By Kathleen Casbarro
Technology is the next step in effective documentation, or is it?
Can Alex rely on the new technology in his practice to help with clinical documentation?
Alex tossed his briefcase on the sofa — it was a lot lighter than it had been since they had begun using more modern methods in his mental health practice — and submitted to the dog’s enthusiastic greeting. His wife stood watching and laughing.
“Don’t just stand there,” he joked. “I need to bounce something off you, as soon as I get this dog off of me.”
Laura’s eyes narrowed. “You’re expecting problems?”
Alex squinted at Laura. “Why would you say that?”
“Well of course I’ve never read any of the case files from your practice, but I know about notes issues at the preschool.”
“What kind of notes do you have at the preschool?”
“All kinds!” laughed Laura. “We have people who write terse little notes like, ‘Diaper change 2:10 p.m.’ and others who write notes like they’re sending a letter to their grandma who is lonely and wants to know every little detail of their lives.”
“How much do those notes matter?” Alex asked. “For us, inadequate documentation can mean compliance issues and improper insurance codes. We could have trouble getting paid or face greater risk of being audited.”
“I guess we could face the possibility of getting sued,” Laura said wryly. “Or losing our government funds. We have to document the kind of learning experiences, special accommodations for special needs kids, behavior issues — all kinds of things. We have documents we have to provide for parents and government agencies and sponsoring organizations and so forth. It might not be as big a deal as yours but it’s pretty important for us.”
“But the main thing is, I can see where you might face problems. Your practice hasn’t really tried to standardize documentation before. We try hard to standardize it, and I know that doesn’t come naturally to all our workers. But when it gets down to whether Madison bit Kyle first, I’m glad we made the effort to get notes everyone can work with.”
“So … as long as there’s no biting, I’m probably okay?”
“I’m sure you’ll be okay,” Laura smiled. Then she grew serious. “Just be ready for possible problems, that’s all I’m saying.”