Record keeping: Is it really that important?
Maule, Keith
Some view record keeping as a boring subject, or even a waste of time. When it comes to the business side of a practice, record keeping does not bring in new patients or increase profits, or does it? Is record keeping really that important? Absolutely! Viewing record keeping as boring, unimportant, or a waste of time is taking a narrow view of reality. Good record keeping is intimately linked to clinical and financial success in practice. All of a practice’s records deserve the doctor’s and the staff’s careful attention, including patient information forms, histories, examination forms, daily progress notes, progress reports, x-ray reports, treatment plans, and insurance records.
Patients’ Right to Information
A practice owns the actual file in which a patient’s health and financial information is recorded.
However, the patient owns the information that is contained within the file and is entitled to the use of that information at any time. The patient may need the information to inform other health care providers of past or current conditions and treatments. He may need the information in order to transfer care to another provider, or he may just want a copy of the file for his own information. In today’s information age, patients are curious about their medical records and the degree of accuracy with which their information has been recorded.
Future insurability for both health and life policies may depend on the accuracy of the patient’s records. There will likely be an increase in this type of request, and such requests should not be taken lightly. It is not uncommon today for a patient to search for information regarding a condition or treatment on the Internet and then compare that information with his medical record or the advice offered by his doctor. This type of patient interaction is sometimes cause for concern to a physician, but doctors will have to adapt to this trend.
Proving Medical Necessity
Requests from third parties for copies of a patient’s file used to be rare. Most requests were for files on personal injury or workers’ compensation cases-those involved in a settlement or litigation process. Today, everyone seems to want a copy of the patient’s file. The majority of these requests are for precertification of care or review of care already performed. Medicare, managed care organizations, personal injury carriers, workers’ compensation carriers, utilization reviewers, peer review committees, attorneys, and a host of others are keeping chiropractic assistants, copiers, and fax machines busy. Seldom is an insurance claim paid these days without proof of medical necessity for the treatment rendered. Everyone is looking at chiropractic records.
Professional Image
One of the most frequent criticisms leveled against chiropractic record keeping in recent years has been the discrepancy between billings and clinical records. Billings are usually legible and computer generated, while the records intended to document the necessity of care are illegible or in checklist form. This leaves the insurance industry with the impression that doctors of chiropractic are more concerned about the patient’s bill and payment record than they are with the proper documentation of clinical care. The clinical records should set the standard for all other recorded information in a practice and support the financial and insurance records. Poor record keeping reflects poorly on the individual doctor and the entire profession.
Continuity of Care
Patients rarely spend most of their lives going to only one doctor. This means that several doctors and other health care workers will, at some point, review patients’ previous medical records. Patients have the right to the use of their records.
They also have the right to expect the records to be legible and understandable. It is important for other health care providers to understand patients’ previous diagnostic tests, diagnoses, and treatments.
Knowledge of this information may prevent harmful delays in care and/or repetition of procedures already performed. The legibility of the records also affords continuity of ongoing care and smooth transition of care to another provider.
State Laws
Many state chiropractic associations have adopted suggested standards for chiropractic records. The standards often cite that information should be recorded on a daily basis and require the provider to supply a key for any abbreviations used. Utilization reviewers and third-party payers are aware of these standards and may accuse doctors of falling below the community standard for record keeping if the guidelines are not met. Peer review committees may also use these standards when reviewing a doctor’s records. It is a good idea for the doctor to know the suggested standards in his state or if his state has suggested standards.
Multi-Discipline or Medically Integrated Practice
A doctor of chiropractic who practices with a group of medical professionals (MDs, DOs, PTs, etc.) is becoming more common in today’s health care arena, and is generally a welcomed trend. However, it does present one problem for the doctor of chiropractic. Medical record-keeping standards are usually higher than the standards within the chiropractic profession. Most medical personnel are associated with more than one practice or have staff privileges in local hospitals and clinics. Most medical facilities have standardized record-keeping formats, established by record-keeping committees within the institutions. Medical personnel can be disciplined if their record-keeping habits do not comply with community standards. The vast majority of chiropractors have always practiced individually and have generally established their own individual standards for record keeping. The doctor of chiropractic entering a multi-discipline practice or working toward medical integration of his clinic may be surprised by the instant, yet logical, demand to improve record-keeping habits.
Legal Defense
When accusations of malpractice are made or a claim is actually filed, the doctor’s main defense is the patient’s clinical records. Accurate, detailed records provide a good defense. Inaccurate, scarcely documented records provide a poor defense. Simply put, if it’s not written down, it doesn’t exist.
Joint Liability
Doctors practicing in a group or corporation can be sued and held liable for the negligence of another member of that group. This can happen even if the majority of doctors in the group have never laid eyes on the patient in question. While good record keeping will not prevent accusations or lawsuits, they certainly help the individual doctor or the entire group defend themselves. This is another good example of why doctors of chiropractic who are practicing in multidiscipline practices need to be diligent when it comes to record keeping. All partnerships or group practices should have agreed-upon standards for record keeping. This provides continuity of care and assists in joint defense if the need arises.
No, record-keeping habits do not bring in new patients. They do, however, have a direct relationship to practice income and security. It is not easy to assist a patient in winning a personal injury or workers’ compensation case without good records. It is not easy to protect yourself, your practice, and your career from malpractice accusations without good records. It is not easy to prove medical necessity and receive payment without good records. Ultimately, good record keeping is a necessity. It is important to everyone: patient, doctor, and staff.
Copyright American Chiropractic Association Jun 2000
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