Consultation #10- Create a Clinical Note not a Story

#3 EMR, Macros and Reporting to the Medical Community

 #10 – Create a clinical NOTE not a STORY

Many DCs that I talk to feel that they have to document their patient encounter in a way that showcases their “technique” or their office specialty.  Many go on and on with information that is not useful creating an unprofessional healthcare report or note.  It is commonplace within our profession to have doctors over documenting some things and then under documenting or omitting others. You have to realize that there is a standard in healthcare reporting, that is governed my your state licensure board, federal and state guidelines as well as interprofessional communication standards. In other words, you are documenting to protect yourself as well as communicate with other healthcare professionals.  

Many offices do not send out any reports or notes except when asked by the carrier. That is an ineffective process since those offices are missing opportunities to build their reputation, communicate with other professionals and increase collections. The quality of your reporting is everything and it has to be done in a way that is fast, accurate and reproducible. The worst thing you can do is to create a “special” note that only YOU understand. If you are confused here are some simple guidelines to follow:

Get an Electronic Health Record (EMR) system that does BOTH billing and reports

Use the template in the EMRMacros program to create an initial and re-evaluation template – the only difference between the two really is the time component

Make sure that you have orders for everything that you are sending out or doing in your office – that includes in office x-ray. The pad that the MRI company gives you to order studies is NOT an order. The macros in the imaging section will help you to get started

Document what you need to satisfy regulatory agencies, insurance carriers and the legal community if necessary. Then use your report to marketing your expertise.

Stay away from overstating techniques, listings and other items that are unique to your practice style. Notice that I said OVERSTATING, you need to document what you are doing, but it should not take up time that you should be spending with your patient. SIMPLY and be more EFFICIENT

Create a system that allows your staff to fax and share your reports with everyone that the patient is involved with, that may be pain management, surgeon and primary care physician.  If you had 5 new patients per week for 3 months that would give you 60 new patients. Your reports become a powerful marketing tool when you share them and in this case you would have (between the intial and reevaluation) in just the first month 20 reports being faxed, then month two you have the 20 initials from the new patients that month PLUS the 20 re-evals from last months patients. On month 3 you have 20 new patient reports (remember 5 per week), PLUS 20 re-evaluations from month 1, PLUS 20 re-evaluations from month 2 which gives you 60 reports going to primary care and specialty providers. 15 reports per week within 90 days and that is just with 5 new cases per week. That is better than ANY advertisement and you should be loosing sleep trying to figure out how to do that in your office. You are missing out if you are not sending these out. It is my opinion that in a short period of time, interprofessional care will be mandatory. If you need help call me, I do this every da

{jcomments on}