Documentation: Create better reports faster

Journal of the American Chiropractic Association, Feb 2001 by Behmlander, Jennifer Lynn

The amount of accurate and timely documentation required by insurance companies has continued to increase in the past few years. Most doctors agree that writing these narrative reports for insurance companies takes too much time. Because doctors of chiropractic are required to justify the treatment of each patient, it is often the quality of the documentation, rather than the condition of the patient, that determines the amount of care deemed medically necessary by the insurance company or auditors. Thus, a software program with a quick, easy way to create daily notes and narrative reports sounds like a wise investment. Computerizing documentation may be an answer. Some level of documentation is needed for every patient visit, and it is essential to develop a method that is fast and easy. By computerizing documentation, templates can be created, allowing a doctor to preset frequently used phrases. An easy way to generate notes will save time. Some DCs do not want to do their own documentation for lack of time or motivation. Software offers another possible solution. Many offices use fee slips or routers with every patient visit. These forms contain very brief information, such as services performed, diagnoses, and general findings, which are often used by the CA to determine the charges for the day. With a little time, these routers can be made much more useful. By adding the common elements of documentation in a checklist format, the CA can also use the router to easily generate a note for the day, or the doctor can use it as a guide to create his/her own note at a later time. This can help to decrease some of the doctor's burden.

Some doctors, no matter how busy, prefer to keep their documentation in their own hands. Amazing software and hardware are on the market that can assist doctors to speed the documentation process. Programs are available that work with touch screens, pen-based or hand-held computers, and voice recognition software. For more information about these specific types of technology, please refer to another in this series of articles, "Software Integration with New Technology" (Vol. 37, No. 7, pp. 26-27). Each of these options can decrease the time spent creating the note, while also increasing the quality. Additionally, it can allow the doctor to create the note while the patient is there so no information is forgotten. An important aspect of software is its ability to be customized. Each doctor has his/her own way of recording information, and different practices offer different services and methods of care. Customizability allows you to keep track of any special tests or documentation that may be unique to your office. Also, it should allow you to weed out information that is not commonly used in your practice. An additional feature that is becoming available in software documentation programs is the ability to assist you with generating special reports. Certain insurance companies may require specific reports on a patient in order to cover services. Imagine the time saved if the computer could generate them for you! Before purchasing a software product, do some research on the documentation forms your office spends the most time on, and see if the software can create the forms for you. I hope this series on chiropractic management software has been of assistance. I welcome your questions, suggestions, and success stories. If you have advice for other DCs, please pass that valuable information along. Technology is ever-changing, as is the health care industry, and with the right information, DCs will be better equipped to handle this transition. V

* Eddor' Note: In the August2000 JACA (Vol. 37, No. 8, pp. 2729) article based on the June 2000 meeting between ACA and 13 of the largest U.S. insurers to dicuss medical documentation, insurers mentioned that an over-reliance on "canned notes" could be counter-productive in the claims process.

BY JENNIFER LYNN BEHMLANDER

Ms. Behmlander is a technical support specialist with Clinic Pro Software. She can be reached at 517/351-1021 or at jenbeemeer@yahoo.com.