Poor recordkeeping can interfere with compliance, bottom line

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.

The claims that it can be put into the computer faster or the technician types in the information as the doctor speaks are nice attempts to become a "paperless" practice, but even paperless practices will capture missing charges if they use a temporary paper travel sheet. The most common reason for missed charges is a failure to complete records in the exam room. The common excuses of: "I need to think," and "I have clients waiting," or "It's rude to write in front of the client" lead to inefficiency and poor communication with your team. Providing complete and accurate medical records serve as the foundation for your staff to work effectively and leads to efficient appointment scheduling. It really doesn't matter if we are talking about an inpatient or outpatient visit. If the medical records are not completed by the doctor(s) and nurse(s), a number of charges are missed. Veterinary Practice Consultants has developed a successful program where client relations staff (receptionists) are rewarded for any missing charges they find before the client leaves. The program has the client relations staff do this by comparing the travel sheet to the medical records and to the charges already entered into the computer.

Tracking a patient with a travel sheet during a visit will help eliminate missed charges and will allow the staff to take the proper steps to ensure patient care is met.

When Dr. Tom Catanzaro, a veterinary practice management consultant, introduced this program into my practice, we routinely wrote bonus checks to several receptionists for several hundred dollars a month. Did I point out that it was pure net? If the client walks out without ever being charged, it's gone! So every missed dollar the receptionist finds and adds to the bill is pure net. So I'd share it with her!

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.

The lower right corner of the patient data sheet is used to increase client compliance with chronic medications and reduce work for the client relations staff (Table 1). Using short-hand under the prescription refills heading allows the doctor to approve refills for six months to a year after appropriate therapeutic monitoring has been accomplished.

Table 1: patient data sheet

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.

By merely reviewing the patient data sheet, any team member, including a doctor, can check the wellness status of a pet on the checkerboard square. This, of course, should be customized for your practice. They can also look at the master problem list for a quick historical summary and which problems have been resolved or which need follow-up care. Finally, any team member can immediately assess the status of chronic medication refills. An added benefit is using pink and blue forms to designate the sex of the animal so no mistakes are made when talking with the client.

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!

"D" means Deferred and "I can't do it today, Doctor, but let's schedule it for two weeks".

Deferred for two weeks is written as [D] 2 weeks. This usually means the client needs to delay treatment because of payday, vacation, work or family problems. Then, we normally expect the client to remember to follow up with the needed care. It's his or her pet after all. Right? Wrong! That's why you paid so much for that computer. Any time you provide symptomatic care, that's a [D].

Example:X-ray [D] 3 d /Rx Rimadyl/ Recall 72h.

So they decided to wait on the X-rays. You said that's OK for 72 hours and somebody will call and see if Rover is OK. If he is, that phone call generates an entry in the medical record that the owner said symptomatic care worked. Six months later, Rover comes back in limping on the same leg. Of course the owner says, "You know Doc, he never got better." Doc can then say, "Gee, Mrs. Abbott, you told Sandy (specific name and date) that three days later he was doing fine. Did he re-injure it right away or maybe a few weeks later? You know how time flies."

Great medical records

By now you can see that this process is all controlled by the medical record. You can see that the patient-client centered practice is using the medical record to follow-up on deferred care to ensure the wellness of the pet. It doesn't really matter if your concern is exemplary patient care, outstanding medicine or effort to increase your bottom line. Whatever path you choose, whatever your motivation - human-animal bond, good medicine and surgery or good business - you will get the best results by putting the patient first. In the context of this article that means you are negligent medically, forensically and financially if you don't keep good records in a timely fashion. No doctor should have 25 records on his or her desk at the end of the day. That is poor client communication, disrespect for the staff, legally liable and just poor business.

You can no longer make the claim that there isn't enough time. If you have 20 percent of your doctor charges walking out the door, perhaps you need a transcriptionist or an outpatient nurse to record your findings? You may want your technicians and receptionists responsible for reviewing your records. To help reduce the number of incomplete records, you may want to institute a system that returns the file to the offending doctor. Who has the most incomplete records? It's important to make it fun and not demoralizing. You're trying to institute change and a way of thinking so you should allow time for this transition. Empower your staff to make sure your patients receive the best possible care. Good medical records are the foundation of team communication, the source of improved cash-flow, and the protection against liability and malpractice claims.

Suggested Reading

Dr. Haig is a partner in a six-doctor practice in Minden, Nev. He is co-editor of the Veterinary Information Network Practice Management Boards and a diagnostic consultant for Veterinary Practice Associates. He may be reached at v-p-c.com or e-mail PharaohDoc-@aol.com.