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How do you document?
Choose a method to meet your needs
By Judith Richard
One of the biggest challenges facing any practitioner is documentation, yet good documentation is essential for every practice. Without it, you run the risk of losing reimbursements, reputation, and patients.
Documentation should have several goals:
• It must support the care you give. If it doesn’t, you open yourself up to allegations of fraud and billing for services not rendered. If your records are bad, you don’t get paid.
• It must be detailed. If a chiropractic case ends up in court, good, thorough documentation is especially important. If it is not, you run the risk of losing.
Case in point: A doctor in Wisconsin had a workers’ comp patient. He treated the patient for more than six months, but did not maintain good documentation. His notes were handwritten and practically illegible.
When it was time to discuss the clinical documentation with the attorney, most of his notes proved useless. The patient did not receive the registration of disability, although he was disabled. The doctor’s notes simply did not support the care given to the patient. Later that day, the furious patient arrived at the doctor’s office, and made quite a scene in the waiting area in front of other patients. Needless to say, the doctor lost that patient to another doctor, as well as several other patients, because it was a small town, and the doctor’s reputation was affected.
• It must be legible. As the case above shows, illegible notes can cost a doctor money and reputation.
• It should be easy to use. If a method requires a long learning curve, it is less likely to be adopted.
WHICH METHOD TO USE?
You can document by using a travel card, dictation machine, paper and pen, or computer. And if you use a computer, you have a choice to document directly into a word-processing program through keyboarding or to use some variation of speech-recognition software. (See table, “Methods of documentation: Advantages and disadvantages.”)
Each method has advantages and disadvantages, and some meet most of the goals. The method that meets all of the goals, however, is speech-recognition software.
In addition to allowing detailed and legible reporting that supports your care, speech-recognition software has additional benefits:
• Anytime, anywhere dictation. With a VPN (virtual private network) installation on a laptop and a broadband connection, you can dictate from any location — your home, on the road, or in a hotel, for example.
The office staff has access to the patient database, but you also have access from your computer to dictate notes.
• Short training time. Unlike applications that require considerable time to master, learning to use speech-recognition software takes minimal time once installation is done.
• Additional applications. Once you have speech-recognition software installed on your computer, you can use it to dictate e-mail, letters, and reports. In other words, the software “multi-tasks.”
Judith Richard has more than 26 years of experience in computer teaching and consulting. She specializes in chiropractic documentation and creative computing, and teaches CE classes on documentation across the country. She can be contacted at judy@JRConsulting.info, at 952-474-3426, or through her Web site at www.jrconsulting.info.