Good Documentation Habits for a Healthy Practice

Systems and Habits for a Healthy Practice

We all understand that if you want to be healthy you must make healthy choices and instill habits that lead to overall mental, emotional, and physical wellbeing. Eating nutritious food, moving your body, getting quality sleep, and managing your stress are a few examples. Not unlike being healthy as an individual, your practice health depends on the systems you set up and the habits you implement and follow. We are all too familiar with the concept of symptoms being the sign of an underlying malfunctioning body system or disease. Likewise, there are symptoms of an unhealthy practice!

Inadequate documentation is one of those symptoms. Understandably, most DCs would rather spend their time treating their patients than filling out paperwork or documenting the encounter in their EHR. But documentation isn’t just an annoyance, it’s legally necessary, and it’s imperative for the health and survival of any practice.

The Importance of SOAP Notes

Given the healthcare climate of ever-increasing regulations, it’s essential for doctors to prioritize that dreaded paperwork. SOAP notes are the basis of proper good documentation habits, but only if they clearly articulate medical necessity administered to a patient expected to achieve significant improvement, and only if they reflect episodic care.

It sounds simple, but if it were, a large percent of chiropractic practices wouldn’t be getting it wrong!

How DCs handle documentation is an integral part of the health of their practice. And often, how doctors handle documentation reflects the general organization of their practice. If your SOAP notes are a mess, it’s likely that so are the rest of your documentation and practice procedures.

Health Risks are not Worth it

Chiropractors are not, by nature, great at following rules. They question the status quo; they are change-makers. That’s one of the reasons they went into chiropractic in the first place. But safe and compliant good documentation habits are an area that doesn’t allow for creativity, improvisation, thinking outside the box, or overlooking details in favor of the big picture. Just like taking risks with your health can lead to disease and symptoms, so can taking risks with your documentation, lead to increased liability risk, not meeting your license requirements, or violating payer regulations.

This is where installing systems, establishing procedures, and using reliable documentation tools makes a huge difference. When you have easy-to-follow procedures in place, all that “paperwork” becomes, if not enjoyable, much less effort. You keep your sanity, improve your personal health by lowering your stress level—and you keep your practice compliant, healthy, and profitable!

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing 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 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.