Documentation Dangers and the Value of the Self-Audit
Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT
Last year [May 20, 2012 issue], Dr. Tom Necela wrote an article about audits – how to "Protect Against and Profit From Them." It was all about looking at your records and stats, recognizing the issues and correcting the problems. Toward the end of the article, he advocated a self-audit to make sure your documentation is up to par.
I would like to expand on the topic of the self-audit a little more. I was recently involved in a legal seminar and the topic of reviewing chiropractic records came up. There were a number of observations made that I think give good insight into how our records are viewed, assessed and interpreted. Using the self-audit strategy can help protect your practice while increasing your profitability.
The first and probably most scathing comments during the seminar were regarding the reasonableness of the care provided. I'm talking about care usually to regions not related to the area of injury (e.g., treating the neck for a lumbar injury or full spine for a wrist injury). If you are going to treat a patient for a particular condition, treat that condition. This is not the place for philosophy – care has to be specific and relevant. A patient with a lower back injury may very well need care to the neck, but if you cannot correlate the neck to the lower back injury, do not treat it as part of the injury claim. (I have covered this issue in previous articles.)
Do Your Notes Make Sense?
Is there a logic to your care plan? Can someone reading your file tell what your care plan is? We have all seen any number of treatment protocols, usually progressing from acute pain relief to functional restoration to active rehabilitation. Make sure your notes are clear that you are moving your patient progressively through a continuum of care. Ongoing treatment with ice packs, EMS, and full spinal manipulation is very quickly perceived as palliative care that is not providing tangible benefit.
This is not to say that the patient does not experience relief from their initial complaint – that is a good thing – but our responsibility goes beyond the feel good, as I have noted before. We are here to improve their overall condition. Especially when dealing with an injury claim, make sure you can show that the patient is measurably improving with your care. This advice also applies to products you provide a patient – lower back supports, seat cushions, etc. Giving a patient a soft collar for a lower back injury is hard to validate.
Beware of Your Advertising
I have seen this come up several times. It seems some chiropractors like to use marketing gimmicks to get new patients – online coupons for a free initial consultation and X-rays is a common offer. This is bad practice! I have known attorneys to confront a doctor in court and ask why they billed for an exam on the patient when their website clearly says that the initial visit was free. Ouch. No way to defend that. Be careful how you advertise and what you offer; clever marketing gimmicks are not always your friend.
Billing Forms Do Not Constitute Good Office Notes
Make sure you have clear, concise, relevant daily notes. Sending an attorney a stack of billing statements so they can interpret your care plan is not good practice. Often, they will be viewed as a simple listing of dates and procedures. With no supportive documentation this will quickly be interpreted as rote billing for procedures. This is highly suspect and will usually be disputed. Billing records are for billing; they do not contain the information of a full SOAP note to list your findings, your assessment and the rationale for the care you provided on that date.
Don't Let the Computer Do All the Work
The last red flag I will discuss here is computerized records. Certainly the world is moving in that direction, and most practitioners keep their records in electronic format. However, be careful and pay attention – it becomes too easy to hit that "carry-over" button and copy the same records forward. I have been involved in some case reviews in which 60 or more daily notes were exactly the same – the doctor just copied the same note forward each visit. As discussed above, this quickly supports the notion that care is static, ongoing and of no benefit. Make sure you take the time to input data so each daily note is accurate and relevant to that patient encounter on that date.
I will close with a bit of Dr. Necela's advice from his article, because I think it deserves repeating: "Take auditing seriously and preventatively. Most chiropractors who have been on the down side of an audit wish they had taken steps like these before they were under the microscope. Had they done so, I am sure the outcome of their audits would have been much more favorable. Use the self-audit strategy today to help protect and profit from the good work that you do."
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