I am sure that many of you have considered this question: “How can I
be expected to raise the standards of my documentation to the level that
insurance companies are requiring, and still provide the caliber of patient
care that I am known for?”
In some way or another, my entire family works in healthcare. My father
manages a hospital laboratory, two out of my three sisters are nurses at
that same hospital, and the other is a senior consultant for a major health
care insurance company. Surprisingly, we don’t talk healthcare all the time.
However, when we do, I try to take in the bigger picture of healthcare
outside of O&P.
A quote that I heard my sister say recently was particularly interesting to
me. She said to my father, “The (documentation system) that they have
implemented is so much extra work that I am not spending as much time
with my patients.” This really got me thinking about the documentation
requirements that are required of our profession and how a lot of O&P
practitioners feel that same frustration. The heart of the matter is that we
are spending time away from our patients, both physically and mentally.
Someone moved our cheese again. In order to keep our high standards of
care, we must solve the problem. That is to create better documentation
and keep the level of care that we are proud to have offered in the past.
The term that forward thinking healthcare providers are using is Clinical
Documentation Improvement (CDI). They are using it to communicate
to other healthcare members, reduce their financial risk, and create more
effective patient care.
After reading several articles about the subject, there are a few things our
profession can take away from this movement in healthcare.
- Improving documentation is an opportunity to improve operational
efficiency of the organization.
- Failing to address documentation flaws not only leads to increased
financial loss, but also diminishes patient care.
- Improved documentation is a requirement for the team-oriented
approach to patient care. If we want to be a part of the team, we have
to step up our game by creating workflows that are parallel to the
rest of the team.
- The most advanced hospitals are grasping CDI as a way to actually
increase the amount of time that clinicians spend with their patients. One
way of doing so is by using technology that can help reduce your
- Stop writing or typing – Dictating or using guided clinical
documentation tools for as much of the process as possible reduces
the time required to document the appointment.
- Dictate and document immediately – When the visit is over,
dictate while you are in the room with the patient. To make sure
you mentioned everything that was a concern to the patient (they
can add at the end if you missed something), and to make sure
you remember everything while it is fresh in your memory. This
will help remove unnecessary distractions when you see your
next patient, allowing you to spend more time with your patients
(Oh! Don’t forget that I have to order that smaller shrinker for
- Photos/Videos – Implement a procedure in your facility that starts
to capture more than a verbal count of the visit. An assistant/
technician and/or resident can take the photos and video for the
clinician for elevated documentation. Think of a doctor dictating
on lab results of a blood test, or a surgeon dictating on an x-ray.
Photos and video can form a concrete form of documentation that
accompanies the clinical notes as a form of data.
- Create a role of CDI Specialist – I am not suggesting you hire an
additional staff member. I suggest that you take 3-4 hours a week
for one of your clinical staff members (perhaps even a rotating task)
to review and identify areas for improved clinical documentation.
Furthermore, start to think of improving your clinical documentation
before you enter the room for each visit. Think of documentation as a
guidebook of care for another clinician to take over for you. What would
you want them to know if you suddenly could not take care of that patient?
About the Author:
Cara Negri is an American Board Certified Prosthetist with over 17 years of experience in the prosthetics profession. Her experiences include Technician, Clinical Educator and R&D for Ossur, Gait Society Chair, and Gait and Biomechanics Instructor at CSUDH. Cara is currently the Director for PnO Data Solutions, a division of the Siliconcoach software company that specializes in video movement analysis for the orthotic and prosthetic profession.