Documentation | Keeping Notes Compliant

indexCooking Up a New Plan

Can Shannon make the commitment to find a better way to achieve fast and compliant patient notes?

Shannon arrived home after a busy day to find Mike surrounded by their kids. She swung Sam up in her arms and gave him a firm hug.

“How was your day, Mommy? asked Heather.

“It was so busy,” Shannon said. “I’m tired but very happy to be home!”

“Mommy, I’m hungry, announced Laurie, who was always hungry.

“Laurie, why don’t you, Heather and Sam go upstairs and finish your homework?” asked Mike. “Your mommy and I will get started on some dinner for everyone.”

Mike held Shannon’s hand as they walked toward the kitchen.

“So tell me about your busy day,” Mike said.

“Well, Teresa and I had a really good conversation this morning and I’ve been thinking about it all day,” Shannon 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 Teresa 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 Mike. “Plus, you know, I’ve heard Teresa give you a hard time for your handwriting.”

“Yes, that’s certainly a continuing topic of discussion in the office,” admitted Shannon. “But it’s so important to capture every detail. Therapists 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 restaurant,” said Mike. “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.”

“Teresa and I were talking about that today,” said Shannon. “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.”

Mike 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 bestPT coach, Tom, 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 Shannon. “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 Mike. “Preparing dinner, or else Laurie might grow weak with hunger!”

Shannon laughed and opened the refrigerator to get out the salad fixings. But she knew she’d be thinking more about this issue in the coming days.

What are Shannon’s options to simplify the patient notes process while enabling her 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.


6 replies
  1. Josh Wolf
    Josh Wolf says:

    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.

    What can possibly be a better argument for using the right software to create compliant notes?

  2. George Konold
    George Konold says:

    Shannon could be entering her notes herself with a few typed words and a few clicks on buttons rather than having Teresa do it for her. bestPT documentation would free up time for both of them and they could concentrate on keeping their patients happy.

  3. Christine
    Christine says:

    bestPT could do so much for Shannon. Dr. She could simplify the patient notes process if she only signed up with bestPT already!

  4. Tim Helfinstine
    Tim Helfinstine says:

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

  5. Robin Kortman
    Robin Kortman says:

    Insurance companies are requesting more and more information
    from clinicians in their documentation to pay claims. As a coach I work with many clinicians 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 hat become so overwhelmed they don’t
    document at all, I am not a compliance officer, however, I have found clinician
    who use “Best PT” 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.

  6. Heather Miller
    Heather Miller says:

    Doing the work twice is not efficient and it allows room for more errors. The best option would be for Shannon to do her 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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