Doctors ask me all the time why I chose the worst subject in the history of subjects to teach – documentation.
Originally, it was simply because many of us were getting absolutely hammered by insurance companies (commercial and auto) and our reimbursement was getting hit hard, or we were asked to PAY BACK money that had been paid to us (think Medicare and PI post-payment audits). Back then, I spent a lot of time, energy and money to figure out what the hell these insurers were talking about how we can finally beat them at their own game.
But, then, something happened. I started to get requests from these same insurers to review chiropractic records. The first few I saw, I thought, “Wow. These are pretty bad. Good thing this is just a small sample size.” After reviewing a few hundred more, I thought…
Ruh Roh.
I mean, let’s face it. None of us really like to or even WANT to document. We know we have to (sort of…most of us), but we don’t want to do it. Trust me – I get it. But in my 33 years as a chiropractor and growing up with a father who was a chiropractor (60 years – can you believe that?), I’ve thought and heard from other chiropractors how no one takes us seriously, how we can never seem to get ahead legally and how that old friend “cultural authority” has seemed to elude us for all these years. But it wasn’t until I started looking at chiropractic records – and I mean, a LOT of them – that I realized that much of it is…
Our Fault.
Now, don’t get me wrong. I really believe that what we do as chiropractors is still as mind-blowing now as it was when I started practicing all those years ago. I really believe that the VAST majority of chiropractors mean well and just want to do their best for their patients. But the way we communicate what we do – what the rest of the world SEES from us – in our documentation – is not just bad – it’s downright AWFUL.
And don’t think I’m giving you crap because you might be using a travel card and haven’t spent thousands of dollars on some computerized software (most of which suck, by the way) – I’m not. I’m giving an equal amount of crap to the doctors who think that because they DID spend a lot of money on software, that makes them special and their documentation better. Nope. They’re just wrong.
Then I hear other people teaching that our documentation should “tell the story.” As one who gets to read this crap all the time, let me save you some trouble. We’re not reading your damned story. Not now, not ever. But there ARE certain and specific things we ARE reading. Some doctors document hardly anything. That’s a problem – maybe. Other doctors are just throwing as much crap as they can into their documentation with the hope that some of it sticks. I hope they didn’t spend too much on THAT software.
So what is that that I’m looking for in your documentation? What ONE thing am I looking for on your FIRST visit that will help you TREMENDOUSLY with your future care?
I’ll tell you…
Next Time.
