Level Up Your Documentation Skills

When you head into your office to start your day, are you confident that your patient documentation is spot on?

Do your notes fully convey the plan of care for your patients as well as their progress through their treatment plan? Uncertainty about how to correctly document patient care can take the enjoyment out of caring for your patients and make you susceptible to incorrect billing and payment.

This is the perfect time of year to check in with your documentation skills!

If you just keep tiptoeing around not knowing if your notes are up to par, you are putting your practice and your license at risk. The shortcomings of documentation should not have that much power over you! Nor should the fear that even a routine audit might require the return of thousands of dollars that have already been spent. The days of feeling confident in your patient records and billing by virtue of payment are gone. The confidence must come from correctly documenting every patient visit per your state documentation guidelines and the payer’s requirements.

Resolve to improve your documentation skills this year beginning with these suggestions:

1. Look at your initial visit note and your routine visit note. They should look different. The initial visit should identify the reason the patient is seeking care, the information surrounding his/her area of complaint, exam findings, your doctor’s assessment and diagnosis codes, and your plan of care. The daily visit should document the patient’s functional and objective progress from visit to visit as they progress through the treatment plan, the complaint area(s), objective findings, and treatment rendered.
2. Make sure your treatment plan contains clearly stated functional, measurable goals for the areas that need to be improved as well as recommended services with rationale. Use this throughout each episode to demonstrate the patient’s progress. It serves as the foundation from which you may change the course of their care such as shortening or lengthening their duration of treatment depending on how they respond.
3. Appropriately define all the services that you provide in your practice. Be certain that you are documenting them accordingly, and always code from what is documented on each date of service.

You must know the rules so you can follow the rules.

Locate your payers’ policies regarding what is expected to be documented for the services you are providing and billing. Be sure to also implement a process of self-auditing your notes as part of your compliance program. Become a stronger documentarian! It is possible with the proper resources and training to hone your documentation skills to an expert level.

Turn your practice into a comfortable place of healing rather than a place that feels like a burden, heavy with the stress of not being certain. You can do it! Your peace of mind and your peace in practice are worth it!

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, a Certified Professional Medical Auditor since 2022, and a Certified Professional Compliance Officer since 2024. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020. She is now the Director of Education, and is dedicated to bringing you accurate, current, and reliable information. You may reach her by email at info@kmcuniversity.com  or by calling (855) 832-6562.