Bert if you don't document a breathing treatment do you ever get any trouble getting paid? If it isn't written it wasn't done? I am interested in using this more for an internal audit, I give the job to a specific MA and I want to track what is done. Especially with regard to referrals and follow up appointments. I will of course use it for treatments also where needed. A breathing treatment deserves a note, with the lot number of meds etc. An EKG does not
I document in the A/P that I gave a neb. I am certainly not going to put in a lot number of the albuterol. We also circle the neb on the Superbill which is kept indefinitely. I hate to say it, but being a doctor is hard enough without worrying about being audited. I am just not. If I do, then I do.
Any workarounds? I think the idea of sending email to staff is silly. Using the chart forward feature disrupts my charting.
I agree. AGAIN, I am not disagreeing with anyone's method. As I said, I am impressed you can do that. My MA would never see my message. She is just all over the place. Besides, we click on 99213, then on 94664, etc. and everything is captured.
@Leslie,
I agree with you about Instant Messaging. I have used over 15 (literally) LAN or network IMs which are HIPAA compliant. The best I have found by far (and it's free) is IPMSG. It can actually track four things for computers automatically and manually: Computer name, IP Address, Nick name and Log on name. It's awesome in a domain, because you will see Checkout, but you will see that Lisa is signed into that computer, so you know you are sending to Lisa on Checkout. The IP address is nice, because it maintains connectivity very well. I was getting frustrated and thought about Yahoo, but I just figured it would be too difficult with initials and everything. Plus, my staff already hangs out on the net too much. I find that would be too tempting unless you just laid down the law. You may want to check it out. It's not hard to configure, but it is better with ultra-configuration.
