By Pamela Miller, OD, FAAO, JD
Comprehensive record keeping of all patient interactions ensures topnotch care for your patients—and it protects your practice legally. Here are pointers on creating a strong record-keeping system.
When patients leave your office, or even when they call in to report a problem with a contact lens or a medical eyecare issue, do you have a system in place for ensuring the information doesn’t slip through the cracks? More importantly, following each patient exam, what is your process for making sure all prescriptions and information given to the patient, along with patient self-reporting, are included in that patient’s health record?
If you can’t answer those questions, your office’s record keeping may not be as strong as necessary. Detailed, consistent record keeping gives the doctor the security that she has the most accurate, up-to-date information about each patient. It also protects the patient from receiving prescriptions that may not be optimal based on past experience or diagnoses and–essential to note–protects the doctor should a legal issue arise. It is not your memory but documentation in the form of thorough health records that will back you up in a court of law. Here are my top best practices for improving the record keeping protocol in your office. As with all legal matters, it is best to consult with your own attorney and state optometric board before taking any action.
Documentation Strong Enough for Court or Insurance Audit
Shoddy record keeping in which the doctor forgets to note tests conducted or follow-up that was given for a medical eyecare issue are never a problem–until the doctor is faced with a potential lawsuit or an audit by an insurance company. For example, consider a suit brought against a doctor alleging that the doctor was negligent because she did not provide follow-up care for a patient diagnosed with glaucoma, and the patient goes on to lose his vision.
The doctor and her staff remember clearly that they thoroughly explained the diagnosis to the patient while the patient was still in the office including the likely consequences of forgoing treatment. When the patient did not make it to the first follow-up appointment, the staff called the patient at least a few times to remind them reiterating in their message the importance of coming back to the office for additional care. But the doctor made the critical mistake of not documenting in the patient’s health record that the diagnosis and possible consequences were thoroughly explained to the patient, as well as documenting the follow-up visit that was missed and each follow-up call made by the staff for the patient to reschedule.
Lesson: For any diagnosis, but especially conditions that could result in loss of vision, document and have the patient sign a form showing that she fully understands her diagnosis and agrees that your office thoroughly explained the condition and the possible consequences including loss of all vision. Also note that it should be documented when important follow-up care was not received due to the patient’s, rather than the doctor’s, negligence. Repeated attempts by the staff to contact the patient also should be documented. If the patient refuses to sign, simply make certain that the appropriate documentation (including the refusal) is recorded.
Beware of Automatically Populating Forms in Electronic Records
The beauty of electronic records is that doctors often can fill out forms with pre-populated templates faster than they could on paper. But beware of the danger of templates that automatically populate fields. For instance, a form could have a list of tests in which you check a box to indicate the test was performed. If there are tests you give to the majority of your patients during their exams, you might think you gain efficiencies by having to uncheck when you don’t do a test rather than the other way around. The danger in that is having the system automatically check that you performed a test you didn’t. That could be problematic if an insurance audit arises and it turns out you billed for a test that you never did.
Lesson: Even if it is more time consuming, consider templates that force you to check boxes next to each test performed rather than relying on remembering to uncheck the box the rare time you don’t perform the test. Force of habit is so great, you are likely to forget and potentially bill for a test that was never conducted.
Go Over Record of Medications With Patient
You have the patient’s health record in front of you on your computer screen listing all the medications they reported taking when they last visited your office. You then ask the patient whether there have been any changes to their medication regimen since their last visit and the patient tells you “nope–all the same.” Funny then that half-way through the exam, after a fierce coughing fit, the patient mentions casually: “Oh, sorry, excuse me–it’s just my asthma, it’s acting up again. My doctor just put me on a new medicine but I guess it hasn’t kicked in yet.” That information would be good to have upfront. Imagine the problems the patient would experience if you happen to prescribe a drug for an eye condition that interacts dangerously with the new asthma medication.
Lesson: Don’t leave it at “Nope–all the same.” Instead, while the patient is in your exam chair, go over the medications they listed during their last visit and then when you are finished reading off the list, ask them again if there are any new medicines that have been added. To jog their memory, you might also ask: “And any new general health issues you’ve been dealing with?” That question might be all it takes for them to remember a recent health issue that worsened enough for another doctor to prescribe a new medication.
Include in Record Info Given to Support Staff
It is probably not unusual in your office for a patient to mention as an after-thought to a staff member such as an optician something very important. For example: “I would take advantage of the second-pair sale for new sunglasses but I can’t go outside much this time of year anyway because my eyes are so itchy.” Or upon checking out: “Actually, I probably shouldn’t buy an annual supply of contacts because I don’t really like them that much. So, a month’s supply should last me a while.”
You definitely asked the patient how his eyes felt while he was in your exam chair and reviewed with the other patient the comfort level of her contact lenses, yet these patients left the exam room without imparting to you the vital information they dropped as an after-thought to your staff. What happens to that information? Is it gone with the wind, or do you have a system in place for capturing it? You may elect to give staff members access to health records so they can annotate the “notes” section of the records, but the most important point is that the staff member ensures the doctor is made aware of the new information.
Lesson: As part of your staff training, cover your office’s record keeping system including how you handle information given by patients to staff in your optical or even as they are walking out the door. If you decide to give the staff access to your records so they can go in to make notes, make sure there is a way of alerting you to the new entry. It could be as simple as a recapping e-mail sent to you by the office manager at the end of each business day pointing out new notes that were left by staff in patient records, or simply filing the record only after it is seen and/or checked off by the doctor.
Create System When Different Doctors in Practice See Same Patient
Whether you have one partner or associate or you are in a practice with five or more other doctors, you have to consider what your consistent system will be for adding to the patient’s health record. You probably already have a record of which doctor the patient saw on which date, but what happens when one of the doctors leaves an update in the notes section of a patient’s record and you are not sure which doctor placed it there, or what happens when you need to refer back to the note for legal protection?
Lesson: Have each doctor or staff member electronically or physically initial or sign each note they add to a patient’s record. It is not enough to rely on the electronic records’ automatic signifier of who posted. What happens if a staff member was using the doctor’s sign-in to the system? In that case the automatic signifier would be inaccurate as to who left the note. The electronic or manual signature ensures that each doctor takes responsibility for new notes added to the record. It also helps to have an agreed-on style for notes such as leaving all information in the notes section in caps so it’s hard to miss.
Do a Self-Audit of Records
Due to an ineffective record keeping system, are you billing for tests that were never conducted or recording that follow-up visits occurred that never ended up happening? Or are you billing vision rather than medical insurance because you failed to record that the patient’s eye condition relates to a medical condition? When your records are inaccurate you not only run the legal risk of over-billing for services that were not given. You also may be limiting your own reimbursement.
Lesson: Conduct an annual self-audit in which you check your records against what you billed for. This is a time-consuming, arduous task so it may be worthwhile to enlist third-party help to make sure it is done right. When it comes to the health records you maintain, it is worth making an investment to ensure accuracy.
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Use EHR to Optimize Billing and Coding Process
Effective Billing Policies to Limit Collection Problems
Pamela Miller, OD, FAAO, JD, DPNAP,has a solo optometric practice in Highland, Calif. She is an attorney at law, holds a therapeutic license, is California State Board-certified and glaucoma-certified to prescribe eye medications, and offers comprehensive vision care, contact lenses, visual therapy and low vision services. To contact her: drpam@omnivision.com
