Tuesday, September 11, 2007

Building A Paper Trail

Doctors are notorious procrastinators when it comes to dictating reports. Their behavior often parallels the extremes represented by the fable of the tortoise and the hare. Some doctors (like tortoises) do a steady job of dictating their reports every day, week in and week out, in a plodding, methodical manner. Others (like hares) procrastinate until there is an urgent need to have their work transcribed. Like students who have goofed off all year and must suddenly cram for final exams, they display a sickening level of panic and paranoia when their charts come up for review.
There are two solid axioms which can be applied to this situation. The first applies to people who have been pulled over by the highway patrol for a random sobriety test:

"If you're sober, there should be no problem."

The second applies to life in general:

"Lack of planning and foresight on your part

does not constitute an emergency on mine."

Whether the documents you produce relate to a hospital patient or a patient being seen in your private practice, you always want to make sure that the trail of documentation regarding your interaction with the patient leaves nothing open to imagination or misinterpretation. Why? Because the approach taken by anyone auditing your work will be that"If it's not in this report, you didn't do it."

If a patient calls to cancel an office appointment, request medications, or complain about any type of perceived mistreatment, you want these facts clearly documented in the patient's chart. If a patient pulls a "no-show" (which deprives you of anticipated income), you want that fact documented for future safekeeping.

Next: Documenting Violence In The Workplace

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