Have you been documenting your S.O.A.P. notes all wrong? And is your documentation process inconsistent, unreliable, or just a mess? You could be losing hours each month that you could be using to see patients if your EHR software isn’t designed to document faster, better, and stronger notes.
In the webinar Quick & Compliant Daily Notes, Dr. John Davila covers why notetaking must shift from being pain-based towards a function-based documentation model that makes you faster, more compliant, and more effective in what you’re trying to accomplish with patients.
Here’s a recap of Dr. Davila’s webinar, Part I:
Documentation Expectations Have Changed
This is probably a low estimate, but at least 25% of the doctors that come to us have no notes and wouldn’t pass a board review. In a Medicare 2013 review of documentation, only 40% of doctors responded to Medicare requests for claims. And you know what happens if you don’t send in documentation requests—it’s automatically considered unallowed payment and you don’t get credit for it.
So why wouldn’t doctors send in documentation? Because they have screwy notes, probably based on PART. But if you’re taking PART based notes, your notes are 10 years old. In 2009, the Medicare manual changed the definition of medical necessity to: “The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition.”
That seems straightforward, but then why is today’s denial rate ranging from 60 -100%?
- What has changed in last 10 years is the expectation of documentation to provide reasonable expectation of recovery or improvement of function.
So if Medicare is asking you for records, they may want to see the treatment on June 5, but they also want to see 30 to 60 days before that. Before 2009, Medicare looked at one day, like 1 tree in a forest. Now they want to see the forest. The idea is that the patient should improve, not necessarily just have the adjustment. And like a math problem, you have to break it down and show your work of how you got to the answer.
- It’s the patient’s response to care that’s key to documentation, which is why levels of function are more important than levels of pain.
Change The Language To Function
Pain versus function is the important question in customizing an EHR system that takes notes that matches the way we think. When you have documentation matches a patient’s thought process it becomes more accurate. For example, if a young mom says she doesn’t have time to come in, it’s not the pain that’s driving her to come in. But when she can no longer do laundry or pick up her children it’s the loss of function that’s driving her.
So the question you need to ask each new patient at the very beginning is:
- What can’t you do today that you could do before you hurt yourself?
Then you can create a documentation system that allows the patient to improve based upon their functional loss. For example, have you ever fixed someone’s range of motion in a couple visits? Of course. But if you gave someone a treatment plan of 30 visits to get rid of headaches, what do you write down if their pain is gone after three visits? If there’s no pain after three visits and your notes reflect that, then what happens to approval of the treatment plan?
The pain may be gone but the patient still has to get back to their normal level of endurance, and endurance based improvement is slow. This goes back to the key question—”What could you do before you were hurt?” Then you build a plan for 30 visits to get back to that endurance level and Medicare will pay for it.
- Function and endurance become the goal with documentation.
For example, a patient may come in for the third or fourth visit and say that his neck pain is mostly gone and he can now drive three hours, but the endurance goal is eight hours because he’s a taxi driver. Function based notes are more compliant, effective, and accurate.
This is why I like Platinum System EHR software, because you can customize to make it function based. Plus it’s designed to make notetaking so much faster and more compliant, which I’ll go over in Part II of the webinar recap. And if you’d like to view the webinar, click here.
— Dr. John Davila
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