#1 Program and Office Infrastructure
#39 Sending Reports
The reports that are coming out of your office (or should be) are just as important as what your patients say about your care. Your reports showcase your expertise and if you want to grow your practice it is non-negotiable. The federal government is mandating by 2015 that you have an electronic record system. Regardless of the system that is out there, you will need to process patient information properly in order to maintain order in your office.
I have tried many different methods of providing reports, but there is only one way to do it CHEAP and with little effort. We do not mail notes and we not use fancy letterhead on high quality paper, it is all done through fax. Here is the flow…
A new patient is examined or an existing patient is re-evaluated. Your intake paperwork should MATCH the flow of your EMR note system. When you are coding to fulfill a level 3, 4 or 5 examination, the patient can fill out most of the categories such as Past Medical History, Family History, Social and Working History, Allergies and Medications. That way all you have to do is review that information with the patient when you are in the room. That will save a lot of time, and allow you to focus on the examination. If they are an auto or working injury, your forms should have a detailed questionnaire so that again all you have to do is review the details with the patient and ask additional questions where necessary. They spend the time filling out the paperwork while you are seeing other patients.
If you use your EMR while you are examining the patient you can enter everything into the system as you go, if not you will need to use the Comprehensive Evaluation Form (available at www.mdreferralprogram.com). If you are more comfortable using paper, this form will allow you to cover every aspect of the E/M coding requirements. Then you can transcribe that information into your EMR or have a staff member do it.
Once the Initial or Re-evaluation Report is complete (this template is available as part of the EMR Macros program at www.emrmacros.com or as part of the ACM program with Software Motif) in this format it will meet coding, compliance and marketing requirements. In other words, it will meet the needs of the MD, the lawyer, the insurance carrier and it will serve to showcase your expertise.
Finally, under your signature, you will add the parties that will be cc’d so that your front office staff can FAX the report to all those parties. The first page of the report is actually a fax cover so that it is all set for you when it prints out. SIMPLE. Here is what it may look like…
William J Owens Jr DC DAAMLP
Law Offices of Michael Burns Esq. Jones Orthopedics Smith Neurology
* (this gets included so everyone knows that it went to the carrier, but it actually goes out with the billing, unless it is electronic)
When you use this template properly, a new level 4 or 5 evaluation will take 4-6 minutes to put into the EMR. That report then will be FAXED for FREE to 4 offices and mailed with the billing to the carrier. One report to meet all the needs of the MD, lawyer and carrier. That report and the ones to follow are a CONSTANT piece of marketing material to the medical community and it takes NO MORE EFFORT than required to generate the initial visit note.