7 Reasons Documentation is Critical to Your Medical Practice

7 Reasons Documentation is Critical to Your Medical Practice

Documentation: you hear about it constantly, but is it really that important? Do you need to document everything in order to effectively meet your practice’s goals, or are you worrying for nothing? Proper documentation is one of the most important elements of keeping up with your daily practice requirements. When you properly document, you’ll find that many of the aspects of your practice move more smoothly. Let your documentation fall by the wayside, on the other hand, and it won’t take long for you to start experiencing problems with your patients, the insurance companies you work with on a daily basis, and in many of the other aspects of your practice.

Reason #1: Documentation Meets Reimbursement Requirements

Like any other business, it’s important that you are reimbursed for your services. In the medical field, however, reimbursement isn’t an easy process. You have insurance companies–sometimes more than one for even a single patient–to deal with as well as the patients themselves. Without proper documentation, many insurance companies will deny coverage for even procedures that are highly necessary for your patients. In other cases, they may delay payment while attempting to sort out the details. Meanwhile, you’re left without the funds you need to cover daily operating expenses.

Reason #2: Documentation Improves Patient Care Across Multiple Facilities

Your patients aren’t just seeing you. In many cases, they’ll work with several different doctors across multiple different facilities–sometimes to deal with a single illness or injury! By providing clear, accurate documentation, you’ll improve communication between your practice and others that are seeing your patients, ensuring that they won’t miss out on any of the important details of the treatment plan that you’ve created. Clear documentation will ensure that other doctors know what medications your patients are taking and anything else they need to know in order to provide care based on the treatments you’re already using. This is particularly important if you use an online record-keeping system that is accessible from more than just your practice.

Reason #3: Enhance Patient Communication

You get to see your patients for a comparatively short period of time over the course of their lives. Often, you get to know a great deal about them during that time: sharing their struggles, their hopes and dreams, the challenges that they’re facing as a result of their medical difficulties. You also share a great deal of information, often information that patients may not clearly hear or understand during the appointment itself. By documenting everything clearly and providing your patients with necessary copies of that documentation, you can improve communication with your patients. Clear documentation can also enhance communications about when bills need to be paid, any attempts that you’ve made to share information with your patients, and future upcoming appointments.

Reason #4: Improve Patient Recall

When they’ve attended an appointment, patients often must absorb a great deal of information very quickly. Sometimes, that information can be overwhelming, especially if they’re dealing with new medical problems or conditions. Other times, patients may struggle to recall even simple information. Providing accurate documentation accomplishes two tasks: first, it improves patient recall; and second, it ensures that you won’t be held liable for poor patient recall, which could cause substantial legal problems for you later.

Reason #5: Help Evaluate Effectiveness

Is the treatment you’re using working effectively for your patient? This is one of the most important questions you as a medical provider must ask on a regular basis. You want to be sure that you are providing the best care possible for every patient that walks through your door. With appropriate documentation, you can evaluate the effectiveness of your treatment more efficiently. What treatment has been attempted on the patient? How is it working? If a patient showed similar complaints in the past, how was it treated, and did it work? The more you document, the better care you can provide for your patients in the future.

Reason #6: Enhance Internal Recall

You have dozens of patients walk through the doors of your practice every day. Some of them are highly memorable. In other cases, you may struggle to remember the exact circumstances of a particular patient. Why did you choose a specific method of treatment for this particular patient? Did something the patient said, whether an indication of a specific symptom or a problem with past care, lead you to conduct a particular test or decide on a method of treatment? Chances are, you won’t be able to bring the exact circumstances to mind later, especially if a great deal of time has passed. On the other hand, if you’re able to check back in your records and you’ve properly documented the interaction, you’ll find a clear and accurate representation of the interaction you had with your patients that will help prevent problems in the future.

Reason #7: Improve Future Care

When your patient leaves your office, they expect their problems to start improving. In many cases, they do. In other cases, problems may emerge again later or your treatment might not reach the patient’s goals for overall health and wellness. With proper documentation, you will ensure that you, your patient, and any future providers have accurate information about any care that was given, including treatment attempted. As a result, you’ll improve your patients’ ability to receive high-quality medical care in the future, whether they come to you with the same symptoms again or they’re visiting another provider with their medical records in hand. Online record access also helps ensure that other doctors can more easily access the documentation you’ve provided about a specific patient, ensuring better continuity of care even if the patient visits another practice.

Advantage Healthcare Consulting, a division of Advantage Administration, is a Management Services Organization (MSO) that helps healthcare organizations remain current with healthcare trends. MSO members get reduced rates on a huge variety of services and products they need to run their day-to-day business as well as plan for future changes. Services such as medical billing, IT management, telemedicine and more help our members not only succeed in today’s climate but also predict changes and make necessary adjustments proactively. To learn more about our MSO, contact Advantage Healthcare Consulting today.