4 Reasons to Finish Patient Notes During Appointments

Depending on the size of the practice, chiropractors see an average of 20-50 patients a day. In addition, according to the Association of Chiropractic Colleges, properly documenting patient electronic health records (EHR) may take up to 25% of the chiropractor’s daily time.

With such a heavy workload, it’s no surprise that chiropractors are tempted to update or finish patient notes at the end of the day or over the weekend. That way they can spend valuable appointment time focusing solely on treatment. But while that may seem perfectly sensible on the surface, this approach may actually be hurting your practice.

Following is a reminder of why documentation is so important, and the most compelling reasons why you should finish EHR notes before the patient leaves.

Why EHR Notes Are Important

Chiropractors most commonly use a method of EHR documentation called SOAP notes, which is an acronym for Subjective, Objective, Assessment and Plan. SOAP notes are a necessity for successful practice management, because at a very basic level, they:

• Allow providers to record and share information in a universal, systematic and easy-to-read format.
• Document a patient’s progress and determine the quality of care they receive.
• Ensure accuracy in coding and billing.

For a better understanding of how crucial comprehensive SOAP notes are for your practice, see How to Write a Chiropractic SOAP Note.

Top Benefits of Completing Soap Notes ASAP

1. Better Work/Life Balance

Chiropractors often express their dismay at having to spend weekends, evenings and even holidays behind a laptop or at the office, catching up on SOAP notes. This can negatively affect personal relationships and inhibit a full, well-balanced life. By completing patient notes during daily appointments, you can leave the office and fully focus on other aspects of your life, like hobbies, outdoor activities, entertainment and community events.

In addition, there are plenty of well-documented health risks that come with working longer hours. According to an article published on CNBC.com:

A study released … in the Journal of American Heart Association found that working 10 hours or more a day, just 50 days per year, can increase stroke risk by nearly a third (29%). That’s as easy as working 8 a.m. to 6 p.m about once a week.

In addition, longer work days can put you at higher risk for depression, anxiety, and other mental health disorders.

2. Credibility

As much as we’d love for our long-term memory to be flawless, the truth is that the more time that goes by after any type of interaction, the less our brains recall. That’s why the timing of your notes is crucial, should they be scrutinized by an auditor or attorney.

According to statistics from the National Practitioner Data Bank, as published by Medical Malpractice Lawyers, from 1990 to 2012 there were 5,796 malpractice claims filed against chiropractors. If you happen to be sued for malpractice, or your SOAP notes become part of a legal case, those who review records will assign higher credibility to documents that were completed closer to appointment times. The longer you wait to sign off on your notes, the more you must rely on memory alone, and this could cause doubt among those same reviewers.

3. Healthier Patients and Practice

The primary purpose of a medical record is to provide a complete and accurate description of the patient’s medical history. This includes:

• Medical Conditions
• Diagnoses
• Care and Treatment
• Treatment Results

Medical records should be well-documented to properly reflect all clinically relevant aspects of the patient’s health, and serve as an effective communication tool. Therefore, the sooner you document your patients visit, the more accurate and detailed your notes will be.

This, in turn, will help you provide higher quality of care, which translates to more satisfied patients. And when your patients are happy, they are more likely to refer new patients, which leads to practice growth. In short, healthier patients lead to a healthier practice.

4. Thorough Information

There’s an old adage that states, “if it’s not documented, it didn’t happen.” This is applicable to SOAP notes, because it’s impossible to prove something did or didn’t happen if there is no documentation to support it.

At the time of a patient visit, it’s easy to think you’ll remember all the appointment details later, when you have time to write them down. However, science tells us that you most likely won’t. According to Is Your Memory Normal?, published on New Science.com:

Memory is actually mostly about forgetting: all brains discard most of the sensory data they receive. Direct sensory memories only last a few moments. Some go on to make short-term memories, such as the phone number you just dialed.

Exact figures are hard to pin down, but an average brain can probably keep around four things in mind at once, for up to 30 seconds.

That’s why it’s so important to immediately document any important information a patient shares during an appointment. In addition, if you take notes at the time of your appointment, it might serve as a prompt to ask more details for clarification, if necessary.

Additional Resources

We know that as important as SOAP notes are, they can also feel laborious, time-consuming and monotonous. ACOM Health can offer you solutions that will help make SOAP notes easier, while improving accuracy and giving you peace-of-mind in the case of an audit or lawsuit.

Our billing services and chiropractic EHR and practice management software make SOAP note documentation a breeze, and will increase practice efficiency. Let us show you how.