Documentation | Keeping Notes Compliant
Can Dr. Ben make the commitment to find a better way to achieve fast and compliant patient notes?
Ben arrived home after a busy day to find Carmen reading to Jonathan on the couch. He swung Jonathan up in his arms and gave him a firm hug.
“How was your day, Daddy?” asked Jonathan.
“It was so busy,” Ben said. “I’m tired but very happy to be home!”
Jonathan gave Ben a big hug back, then turned to Carmen. “Mommy, I’m hungry,” he announced. This was not surprising, because Jonathan was always hungry.
“Jonathan, why don’t you go upstairs and finish your homework,” said Carmen. “Your daddy and I will get started on some dinner for everyone.”
Carmen squeezed Ben’s hand as they walked toward the kitchen.
“So tell me about your busy day,” Carmen said.
“Well, Luisa and I had a really good conversation this morning and I’ve been thinking about it all day,” Ben said. “We’re both getting pretty frustrated with patient notes. I have to write everything down – every single detail of each patient visit – and then Luisa has to take my notes and enter them into our system, along with images, forms, test results and more.”
“That sounds like you’re doubling the work for yourselves,” mused Carmen. “Plus, you know, I’ve heard Luisa give you a hard time for your handwriting.”
“Yes, that’s certainly a continuing topic of discussion in the office,” admitted Ben. “But it’s so important to capture every detail. Medical professionals have it drilled into their heads that if we don’t write it down, it didn’t happen.”
“Sounds just a bit like our inventory process at the pizzeria,” said Carmen. “Every tidbit of food that gets pulled out of the freezer or off the shelves has to be recorded. I have to know how much we use of everything and how quickly, or else I may not reorder in time. If we don’t have the ingredients customers want, they may never return – and they certainly won’t refer us to their friends and family.”
“Luisa and I were talking about that today,” said Ben. “The less time we spend on patient notes, the more time we can spend on patient interactions and care. Happy and healthy patients are going to be much more likely to refer us to others.”
Carmen nodded. “Plus, my bookkeeper needs to track my inventory costs in exquisite detail, or else we might be in trouble if there’s ever an audit,” he continued. “So even though I grumble about what a pain it is to manage and report on our inventory, I make sure to dedicate enough time to the process to do it right.”
“You know, our Genesis coach, Charlie, has warned us that every practice that has been in business for more than five years will likely be audited by a state board or insurance regulatory agency,” said Ben. “It’s been a while since our last audit – we really need to do better with our documentation. We need to be able to have notes that are both fast and compliant with state, federal and insurance rules.”
“You know what we really need to do better with?” asked Carmen. “Preparing dinner, or else Jonathan might grow weak with hunger!”
Ben laughed and opened the refrigerator to get out the salad fixings. But he knew he’d be thinking more about this issue in the coming days.
What are Dr. Ben’s options to simplify the patient notes process while enabling him to remain in 100% compliance with state, federal and insurance rules?
Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.