Quality Medical Transcription Services

What Are The Medical Record Documentation Requirements For Podiatry?

Podiatry

Podiatric physicians basically treat foot and ankle problems. However, today, they are playing an increasingly important role in the health care team. Podiatrists often treat patients who have other medical conditions such as diabetes and are well qualified to identify and respond to findings that impact overall health. As in any other medical specialty, podiatrists must create and maintain error-free patient records to promote the provision of safe, effective and continuous care. That’s where podiatry transcription services come in. Outsourcing transcription can ensure error-free, legible and understandable clinical records with all the details needed to provide quality care.

Podiatrists diagnose and treat a wide range of foot and ankle problems. Accurate documentation should be maintained about diagnosis and treatment provided for these conditions, which include:

  • Injuries such as fractured or broken bones, sprains, and strains
  • Diabetic foot disorders, such as infections, chronic ulcers, and nerve damage or neuropathy
  • structural foot deformities, including hammertoe, flat feet, and high arches
  • Arthritis-related foot pain and inflammation
  • Warts, corns, plantar dermatosis, and athlete’s foot
  • Nail problems such as ingrown nails and nail infections
  • Heel pain

Companies providing medical transcription services for podiatrists have expert transcriptionists who are familiar with anatomical and surgical terminology and jargon relating to these conditions. They can transcribe accurately complex podiatric words such as achillobursitis, anserinoplasty, atavistic tarsometatarsal joint, brachymetatarsia, Bart-Phumphery syndrome, Bodsky ischemia classification, calcaneonavicular, cheiropodalgia, desquamates, Essex-Lopresti fracture, Freiberg infraction, guttate keratoses, koilonychia, metatarsocunieform, pemphigus, retrocalcaneobursitis, seborrheica, and much more.

Patient records should support the need for care and services provided. The medical documentation requirements for podiatry are as follows:

  • Comprehensive initial history and physical (H&P): This should be completed at the initial visit before treatment is provided. This initial H&P has two components.
  1. The first is the patient completed form providing medical, social and family history and information pertaining to the current problem for which he/she is seeking podiatric care as well as insurance information. The provider should review this form with the patient and provide evidence of the review.
  2. The second component is the H&P done by the podiatrist, which should include:
  • A review of systems – vascular disease, arthritis, skin disorders, psychological, miscellaneous illnesses.
  • The chief complaint and a chronological description of the development of the patient’s present problem from onset to present. Documentation of complaints should include the nature, location, duration, onset (spontaneous/injury/activity), course, aggravating/alleviating, treatment, and vital signs.
  • Wound documentation should be done at each visit and clearly describe location, specific size of the wound, accurate grading, drainage, odor, redness, and swelling.
  • Allergies, illnesses, any drugs taken, prior surgery, and hospitalization/injuries.
  • Documentation of systematic conditions (gout, diabetes mellitus, neurological disorders, vascular impairment, arthritis and others).
  • Lower extremity examination (vascular, venous, neurologic, dermatologic, structural/biomechanical) and current clinical condition.
  • Objective findings.
  • The patient’s expectations and goals for treatment.
  • Individuals present in the treatment room with the patient, if applicable.
  • Presence or absence of functional limitations.
  • Podiatrist’s diagnosis or impression.
  • Treatment plan, including diagnostic and radiologic tests and results; treatment provided expected frequency and duration of treatment, and treatment results, including complications. Plan documentation includes: discussion of diagnosis/differential diagnosis with the patient and treatment options, diagnostic studies or consultations ordered, therapy/medications ordered, patient education and instructions, goals of care; and expected duration of treatment
  • Medications or therapy ordered and copies of the prescriptions and/or referrals given to the patient
  • Whether or not any special procedures are anticipated
  • Education provided
  • Instructions for follow-up

 

  • Progress notes (practitioner, nurse, and ancillary): A consistent format should be maintained for documenting each patient visit. The documentation should capture the essence of the encounter. The SOAP (Subjective, Objective, Assessment, and Plan) method is a widely accepted recordkeeping method that allows for organizing a large amount of information. Well-maintained records in SOAP format are easy to review and reduce the risk for missing a problem. Progress note documentation should also include all referrals for consultations, labwork, diagnostic testing, etc. considered necessary for the ongoing care and treatment of patients.
  • Operative / procedure report: Documentation of surgery performed in the office should meet state requirements or guidelines. It should include preop assessment, patient’s written consent, assessment and monitoring during surgery, vital signs, description of findings, procedures performed, any complications, post-op diagnosis, and discharge instructions.
  • Patient non-adherence: While physicians may be sued by the patient for a poor outcome, this is often the result of the patient’s non-adherence with instructions or the plan of treatment. That’s why it’s critical for podiatrists to document all observations and patient comments revealing non-adherence.

Along with the above, the podiatry medical record should include documentation of all communication with the patient such as telephone calls and that in the form of e-mail, cell phone calls, texting, social media or ePortals. Also, if any treatment or procedure has potential for significant risk, the provider should hold informed consent discussions with patients and document them.

Podiatric care is a crucial component in multidisciplinary sphere of foot and ankle treatments. Podiatrists need to ensure proper documentation to provide safe and effective care, communicate with other healthcare professionals, meet regulatory requirements, support necessity of care for proper reimbursement, justify conformity with Meaningful Use criteria, and prevent or defend medical malpractice allegations. However, in an AMA survey, up to 52% of practicing podiatrists reported they experienced burnout and spent too much time on the computer, leading to less time interacting with their patients. Medical transcription outsourcing to an experienced service provider that specializes in podiatry transcription is a practical way for these specialists to ease the documentation burden, maintain accurate, legible, logical and timely medical records, and focus on providing quality patient care.

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