A Gallup poll conducted in 2015 found that more that 33 million adults in the U.S. had seen a chiropractor in the last 12 months, with twice as many saying that a chiropractor would be their first option to consult for neck or back pain. Improved electronic health record (EHR) documentation through medical transcription outsourcing and data sharing among providers can optimize chiropractic care.
Like all other healthcare providers, chiropractors need to maintain proper patient records. Subjective, Objective, Assessment and Treatment/Plan components should be consistently included in patient records at each visit. Changes in the patient’s condition should be noted and valid chiropractic terminology should be used to document care and treatment. Abbreviations and indexes should be defined. Quality documentation will not only protect practitioners against all types of medical/legal issues but also help prevent coding and billing errors.
According to the American Health Information Management Association (AHIMA), the common causes of documentation mistakes are as follows:
- Using Templates: EHR templates are intended to speed up and improve the documentation process. However, they can pose challenges when physicians use templates that auto-populate a lot of the information within the patient encounter as documented in the EHR. Some of that data may not be relevant currently, while some information may be missing. This may lead to over-billing or under-billing.
- Using voice recognition software: Voice recognition software may result in inaccurate records of dictated notes. On the other hand, outsourcing EHR documentation to a reliable medical transcription company can prevent such errors. They have stringent quality control processes in place and review dictated notes for accuracy.
- Copy pasting: Copy pasting information from a previous encounter or from another patient often results in serious documentation errors that can affect patient care. A 2014 Department of Health and Human Services report found that copy and paste functionality can lead to healthcare fraud.
- Failure to track changes and corrections: EHR systems need to allow providers to make changes, have the ability to track corrections, and identify that an original entry has been changed. The ability to track changes can help prevent fraud.
- Authorship integrity issues: When multiple persons make entries in the document, all their signatures should be retained so that each person’s contribution can be clearly identified.
- Lack of adequate audit trail functionality: EHRs that lack proper audit trail functionality can create uncertainty regarding the integrity of healthcare documentation.
According to an article published by Chiropractic Economics in June 2016, providers should use a combination of administrative and software strategies to maximize EHR potential. These include establishing policies for finding and reporting mistakes as well as customizing the software to provide automated alerts on potential problems to help prevent documentation errors. EHR-integrated medical transcription services are a great option for busy chiropractors to ensure flawless, timely notes.
Once chiropractors take adequate steps to ensure error-free clinical documentation, they can improve care with data sharing. A November 2016 report in Chiropractic Economics says that practices can make agreements to share patient data electronically with a medical clinic or another chiropractic practice. Sharing patient records on a secure, interoperable system will promote clearer communication between different practices and specialties, which can make holistic care a reality.
Before entering into a data-sharing partnership, providers would need to:
- Notify patients depending on how they use patient information
- Update how you plan to file your breach notification in the event of a data breach
- Perform a security risk assessment
They must also follow HIPAA regulations and use health information exchanges properly.
Chiropractors can avoid EHR data entry issues and ensure sharing of accurate patient information with healthcare partners by outsourcing medical transcription. Trained and experienced transcriptions can provide accurate documentation of dictation pertaining to biographical or personal data, patient history and physical, clinical findings and chiropractic evaluation, treatment plans, progress notes, and laboratory and other tests. This will promote adherence to best practices in documentation and optimize patient care.