Even with an electronic health record (EHR) system, using it can still take a great deal of time. With a better EHR management system, this can be avoided. Here are a few of the better features of EHR management that chiropractors should look for.
One important principle of EHR management is having accurate SOAP notes. These make it easier to find out what procedures were done on a previous visit, and they can show what procedures and tests were or weren’t done at a visit, in case a claim is made. If you are audited, SOAP notes are your best protection. The more accurate they are, the more protection you have. An EHR system like ChiroSpring can be automated so it checks to see if all the codes match. If the documentation does not support something, it will alert you. If it is correct, you can input your signature and approval of those notes.
EHR management can make doing those SOAP notes easier. With ChiroSpring, areas to fill out can be brought up with a few clicks. Ideally, a system should move to the next portion of the form once one area is filled out, so none of them are forgotten. Patients who fill out online intake forms can be integrated and added to the system automatically, so all records are in the same place for easy access. Specific forms can be added and classified as well, like personal injury records. This makes the notes simpler to compile and creates an audit-friendly record. With ChiroSpring’s Edit process, SOAP notes can be created even faster. Content such as charges, diagnosis (and pointers), adjustments, and SOAP-free text can be automated. If they are not changed, the system can note them as “SALT” (Same As Last Time).
The best EHR management systems can go beyond those features. They can also automate work from patient insights. “X person was involved in Y incident on (date)” is a simple statement, but it can begin a patient story from intake. These clicks can be the beginning of a narrative for the chiropractor to work with during future appointments.
A further developed story can continue like this: “The injury was a result of a fall at work. They injured the following areas: left leg, left ankle. They describe the pain as 9 out of 10. They did not go to the hospital.” Accurate notes may take longer, but ChiroSpring’s automated process will put all that work directly into the system. Once done, only minor adjustments and expansions need to be added. Exams, such as range of motion, orthopedic tests, and more, can be pulled from the previous exam in one click. Online intake done by the patient can provide all the personal information for their visit. The system can be modified to include all sorts of different categories, such as patient complaints, review of systems, outcome assessments, medications, allergies, problems, and even your own customized intake questions. The system should be set up so you can add customized text to any charge or diagnosis code in Settings. When those charges or diagnoses are used, you can be guaranteed that your note will describe the correct one in detail.
Basic SOAP notes are not the only process of ChiroSpring EHR management that can be automated. Text codes can be added to notes that create adequate documentation of conditions and diagnoses if you are audited. A good system can also remind you of any missing forms for any given patient, so there are no gaps in the record. A cloud-based system can also easily travel from one office to another, so there isn’t a concern about records that only exist in one office.