Documentation does not have to be a painful hassle. By applying these straightforward tips and techniques, you can simplify the documentation process.
A recent report published by the Department of Health and Human Services claims that chiropractic care has “the highest rate of improper payments among Part B [Medicare] services” and that just two percent of chiropractors filed nearly half of the $76 million in inappropriate claims in 2013.1 In a press release, the American Chiropractic Association (ACA) responded to the report by emphasizing the importance of proper documentation practices and appropriate documentation training for chiropractors.²
By simplifying documentation processes in your practice, you may be able to reduce your own error rate and prepare your documentation more efficiently.
EHR system documentation benefits
Many EHR systems have features that assist with documentation. Allowing the software to do part of the documentation work may improve accuracy and reduce the complexity of writing documentation.
According to the American Health Information Management Association (AHIMA), EHRs may provide part of your documentation but this information must be verified for accuracy with every new patient encounter.³ Your EHR may already have common templates for the conditions you treat in your office.
EHRs can also guide you through the documentation process and provide you with an idea of what is required for a proper claim. Healthcare providers should be appropriately trained in documentation even if they use an EHR, though.
The U.S. federal government’s HealthIT website lists several advantages to using EHR documentation, including:⁴
- Improved writing legibility
- Documentation efficiency
- Decreased paperwork costs
- Greater accuracy
Ease of writing SOAP Notes
SOAP notes make it easier to provide complete notes about each patient and provide sufficient documentation. For the first visit, you may need to write a longer record than with future visits. Documentation must be very specific and provide the correct information, both of which may be accomplished with relatively short notes using SOAP.
Great SOAP notes will help protect your practice from malpractice liability and help you during an audit. This documentation strategy also improves patient care quality by providing your practice with more thorough patient history and care records.5
Use templates wisely
Using your successful claims, you can copy documentation as long as you adjust and customize this information to the patient and for that specific encounter. Forgetting to customize is a common mistake that can have serious consequences for your practice.3 Using template properly, you can increase your accuracy and save time.
Keep guidelines for great documentation on-hand and easily accessible to help prevent problems, according to AHIMA.³ Signing each entry with your initials and a time and date stamp will help remind you when a template is in use and needs revision.
Know your documentation
When you know how to create proper documentation, finding strategies to simplify writing notes becomes easier. Stay in compliance and streamline your work by understanding documentation best practices and knowing how to get the most from EHR features.
1 Department of Health and Human Services. “CMS Should Use Targeted Tactics To Curb Questionable and Inappropriate Payments for Chiropractic Services.” http://oig.hhs.gov/oei/reports/oei-01-14-00200.pdf. Published September 2015. Accessed November 2015.
² American Chiropractic Association. “Federal Report Outlines Medicare Documentation Deficiencies.” https://www.acatoday.org/press_css.cfm?CID=5758. Published October 2015. Accessed November 2015.
³ American Health Information Management Association. “Integrity of the Healthcare Record: Best Practices for EHR Documentation.” Journal of AHIMA 84, no. 8 (August 2013): 58-62
⁴ HealthIT.gov. “What are the advantages of electronic health records?” https://www.healthit.gov/providers-professionals/faqs/what-are-advantages-electronic-health-records. Published September 2014. Accessed November 2015.
⁵ American Chiropractic Association. “Keep your Records Clean with SOAP.” https://www.acatoday.org/content_css.cfm?CID=5341. .” Published November 2013. Accessed November 2015.