Seeking Direction
By Kathleen Casbarro
For ICD-10 transition, It’s Essential to Choose the Right Path
Should Ben start practicing the new style of documentation long, or wait until he has to do it?
“It’s great that you’re not experiencing pain any longer,” Ben told his last patient of the day, “but remember to come in for regular adjustments and keep it that way.”
The young woman hefted her tote bag and stepped through the door. “I know I should, but somehow if I’m not having any pain I don’t make the time.”
Ben commiserated. “Let’s go ahead and make your appointment now,” he suggested. “That way you’ll have that part done. Pam, can you help Sheila?”
“Of course!” Pam took over with a warm smile.Ben understood what his patient meant. He had been trying all day to get used to the new clinical documentation he’d have to be using once the shift to ICD-10 codes took place. He had tried to note which side of the body each issue involved and to write notes with the level of specificity the new system would demand. It hadn’t been hard at first, but it had been a busy day. As patients mounted up and he and Pam skillfully navigated through a day filled with surprises as well as scheduled events, it got harder to take the time for the new style of documentation — and easier to fall back on the old system he found so comfortable.
After all, it really wasn’t a problem right now if he skipped the notes on laterality or wrote something with less detail. The pain wouldn’t come up till later, so it was tempting to just wait till later to make the changes.
In fact, Ben mused as he moved through his end-of-day routine, making the changes now was actually causing some pain. It was slowing him down a bit, distracting him from his key priorities, and probably irritating Pam and the rest of the team.
Was it better to get a head start on it now, possibly lessening the pain of the transition in October but also perhaps lengthening the amount of time there’d be pain in the office? Or should he wait till closer to the time?
In fact, maybe the best solution would be to do his documentation in the usual way and pass those on to Pam and the team, but then also to produce a second set of notes that would provide enough detail for the new set of codes? But then, Pam and the rest of the team wouldn’t benefit from the head start he would be getting.
Ben suddenly realized he had been standing frozen in thought, one hand holding his car keys out in front of him and the other reaching for the door, for — well, an embarrassingly long time if anyone had happened to be looking.
He shook his head and got back in motion. It was hard to know the right thing to do, that was all there was to it.
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