Personal Injury–EHR Wins the Case
By Paul B. Bindell, D.C.
UTO ACCIDENTS, FALLS AND OTHER PERSONAL INJURIES
happen regularly. In order for your patient to benefit
from your care, and for you to get paid, you must
have substantial documentation in your SOAP notes
that justifies the care you provided. Due to insurance rules and
policies, State Board regulations, and Federal legislation, the
depth of detail in SOAP notes must be very extensive. And it
must be legible and understandable to claims examiners and
insurance auditors as well as attorneys. Many SOAP notes that
were considered excellent as recently as 2 years ago would be
considered mediocre, at best, and inadequate, possibly indicative for fraud with the new standards that have been established.
The answer to this bureaucratic nightmare is an Electronic
Health Record system. The bottom line is that Electronic Health
Record (EHR) systems are critically essential to the long term
survival and growth of your practice.
EHR uses a computer instead
of pen and paper. It empowers
you to produce a dictation quality SOAP note in a matter of
seconds, just by pointing and
clicking on the necessary items.
The result is a SOAP note that is
in English with correct grammar
and spelling and contains all the points of information required
by law, statute, and policy contracts. Keep in mind that, in most
states, and under Medicare, the SOAP note is supposed to be
created at the time you are providing the service to the patient,
not at a later time. EHR minimizes the time you must spend
documenting, so you can concentrate more on patients.
How does this help your practice? A complete EHR system
streamlines your practice in many ways, leading to increased
income, higher patient visit averages, and greater productivity
by your staff. A patient, signed in at the front desk, automatically appears on the doctor’s computer in the adjusting/treat-ment area. Entering a diagnosis in the documentation end of
the EHR instantly places it in the billing area. The services
the doctor documents generate the charges for the day as the
patient checks out. Since the EHR system is producing the
charges based on the SOAP note, the documentation and billing always match. When the patient signs out electronically,
the patient’s signature shows that the patient witnessed that
the services billed have been provided and that the patient is
ultimately responsible for the charges. This provides both audit
and collection protection for you.
And, in a personal injury case, you will need narrative reports
for attorneys and insurance. EHR systems produce narratives in
seconds, pulling the information directly out of the patient file.
Thirty-five years ago, when I first began my practice, narrative
Aproduction was a major challenge, sometimes taking hours to compile all the material. Now, from the time I receive the re- quest, produce the report and send it to the attorney (either fax, e-mail, or printed and stuffed in an envelope) takes 5 minutes
or less. EHR systems typically come with narrative templates
already built in. Some EHR systems provide you access to
the templates, so you can edit and modify them or create your
own. Since you get paid for the narrative, and it is the narrative
that will make or break the case for you and your patient, it is
critical that the narrative provides the substance that enables
the attorney to win the case.
Many doctors, when they get busy, will postpone the comple-
tion of a SOAP note until a later time. For some doctors, “later”
never happens. The result is that the note is not produced, even
though charges were entered for the patient. If you are one of
those “later” doctors, you must now get caught up on your notes
ASAP. In order to be sure the
SOAP notes are completed, it
is imperative to have an EHR
system that generates a report
listing every patient that has
charges but no SOAP note for
that specific date of service.
This report should be run at
least once daily so that the notes are created in a timely manner,
while the information is still fresh in your mind. It is important
to note that certified EHR systems include an audit log required
by the federal government. The audit log tracks every entry,
modification and deletion. In the future, when you are using
certified software, an auditor or claims examiner will demand
to see the audit log. If your notes were created weeks or months
after the visit, they will know and charge you with fraud.
When you use EHR as it was designed, it improves the ef-
ficiency of you and your staff, eliminates duplicate entries,
minimizes the chance of human errors, and increases your
income and patient visit average. EHR gives the attorneys the
meat and potatoes to win PI cases, and this builds your reputa-
tion and practice. The benefits of EHR are available today. Take
advantage of them.
“Many doctors, when they get busy, will postpone the completion of a SOAP note until a later time. ”
Dr. Paul Bindell is a 1975 graduate of Palmer College
of Chiropractic, in practice in Rockaway, NJ, since 1976.
Dr. Bindell is a past Chairman of Public Relations for the
Northern (NJ) Counties Chiropractic Society. In 1991,
Dr. Bindell and his family began Life Systems Software
so that the profession would have reliable computer
programs based on real chiropractic practice. Dr. Bindell is available
to speak to your group or organization and can be reached by email
at administration@LifeSystemsSoftware.com, or you can call Life
Systems Software at 1-800-543-3001.