Documentation may not be child’s play, but it’s not complicated, either, once you’ve mastered the basics. Many doctors get hung up on the requirements without taking the reasoning behind them into consideration. We hear this when a DC expresses frustration over having to fill out “all this paperwork.” That’s the what. But what’s the why?
Documentation, at its most fundamental, is a story of what happened during a patient encounter, told so that even the busiest and most distracted insurer can understand it. Like all good stories, it has a beginning, middle, and an end—usually, though not always, a happy one. The more simply you tell this story, the easier you make it for an insurer to follow it. And pay you.
Your patient came to see you and presented with a complaint or issue. You asked the patient specific questions and learned subjective information. You examined the patient and got more objective information. Based upon history and examination, you arrived at a diagnosis. You created a treatment plan with goals for improvement. You treated the patient. They improved in measurable ways. And if they didn’t, you revised your treatment plan.
Jane’s neck hurts. Jane has a subluxation. Dick adjusts Jane’s neck. Jane’s neck feels better. Jane can turn her head. Turn your head, Jane, turn.
With your documentation distilled to its most basic elements, it’s easier to see that if you skip over any element, your documentation story no longer hangs together. It’s like writing a story but leaving out the plot!
How simply can you tell your story? The easier you make it on the reader, the lower your rate of kicked-back claims and records requests. And, best of all, the more you’ll see your revenue increase.