Evolving your Documentation

It is clear that documenting your clinical encounter with anything less than a SOAP note is not only putting your office at risk legally, but it eliminates your ability to be taken seriously in the healthcare community.  I recently had a conversation with a friend about the concept of “evolving” and what it really takes to “evolve” both personally and professionally. This is an idea that is going on around us constantly and without it we would still be walking wooded trails to barter for goods.  There would be no Target or Best Buy, no Chevy’s or Ford’s.  There certainly would be no plasma TVs or iPads…You get the point.  It is easy to expect evolution from others and it is a critical part of growing and staying in business.  We all know the feeling of working with people that are inspiring and often we can’t wait to see what’s next.  In healthcare, it may be new procedures, new equipment or simply getting better at what we are already doing.  Patients and their MDs are simply unaware of the chiropractors that are not growing or evolving professionally.  What do you have to offer them if you are not reinventing yourself as a doctor?  Nothing…Your documentation is no different.  It must be pointed out that evolution is: “a process in which something passes by degrees to a different stage (especially a more advanced or mature stage); ‘the development of his ideas took many years’; ‘the evolution of Greek civilization’; ‘the slow development of her skill as a writer’ (http://www.thefreedictionary.com/evolution). 

When we take a look at something as complex as clinical documentation and the evolution from a travel card system or check box system to dictation or EMR, it may seem impossible to implement that into a busy practice.  What is important to understand is that your documentation must be in a format that will serve multiple needs, not just one or two.  It needs to serve compliance, billing, clinical and marketing needs in one single format.  “Reporting” is a great term to keep in the back of your head when you are documenting, so think of it as a report of findings to the medical doctor.  We all do focused individual or group reports of findings with our patients and their families, why then do we NOT do that with the medical community? 

How do we evolve our documentation?  The first thing to do is to IMMEDIATELY become compliant, if you are not already, by using the comprehensive treatment and SOAP note templates found in the members section.  This is not an option, it is a MUST DO, as it will protect you and your family from predatory retrospective reviews.  All you have to do is download them, put your clinic name on them and print them out!  I will also be doing an audio consultation for your staff to help them understand that they also play a part in this endeavor…More on that later.

The next step is to have each of your patients sign a records release form (this is now posted in the members section and was created by a personal injury attorney for my practice).  Obtaining the medical records of other healthcare providers should be a standard part of your treatment regimen, but for the purposes of this discussion, it is important that you understand how other specialists in your area are reporting.  Take a look at the documentation from the busiest practices, pain management, rehabilitation, orthopedic or neurosurgery and study them.  This will give you a look at the depth of reporting in your community.  Compare that to what you are currently doing and start reporting like an expert. It will also give you the ability to start a listing of the physician assistants and nurse practitioners in these practices.  Remember, most of the initial evaluations are done by mid-level providers. Therefore, they are signing off on the reports.  Use this method to get to know who these people are and reach out to them.  Many of my weekly referrals are through PAs and NPs. 

Thirdly, start learning about EMR (electronic medical records).  If you haven’t already, please go to the members section and listen to my interview with James Calburg on EMR.  This is eventually going to be a MANDATORY part of practice and as James pointed out, the doctors that choose NOT to participate will be on the periphery of healthcare.  That is not good for patients or chiropractic.  This program’s focus is on getting 95% of the population under chiropractic care while staying true to chiropractic principles.  That cannot be accomplished through fringe efforts.  We all need to be in the game and stay the course.

Lastly, is it CRITICAL that we realize on a daily basis that we are DOCTORS, not technicians.  We must have respect for what chiropractic does to properly report what we are doing for our patients in our offices.  When we combine that effort with professionally reaching out to other healthcare providers, we will evolve from 7% of people under care to 95%.  


Evolution simply starts with the DECISION to evolve.