Is This Visit the Same as the Last?

Be Aware!

It can be a red flag if every daily visit note looks exactly like the one from the previous encounter. And this is often the case with the use of electronic health records (EHR). Be aware, cloned notes could be considered fraud upon review. The expectation for documenting a patient encounter is to record that encounter as it happened. Each daily visit note should look different because the patient’s presentation changes as you proceed with treatment. Even if the patient’s condition is not changing or is getting worse, there should be documentation explaining why that patient is not progressing as expected and the doctor’s thoughts about managing this patient.

Same As Last Treatment

The SALTing process began when EHR expanded into healthcare offices. SALT (Same As Last Treatment) is used with EHR software to copy forward the previous note. Its original purpose was to copy the information forward to cue the doctor on the details from the prior visit…and then to update from there to personalize the current visit’s note. However, in the fast-paced healthcare environment, the SALTed note is not always updated from the last visit or is only minimally changed. The record of what happened during that specific encounter is not accurate, and therefore, does not support medical necessity for billing or reflect what did occur for liability considerations.

If you do not have a previous encounter that you can “SALT” forward, the problem is avoided altogether. It is why many doctors still choose to remain “old-school” and write paper notes. To create more effective and efficient paper notes, many chiropractors choose already formatted paper documentation because it is easier to “fill in the blank” when you are prompted about what to write as you create a compliant note. Each encounter then has its separate unique note about what happened, the patient’s progress in relation to what is expected, and what’s next. Just be sure to not use a travel card or some type of multi-visit sheet. It’s nearly impossible to document what’s required for a compliant medical record on this type of record.

Accuracy is Key

A clear understanding of documentation guidelines is always essential as it is the doctor’s responsibility to record all patient encounters no matter the platform used to create the note. Those that use EHR must be extra cautious to ensure that notes are properly managed. The SALT feature can be a time saver when used as a template that is edited and updated for accuracy. Another viable and often overlooked option in today’s market is implementing appropriate paper records such as the Chiropractic Paperwork Project – a valuable (and beneficial) option to document the patient visit compliantly.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and practiced for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016. In November 2020, Dr. Auchenbach joined the excellent team at KMC University as a Specialist and, as part of this dedicated team, is determined to bring you accurate, current, reliable information. You may reach her by email at info@kmcuniversity or by calling (855) 832-6562.