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Documentation, DO IT ! Thorough documentation is one of the key elements to a successful practice. Several of the doctors I trained with reviewed malpractice cases on a regular basis. I had the opportunity to see some of these cases and noted the majority of the doctors who were sued had inadequate documentation in their charts. The doctor may have acted within the standard of care, but their lack of documentation made it harder to prove otherwise. My residency director always said the medical record should tell a story. It is not how much you say, rather what you say that explains your thinking and actions. Learning and executing proper documentation result in records that support your actions. Additionally, you will be able to bill at the appropriate level and will have the documentation to support it. I have implemented several types of forms into my practice. Anytime I perform a procedure, I have a consent that reviews the indications for the procedure, the alternative treatments, and risks. After the procedure, I provide post-operative instructions for the patient. The consent is placed in the chart and I document that the instructions were reviewed and dispensed and the patient was clear. Another form I have is a patient call log. This is used to document telephone conversations with patients. Every phone call, no matter what the issue, is documented and the form is placed in the patient's chart. I use this form when I call patients for a post-op check and document pain level, compliance, tolerance to medications, etc. Although documentation is time consuming, it is worth the time to do it. Documentation is also important when dealing with insurance companies. When you call a company for benefits or claims information you will get one answer from one representative and another answer from someone else. This is frustrating for you, your staff, and the patient. As a result, each time you or your staff calls the insurance company you want to document the date, time, the representative's name and employee id, and a reference number regarding the issue. If a claim is disputed in the future you will have the documentation to support it. Finally, you should have a log for each employee. Whenever you reprimand or have an issue with an employee you should document the situation as clearly as possible. In the event you need to fire an employee, you would have already built support for this last resort action. As you can see, thorough documentation has its advantages throughout several aspects of practice. Your notes will help to protect you so when it comes to documentation, DO IT!
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