When was the last time you had to pull a rabbit out of your hat? This is what it can feel like when you need to gather documentation on demand for an insurance audit. It can literally take a miracle to find, transcribe, and present your documentation in a timely, orderly manner. This worst-case scenario is all but eliminated with the push of a button, thanks to documentation software that gives you the "bunny" when you need it most.

Why You Need Documentation Software

Soon we will be swimming in the digital sea, with paperless offices seen as the norm. The requirements that are now being put upon health care professionals to submit documentation electronically are becoming more stringent. By putting yourself in the position of already having a documentation software solution in place, you can save yourself the anxiety and trouble of having to conform when demanded to do so.

Rather than wait for a legislative decision to decide for you, you can simplify your life today by proactively implementing a documentation software solution. This way, you will have the ability to provide timely, accurate documentation when required by an insurance company. As chiropractors, you understand the necessity of justifying a patient's treatment, and it is how the documentation is presented that can make or break whether an insurance company agrees that the treatment was medically necessary ... or not. An even bigger issue would be if you were on the receiving end of billing fraud allegations by an insurance company. In other words, if the insurance company doesn't see it (the documentation), they don't believe it, and you get to experience the consequences.

Extensive documentation also can cover you should you go to court. Handwritten notes, scribbles, and Post-Its won't make your case, and could possibly jeopardize your patient's ability to get what he needs, particularly if he is disabled. In such a case, not only do you lose, but so does your patient and the potential referrals he won't be sending to you. Additionally, with Medicare claims it is imperative that you produce thorough documentation so as to avoid the possibility of payments being withheld.

In any case, good documentation makes all the difference, and with the right software, you can quickly and easily create notes and reports, and position yourself to receive the reimbursement you need to keep your practice livelihood going.

Selecting the Right Software for You

Testing, testing, 1-2-3. There are plenty of chiropractic software companies out there that want to demo their products for you. But with so many to choose from, how do you start? Your time is valuable, and selecting a documentation software solution should heed this. Some software companies are happy to send out a demo CD and information kit; this allows you to check out their software at your leisure. Others let you download a demo directly from their Web site, as well as view online video product information. A company representative might even come to your office to give you a personal product demonstration.

To read more about electronic health records, visit the December 2007 issue.

The technology that documentation software lends itself to includes computers that use a pen, handhelds, touch screens, and the ever-popular voice recognition. All of these options can help you increase the quality of your notes while also lessening the burden of creating them. And because you can create notes while your patient is present, there is a lesser chance of forgetting important information.

While each software product seems to offer similar features, it is each product's ability to be customized to your practice that is of utmost importance. How you create your notes is your deal, based on what you like to do and the services offered in your particular practice. With a customized software solution, you can keep tabs on the special services and tests for which you need documentation, as well as edit information that does not pertain to your practice. And the ability to create specialized reports should be a cornerstone to the solution, as different insurers more often than not require specific patient reports before they will reimburse you.

Pulling It All Together

Now that you've narrowed down a few software products for serious consideration, you should look at what kinds of forms on which your practice spends time. Knowing which forms your office continually uses for documentation will enable you to see if the software solution can create the forms for you. Once you've got this figured out, and have a solution in place, just sit back and let your computer do the walking (well, almost). After all, you're busy enough tending to your patients and dealing with the daily paperwork that comes with the territory. With documentation software, you have the coverage you need within reach and at a moment's notice, and the payback for the initial investment can pay off big in the future, both in terms of earnings and peace of mind.

A Quick Comparison of Documentation Methods

Transcription from Dictation—This method is quick and relatively easy, but costs can add up from employee wages and fees.

Travel Cards—The old favorite, travel cards are easy to use, but don't leave room for the details necessary for good documentation. Travel cards are also poorly received as quality documentation.

Handwritten Notes—The ultimate in ease, handwritten notes usually don't allow for thoroughness and often do not meet some state requirements for typewritten notes in WC cases.

Computerized Notes—With touch-screen simplicity, computerized notes look nice and provide good documentation. However, such technology requires computer knowledge and skills, and often comes with a lofty price tag.

Dictation/Speech Recognition—Let the computer do all the work while you "speak" your notes into a digital recording device. This method provides notes that look good ... and speak good, but can create headaches when editing and formatting is required to submit them.

Dictation into Computerized Database Utilizing Speech Recognition—Easy, easy, easy. Not only will your documentation look beautiful, but it will be available instantly to whoever requests it. You're looking at an initial outlay of cash for this system, but the return on investment will be priceless as time goes on.

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