Physician Orders Document Management

by | Nov 10, 2015

There are many factors involved in finding the best way to store physician’s orders: For example, you need to create defensible medical records, follow all applicable regulations, and ensure you’re in compliance with a wide range of rules. This can seem challenging, but technology has brought an incredible solution to all the struggles of document management.

 

Best Practices for Physician’s Orders Document Management

Whether it’s a scope of treatment form, or any other type of document, it’s essential to create defensible medical records. Some of the best practices include:

  • Organization is key.
  • Never use sticky notes, which can easily get misplaced or put on the wrong file.
  • Begin every note with the reason for the patient’s visit.
  • Include allergies, current medications, and names of other doctors on each patient’s chart.
  • Initial or sign every chart entry.
  • Write legibly so your notes aren’t in question.
  • Use electronic medical records.
  • Initial or sign every questionnaire as proof that you reviewed it.
  • Fill in spaces to avoid ambiguity.
  • Initial or sign consultants’ reports, labs, and X-rays to prove you reviewed them.
  • Avoid writing over information. Instead, add a correction and clearly note what you’re changing.
  • Chart both original prescriptions and their refills.
  • Document phone calls with content, names, and dates.
  • Be unambiguous in referral notes.
  • Include full data in progress notes.
  • Add lines, drawings, charts, etc. when appropriate.
  • Document discussions about informed consent.
  • Document discussions about informed refusal.
  • Document noncompliance of patients.
  • Clearly document patient education information.
  • Document return visits.
  • Document cancelled appointments, and appointments that weren’t finished for any reason.
  • Add resolutions from previous medical appointments to a patient’s chart.
  • Write clear return to work or return to school orders.
  • Avoid subjective remarks.
  • Don’t criticize other physicians in your notes. Stick to the facts.

Following these best practices is the best way to build strong, defensible medical records.

 

Organization Challenges: The Difficulty in Maintaining Full Records

There’s no question that following the above tips will help you with compliance and regulations, but it can be a challenge for a number of reasons:

  • HIPAA compliance requires physicians to protect patient’s confidential information. Security can be an issue when physicians have hundreds of pages of files for every patient.
  • Most medical offices simply don’t have the room for files that run in the hundreds of pages. The solution is often to store some files off-site, which makes it difficult for physicians to easily access what they need, whenever they need it.
  • Keeping detailed notes like those suggested above generally involves significant duplication. This may simply mean that physicians are required to leave the same notes in several types of files, or they may have to make copy after copy.
  • Financial resources can be wasted with the postage costs of sending documents from one office to another.
  • No matter how great a physician’s notes may be, if the file is lost, the notes aren’t worth anything. With so many files, and a large number of pages in each file, there’s a good chance that files will be lost at some point, whether to negligence by support staff or a disaster like flooding, storms, etc.

 

Finding a Solution in Document Management Software

Though the challenges of organization aren’t small feats, document management software (DMS) can provide solutions to every one of these issues, including:

  • HIPAA compliance is built right into the best DMS options.
  • Physician’s offices can get rid of paper files for good. This frees up precious time and assures that medical personnel can access the documents they need, whenever they need them, within moments.
  • There is no need for duplication. Storing documents alone allows physicians to keep a single record of every meeting, phone call, patient visit, etc.
  • Offices can email or fax documents, thus drastically reducing their postage costs.
  • Loss is a worry of the past, thanks to high levels of encryption, regular backups, and other security measures.

 

eFileCabinet Takes DMS Options a Step Further

While most any DMS will offer the advantages you see above, eFileCabinet takes it a step further in several ways:

  • Role-based security options make it easy to share documents with exactly who you want to. Instead of having to share each confidential document separately, you can set certain types of files to be accessible by people with security clearances you choose. This offers blanket security approval for top-level employees but prevents support staff from viewing documents that aren’t necessary for their job.
  • Top security features include 256-bit encryption.
  • Incredible HIPAA compliance built into your software makes it easy to follow regulations to the letter.
  • Software integration allows you to use our software in conjunction with other top programs like QuickBooks, Microsoft Office, and more.
  • Mobile apps allow physicians to access their files from any device with an internet connection, including laptops, phones, and tablets.

No matter which DMS you choose, your office will quickly realize that working electronically is simply easier than using physical files. Fill out the form on this page to watch a 15-minute video that will explain exactly why eFileCabinet is the company your office wants to work with.