Notes, Notes and more Notes

It is no longer acceptable to have hand written notes, those days are over as it exposes you to audits, paybacks and it seriously diminishes your reputation as a doctor.  I have discussed the following in consultations on separate occasions, but want to share this with you again.  Here are the reasons to get you house in order with reporting. 

Open Note – this is the National Movement that suggests that patient’s receive a copy of their office visit note from their doctor’s office.  I already see primary care offices giving office summary sheets – this is a national trend and one that will be expected in the not so distant future.

Reimbursement – there is nothing left to discuss IF you send your notes in with your billing.  Every region you touch is one that has to have a symptom and a clinical finding, even if that area is an asymptomatic primary lesion.  You must explain WHY you are treating.

Audits – there is nothing left to ask for if you send you notes in.  Since Medicare only accepts e-billing, it is my opinion that is the #1 reason for audits.  We can’t send in notes!

Marketing reports say everything about you! I realized this early on in practice when I was looking for a spine surgeon to refer to, I actually started by reviewing their notes on patients that found me through other channels. Some local neurosurgeons had only a single sheet for a note while others had a full dictated report.  There was a “visible” difference and that is one of the ways that helped me select the group I have worked with for 15 years.  Many MDs and Lawyers have no idea what you do because you don’t communicate in writing.  Start now!

Referrals and Medical Necessity – proper and legible documentation eliminates letters of medical necessity from imaging centers, EMG doctors and others.  Why would they need to ask you for additional information if the medical necessity of orders is in your note?  In my office our letters of medical necessity requests have virtually fallen to zero, the ones that do arrive all my staff does is copy the note and staple to the request – DONE.

Touch it ONCE – Do not, do not, I repeat do NOT write a different note for different people.  Many docs that I consult with say they do a “summary” for the MD, because “the MD doesn’t want all that information”.  That is non-sense and something that those DCs made up to justify not doing a proper note.  What they find in the end is that it is more work, they have to do the actual note anyway and because it is disorganized and in an improper format, they have write a separate note in summary to the MD.  Guess how long they are able to do that?  Generally, only the first few years of practice, then they get to busy and it ends.  A proper patient note is good for the PCP, MD Specialist, Carrier, the Lawyer and the Patient. 

Transcribe – the treating doctor obviously needs to provide all the clinical information, but when it comes to the initial encounters and re-evaluations it is difficult sometimes to be there for the patient when the requirements are so overwhelming.  This is why in my office, and what we teach in the EMR Macros Program, is to use a clinical encounter sheet for the initial evaluation and subsequent re-evaluations then have a staff member (scribe) transcribe the clinical information into your EMR.  Once the initial visit is in the system, the doctor can then do subsequent visits more efficiently.  Look to creating a transcription system within you office, it will make you more compliant and save TONS of TIME.

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