Patient documentation mistakes are costly. Mistakes can result in rejected claims, audits, POPI breaches & malpractice suits & associated penalties. Avoiding the financial implications of these mistakes means that your patient & practice documentation has to be complete, up-to-date & easily accessible. 

With that in mind, here’s 5 common, yet preventable, documentation mistakes that practices often overlook & how to fix them: 

1. Your documentation is still handwritten/paper-based

Handwritten patient notes are notoriously hard to read, not just by pharmacists, patients & other medical professionals, but by your admin staff too. This can result in billing mistakes, inaccurate claims & ultimately, loss of income.

How can you fix it?

Replacing illegible handwritten notes with easy-to-use electronic clinical notes can help. For example, a good digital system will enable your electronic clinical notes to integrate seamlessly into your billing software. This will enable you to have your clinical notes easily converted into billing instructions that are readily available for your staff to act on in the billing system. By doing this, there are no misinterpretations of what the patient was treated for, plus by using billing templates, you can ensure all the procedures & consumables are included so you don’t lose out on income. 

Still prefer writing your notes?

Software that supports clinical notes has become very smart. In fact, any good electronic notes solution will allow you to document patient information how you want to. This could be via a stylus, text typing, click templates or body charts. You should be able to choose. Learn more here.

2. Your documentation isn’t well organised

When clinical documentation is fragmented or disorganised, it is a sure indicator of waste. For example, losing or misplacing lab test results will mean ordering more tests – essentially wasting time, money, & resources. It also doesn’t help when you’re under time pressure & need access to clear, organised information to make the best care decisions. 

How can you fix this?

By using an electronic medical record (EMR) / clinical notes, patient information is automatically organised & easy to search. Patient visits are stored in chronological order with search functionality for easy recall of past treatments & medications. EMRs also offer a summary snapshot of important information (such as allergies, medical aid information & clinical metrics) so you have an at-a-glance view of the patient’s health.   

3. Your documentation isn’t safely & securely stored

If you’re still using paper files, you might have them under lock & key, but can you protect them from fire, theft, flooding, loss, damage or otherwise? With the POPI Act stipulating how we store & access personal information, medical professionals can’t afford to take risks when it comes to the security of patient information. 

How can you fix this?

Cloud-based solutions remove the risk of loss, theft, damage, or natural disaster. This is because your patient files are only available to authorised users.  Storing files in the cloud boosts efficiency significantly & ensures your clinical & billing documentation is safe & secure from data breaches or unauthorised access. 

4. Your documentation does not contain structured data

Using only ‘free text’ to capture patient notes might seem natural, but it means you can’t easily perform any data analysis. Structured data is important in enabling you to easily trend your practice data from a productivity, billing, or clinical perspective. 

Trends in your practice are enormously useful to help you understand how best to care for patients, what services to offer, who the most prominent insurers are within your patient population & much more. If your data is stored as handwritten notes, there’s no way to access or analyse that data to give you any usable information. This can be costly, but it can also be rectified.  

How can you fix this?

By using a digital system that includes structured data templates. With the addition of structured data, you can generate practice & patient trend reports. These reports can enable you to make data-driven decisions about the running of your business. 

5. Your documentation is not streamlined

One of the biggest (& most costly) mistakes practices make is to use separate clinical & billing systems. Not only do you have to invest in two systems, but you will spend (read: waste) time & resources capturing duplicate data. The result? Entry errors, inaccuracy & increased chance of having your claims rejected, i.e. expensive mistakes.  

How can you fix this?

Invest in a software solution that integrates your billing platform & your clinical notes system. Ideally, you want to capture relevant patient & treatment information once before that information automatically generates billing information – saving you time, money & frustration. 

Are any of these common mistakes costing you money in your practice? The good news is that they are entirely avoidable. Get in touch with Healthbridge to find out how a single integrated digital system can be the best medicine for your practice. Click here to request a call back from one of our skilled Business Consultants.