I am very proud of our accomplishments at Clinicient.  Over the past 10 years, we have listened closely to our customers, paid attention to trends in the industry, and developed  the best fully integrated, totally configurable EMR coupled with the most efficient and cost effective Revenue Cycle Management Service for physical rehabilitation on the planet. (Just my opinion, you understand, but I can back it up.)

The Clinical Content Management System, Template Based Documentation, and ability to develop Flexible Protocols are unique to Clinicient. These tools allow you to accurately and efficiently describe important findings, provide appropriate guidance and assure compliance, making it easier to accurately communicate your findings, establish medical necessity, and demonstrate progress.

Clinicient is a powerful tool that can help you produce excellent clinical documentation and run a successful practice. But it is only a tool, and it will never replace the professional skills and judgment that you use every day to deliver Great Care and can’t think for the clinician.

I recently read an article devoted to SMART Project Management. SMART is an acronym standing for Specific, Measurable, Achievable, Relevant, and Time-Bound. I think it is a great tool to consider using as your Guide to Great Documentation. 

Specific

It is obvious that using “decreased pain and improved strength” as a goal is not specific and not tied to function, but that phrase is written thousands of times every day.

Measurable

Lack of specificity is often paired with lack of measurability. If a test has poor validity it isn’t worth including in your documentation.  My favorite example is Passive Intervertebral Mobility Testing (PIVMs), often used in manual therapy.  We know that inter-rater and test-retest validity of PIVMs is non-existent, so why bother? If I were a chart reviewer and I saw documentation of PIVMs, I would go right past that drivel and look for something that is measurable and relates to the patient’s function.

Here is a recreation of a typical conversation that I heard from one of my staff more than once while doing a discharge interview:

• Therapist Dave: “So, Joe, are you doing better?”
• Patient Joe: “Yes, I sure am!”
• Therapist Dave: “How much better do you think you are?
• Patient Joe: “Gosh, I don’t know.”
• Therapist Dave:  ”Would you say that you are 70-80% better?”
• Patient Joe: “Uh, sure, I guess. Yea, I am about 70-80% better.”

Then Therapist Dave would write something in the chart like “Patient reports he is 70-80% better.” Huh? What does that even mean?

Achievable

Are the goals you are describing even achievable, given the patient’s condition? How do you know?

Relevant

Does your documentation describe a functional problem and why it is important for the well-being of the patient? Does it tell a story about how fixing the problem will improve patient independence, avoid surgery, hospitalizations, or other expensive costs?  Is it concise?

Make it concise and do everyone a favor … forget the fluff! If a detail is not important, leave it out.  (Does the reader really need to know that the patient is “pleasant”?  Sorry, that is nice and all, but no one cares.)

The quality and usefulness of your documentation is often inversely related to the length of the report.

Time-Bound

Seems obvious, but is there an end to this Plan of Care in sight? How long is it going to take, and what is the patient’s function going to look like at the end?

A Road Map

A well-organized plan of care and good documentation is like a great road map. It not only informs you when you are on course, and when course corrections need to be made, it also informs everyone else involved in the patient’s case: the referring physician, the insurance auditor, and, most importantly, the patient.

Your plan of care should be shared with the patient and reviewed with the patient routinely. It can be used as an educational tool, a source of motivation for your patient, and a powerful tool for establishing medical necessity and demonstrating the value of your services.  Poorly done, and it serves little purpose other than keeping chart auditors employed.

A well written evaluation, plan of care, daily notes, progress reports, and other written communication will help you deliver even better care.  Look at your documentation objectively using the SMART Tool. It will make your Great Care Greater.

Interested in getting your practice on the road to success? Contact Clinicient today to get started.