that you don't miss out on any new regulations and are able to keep yourself knowledgeable about the older ones. Finally, have a software risk analyst go over your EHR system once a year or so, just to make sure that your system has not been compromised in any way—this can really be a lifesaver if you ever do face an unfavorable audit.

So although it seems like just one more hassle to deal with in your already busy day, keeping good chiropractic documentation and ensuring that your SOAP notes remain HIPPA compliant is actually a very feasible goal. As long as you take a little time to educate yourself about the regulations, and make use of the worlds of technological advances becoming increasingly available to chiropractors, you'll have no trouble keeping your documentation bullet-proof.

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.