Avoid Salted Notes
It’s been a while ago now since several government agencies made a joint statement that said cloned notes are considered fraud. That’s one of the big concerns with EHR. Cloned notes. Every encounter looking like the previous encounter. That is a big problem that can cost you big money.
That old saying applies, “if you didn’t write it down, it didn’t happen.” When you think about it, it makes sense. We get paid for the work we do. If there is no record of the event, we don’t get paid. If there is a poorly documented record, a missing record – which happens more often than one would think, or a record that comes into question because it doesn’t or cannot convey what happened during the encounter; you don’t and shouldn’t get paid.
So how do you protect yourself and your practice? How do you avoid the cloned notes process? One option that many doctors are still choosing is to continue to document on paper. Computers are designed to make life easier. Anything that eases our daily activities and can be programmed, will be programmed.
That is how the SALTing process came into being. SALT (Same As Last Treatment) is where your EHR software copies the identical note as the last encounter. Designed to make note taking faster, it has instead helped doctors create useless records and put their practice at risk. The problem is, in the fast-paced healthcare environment, many times the SALTed notes do not get changed, or are minimally changed, so the tale of what actually happened during that specific encounter is lost, and in effect, might as well be missing.
If you don’t have a previous encounter that you can “SALT” forward, you can avoid the problem. That is why many doctors are still choosing to remain “old-school” and write paper notes. To create more effective and efficient paper notes, many chiropractors have turned to chiropractic paperwork, because it is easier to “fill in the blank” when you are prompted about what to write to create the perfect note. And each unique encounter has its separate unique note about what happened, how the patient is progressing in relation to what is expected, including their treatment goals and what’s next.
What’s a solution? Of course, having a clear understanding of documentation guidelines is always essential. Those that use EHR also have to be extra cautious to ensure notes are managed properly. Implementing appropriate and compliant Chiropractic Paperwork is also a very common (and beneficial!) step taken by many practices. You can learn more about the entire paperwork system available to you by clicking here. Implement the entire paperwork system or just specific components to this that may be necessary for your practice.
Save $50 When You Sign Up For Library + HIPAA and OIG Compliance
At KMC University we have solutions to fit every practice, personality, and pocketbook. Among them are our Basic Library membership, and our Library Plus HIPAA and OIG Compliance membership.
The Library program is a robust resource that helps you run all aspects of your practice. Along with your access, you are assigned a dedicated Account Manager to assist you with all you do within the Library. This is a great value regularly at $99 per month.
To ensure that they are also able to keep their practice in compliance with HIPAA and OIG rules and regulations, many members choose to add our HIPAA + OIG Compliance to their basic Library membership, for a combined cost regularly of $249 per month.
Use Coupon Code LIB50 at checkout to get your first month of Basic Library or Library Plus HIPAA and OIG Compliance membership for $50 off if you sign up by February 28, 2018.