Poor recordkeeping can interfere with compliance, bottom line
Jul 01, 2003
Are you losing 20 percent of your gross revenue?
If you're not using a travel sheet (speed sheet, circle sheet, charge out sheet) for every inpatient and outpatient visit, it is a scientific fact that you are losing up to 20 percent of your charges.
Getting started Our medical records system includes a patient data sheet (Table 1). The top portion is a computer back-up for practices with paper records that allows doctors and nurses to double check the wellness status of every pet in the household. Sure the front office staff is supposed to do it every time, but they are busy answering phones and dealing with clients, so at times, they miss a few. The technicians, assistants and doctors all have a chance to help out and catch missing reminders, vaccines, lab tests and other follow-ups. We use a two-part program that picks up missing pets and missing clients. Another part of the program is to have the client relations staff and the other members of the veterinary team screen every pet in every household on every visit. Implementing a third reminder into the system that requires a phone call to clients who haven't responded to wellness care (exam, vaccine, therapeutic monitoring) can be combined with these two functions generating $100,000 to $150,000 per year in the average practice.
Example: Rx Thyroxine 0.6 mg BID #120 HHHhhh
This entry allows your client relations staff to fill this prescription three more times before any more testing is due. When the next to the last box is checked, the technician will inform the client that one refill is left and schedule the pet for the appropriate bloodwork before a new prescription is needed. This occurs even before the reminder goes out.
Whether you use a POMR, SOAP, HEAP, or some other version of alphabet soup, our box system will speed up your data entry and allow you to get your records done in a timely manner. Add a 12-system exam sticker and your medical records can be complete before you leave the exam room or discharge a patient. The sticker allows you to check off all the normal systems. In today's society if you didn't write it, you didn't do it! Gone are the days when if you didn't write it down, it was presumed normal. Today, if you don't write it down, it is presumed you didn't look at it! These templates can be put into computer systems as well. The shorthand is actually really simple. A box [ ] equals a need.
Example: CBC [TH]
Chem Panel [ ]
X-ray abdm [ ]
Technicians place their initials in the box. This informs the entire staff who completed which procedure. To exit the exam room, the doctor just needs a diagnostic and/or treatment plan like the one previously outlined. Obviously, the doctor's assessment and treatment plan will follow the diagnostics. The other abbreviations are for follow-up.
"W" means that if you ask a client about cleaning his Yorkie's teeth again, he'll go elsewhere. He then smiles and shows that he is missing multiple teeth!