“It’s Wednesday, 6:15 p.m., and there are two more appointments to finish out the day. It has been another successful and rewarding day at the office. By 6:45 or so, you’ll be ready to say goodnight to the staff, and your team will walk out the door and head home. You’re looking forward to dinner with the family; helping your son prepare for his spelling test; relaxing in front of the television and watching your favorite sit-com or a few innings of baseball; catching up on a little reading, and so on… Ah, it all sounds so nice….”
But then it hits you like a 90-mph fastball to the side of the head: You haven’t done any progress notes on today’s patients! Who are you kidding? You’re not walking out the door with your staff. It looks like dinner, homework, TV and reading will all need to wait, because there is no way you can put off writing your SOAPs.
If this scenario sounds all-too-familiar, it’s because this type of situation is a common occurrence for today’s DCs. All doctors need to document patient visits, and do so in a timely and accurate fashion. Notes and reports must be clear, legible and thorough. Patient charts must be completed to justify your treatment plan to the powers-that-be. And yet, it seems that there is just never enough time in the day to get this all done.
You certainly would like to see more patients. It’s quite important to set aside some quality time with your staff. And of course, it’s essential that you enjoy some all-important free time with family, friends, etc. You want to manage your time and save on expenses. You want to grow your practice, see more patients, and improve the way of life for those around you. Sometimes you wonder how you can find time to do all this — after all, you’re only one person. Never fear: There is a light at the end of the tunnel, in the form of the latest computer technology. To achieve your office goals, and at the same time, complete all of your documentation, you and your staff should make some decisions regarding the following:
Who should be responsible for the notes and dictation?
- the DC;
- a CA;
- an in-house transcriptionist;
- an outside company;
- a computer-generated program.
Opinions may vary on this topic, but many experts believe to accurately depict the patient’s feelings, and your assessment of the patient’s condition, the best person to complete the documentation is you. However, it is also fully acceptable to delegate, as long as the staff member completing the documentation is familiar with the patient’s treatment plan. Be careful with computer-generated documents; although they may initially save you time, in some cases there will be a significant amount of time required for editing and review. And the resulting notes may not be as patient-specific as you would like.
When will the notes be completed?
- now, during the patient visit;
- later in the day, maybe over lunch;
- after work, before leaving for home;
- at home, with the kids running around;
- on Friday, for the previous four to five days.
If it’s possible, many would argue that the best time to complete the notes is now. The patient’s subjective findings and your treatment plan are fresh in your mind. Why put off something that can truly be completed right away? After all, there are solutions that allow you to be totally portable, and avoid the need for extensive computer time.
However, if the practice is really busy, you may choose to develop that alternative delegation plan. Keep in touch with the staff and be sure your solution offers both portability and computer-based options to simplify the process. Technology has certainly come a long way, and you should take advantage of it.
What would be the easiest way for you to get the notes done now?
- portable solution with a hand-held device;
- at your computer, directly into a
computer-based or on-line solution; - travel card;
- voice recognition system, possibly with a recorder;
- forms, paper and hand-written notes.
This is where the real decision-making comes in. In order to answer this question, you need to do your homework and try to see the big picture. All the different documentation systems offer you positives and negatives, and depending on your office set-up, you will eventually find the best solution to meet your needs. The decision can be simplified if you search out a product line that offers choices and versatility, combined with state-of-the-art technology.
Remember, too, that any system you choose must include a solid Electronic Medical Records (EMR) or Computerized Patient Records (CPR) database that is easy-to-use, networkable, and compliant. In the near future, you may be faced with the elimination of those hard-copy patient files, as the newer digital technologies progress, and the e-commerce world fully matures.
So where does it all go from here?
It goes without saying that there are a number of companies that can provide quality programs for your office. Some systems offer SOAP notes only, while others offer narrative reports. A few offer both SOAPs and narratives. And there are a few practice management systems that, to at least some degree, provide everything.
The ideal solutions are those that allow you and your staff to spend most of your time seeing patients at the office, while spending the least amount of time dictating, transcribing, and/or sitting in front of a computer. So if there’s one important factor that many doctors should consider when choosing a system, it would be to search out a product that includes portability as a major selling point, while still allowing you to use other technologies like voice recognition or templates when appropriate.
In today’s competitive computer market, the products are evolving at a record pace. Some of the hottest items at trade shows and on the Internet are the numerous hand-held devices. There are tons of choices available in the PDA (Personal Digital Assistant) world, with the most popular being those written in the Palm OS language. The most popular examples of these products would be the Palm Pilot, Handspring Visor and Symbol Pilot. Using these exciting tools, along with a quality documentation software package, you can create and complete a typical SOAP note in a short period of time.
Many of today’s documentation companies have created their products with the hand-held device in mind. Whether it is through barcoding, point-and-click screens or templates, the technology is available. It’s all a matter of choosing the implementation that works best for you.
And let’s not stop there; other PDA functions can help make your life even easier. Wouldn’t it be great if you could review past notes on an electronic travel card? Then press a single button on the Palm Pilot screen and begin a new note. How about automatic downloading of your notes simply by walking through the exam room door? Blue Tooth (small device networking) technology is about to make this all possible.
Even sending your documents directly to the insurance company or referring doctor via the Internet can be done directly from your PDA. The days of faxing your hand-written notes to the insurance companies are just about over.
Virtually all of this technology is currently available, and it’s affordable for most doctors.
Remember, you can only grow your practice if you know how to manage your time. You should never again need to worry about documentation taking away valuable time with your patients, your family and yourself. Saving time is ultimately more important than saving money, when you consider that you can never replace time.
Once you start using technology to assist you in your clinical documentation, your biggest dilemma at the end of the day will be answering the question: “Does anyone know where I left my car keys?”
