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Documentation | Keeping Notes Compliant

 In chiropractic billing, chiropractic patient experience, chiropractic software

Keeping Notes CompliantCooking Up a New Plan

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.

Read more about Genesis Chiropractic Software’s compliant notes.

Here’s another blog on compliant notes.

Chiropractic Software Features Blog

Showing 6 comments
  • Josh Wolf

    For Many providers the time has come to make an extremely important business decision.

    “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.” say’s Shannon.

    Can there possibly be a better argument for using the right software to create compliant notes?

  • George Konold

    Dr. Ben could be entering his notes himself with a few typed words and a few clicks on buttons rather than having Carmen do it for him. Genesis documentation would free up time for both of them and they could concentrate on keeping their patients happy.

  • Christine

    Genesis could do so much for Dr. Ben & his practice! Dr. Ben could simplify the patient notes process if he only listened to Charlie & signed up with Genesis already!

  • Tim Helfinstine

    Using the most up to date software can and will make documenting patient visits fast and efficient. The Genesis documentation software does just that.

  • Robin Kortman

    Insurance companies are requesting more and more information
    from provider in their documentation to pay claims. As a coach I work with many provider who wait to document their visits at the end
    of the day or week, struggling to remember everything reviewed during the
    patient visit and several providers that become so overwhelmed they don’t
    document at all, I am not a compliance officer, however, I have found clinician
    who use “Genesis” for their documentation needs are able to complete their
    noting in 2 min or less, while the patient treatment is still fresh in their
    minds, decreasing errors or excepting crucial detail need for claim processing.

  • Heather Miller

    Doing the work twice is not efficient and it allows room for more errors. The best option would be for Dr. Ben to do his documentation during the visit. With Genesis that is exactly how the system is setup. That way no one is wasting time transcribing or documenting at a later date were details aren’t as fresh.

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