Countless thought leaders from Einstein to Stephen Covey have touted the benefits of simplicity. But if you’re like most DCs, your practice responsibilities likely feel far from simple. After all, you’re juggling patient care with paperwork. And with what feel like new rules, regulations, and requirements coming from state and federal agencies almost every month, simplification probably doesn’t even feel like an option.
But there’s hope, and help. You’ve taken a huge step in simplifying the financial relationship and processes with your patients by becoming a ChiroHealthUSA provider. Now it’s time to consider what you can do to simplify other systems in your practice.
Ask DCs what takes up most of their time, and they’ll invariably say that it’s documentation. While documenting every visit and episode of care is essential to running a compliant practice and getting appropriately reimbursed by third-party payers, there are indeed steps you can take to save time and simplify. Here are just a few:
Lean on Your EHR System
Most EHR systems have built-in featured to help you with your documentation, including templates for common conditions and prompts that remind you of documentation requirements. Let the software do its job by helping you do yours. Be sure, however, to customize those templates so that patient records aren’t “cloned.” That’s red flag behavior that could get you audited. Also make sure you have a system in place for verifying the accuracy of your information for every new patient encounter. Like any computerized system, the data out will be only as good as the data you put in.
Use Your SOAP
SOAP notes provide a structure that makes it easier to ensure your notes about each patient visit are complete, and that you’ve provided sufficient documentation. That initial patient encounter will, of course, require more notes that future follow-up visits, but if you focus on getting this right the first time, your SOAP notes will tell a clear and compelling story to third-party payers that tracks the beginning, middle, and end of each episode of care. Take SOAP notes with the idea that at any point, they might be reviewed as part of a records request. With practice, you can learn to make these notes while examining and treating the patient, instead of having to wait until the end of the day to write it all up.
For Medicare, Mind Your PQRS
Medicare’s Physician Quality Reporting System (PQRS) gives you two measures to work with: Pain Assessment and Functional Outcome Assessment. A basic numeric scale of 1 to 10 is reliable and easy for patients to understand, and with practice, is easy to incorporate as a required part of each Medicare patient visit. The Functional Outcome Assessment measures the function of the spine and establishes clinical efficacy. But here again, making this a routine part of each patient visit helps both you and your staff become faster and more accurate. A practical alternative to using multiple forms is to use one instrument, the Functional Rating Index (FRI). This instrument can be used with cervical, thoracic or lumbar conditions eliminating the need for multiple instruments for spine-related conditions.
When you simplify documentation, your life and your practice both have room to breathe and grow. Stay in compliance and streamline your work by understanding documentation best practices and knowing how to get the most from EHR features in all areas of your practice. We offer several free webinars on our website to help you become more efficient with your documentation.
ChiroHealthUSA also stands ready to assist you in many other areas of your practice by offering weekly webinars on topics including marketing, regulatory and industry updates, staff training and scripting, documentation risks, compliance, and so much more. Visit our site often. Thank you for being part of the ChiroHealthUSA family!