Dr. Amanda holding baby Luigi, the day we picked him up. His curious brother, Alfi (left), isn't sure what to think yet. Thought this might help reduce the intense nature of this topic. Take a few seconds to feel his love. He's about 9-weeks old here. Who doesn't feel good when seeing a puppy!
What makes a great note?
Before I explain what makes a great note. Allow me to validate a few things, so (hopefully) you'll consider my advice seriously...
FACTS:
- Not one ChiroSimple member, ever brought to their board, has ever received any form of punishment/reprimand at all.
- In fact, every single member, has relayed back to us, that their board
dropped the investigation, with the primary reason relayed as "the quality of their notes."
- Many members have mentioned that their board said, "your notes are the best we've ever seen, not just in the animal chiropractic specialty, but from any provider that's ever come across our desk - keep up the great work!"
- Dr. Amanda (our co-founder) was personally also one of these examples (and boy was it stressful!). Her attorney told us (off record), "the
primary reason you weren't reprimanded, was because your notes were the best they've ever seen, ever. It demonstrated to them how conscientious you are about the care you deliver."
The goal is to not just have notes that pass the requirements, but rather impress! That's how you've got a fighting chance at coming out the other side unscathed. Adequate/mediocre notes might not be enough...
Your notes should be clear, consistent and defensible!
Your notes should tell a story: Why you saw the animal, what you did, and why you did it.
You can't possibly remember every case. Heck, many of our members have relayed to me, they can't even remember the animal's name while they're working on them.
Good notes protect your memory and your
license.
There's no guarantee that your ChiroSimple notes will keep you out of hot water (and we certainly don't promise that), but as of now, we've got a perfect track record - those are pretty good odds.
We're the only EHR with a blessing from a malpractice insurance company. Their legal department helped us formulate our notes and every last detail was designed accordingly, with proven results - our notes win, every time (so
far).
Nobody expects to end up in front of their board. But, when you do, you're going to thank the lord you've got the best notes representing your competency.
Common Note Mistakes
This is by far, not a comprehensive list. But, here's some of the worst practices that should cause you to lose sleep until corrected:
- Hand-written notes. C'mon!
If you end up with notes like this in front of your board, I'll pray for you (you'll need it).
- Quick check-off notes. You've seen them, the ones where you check boxes for pre-written options. Boards hate these.
- Notes taken on your phone's "notes app" or other "cloud based" text document. These are always incomplete, and look worse than awful. Not to mention, they're horribly organized.
- Notes without complete demographic
info of the client and animal. Complete notes are complete!
- Notes lacking your signature. All professional notes have a signature. You're a professional, right?
- Notes that don't follow a SOAP format, at minimum. (ChiroSimple notes go beyond that).
- Copy/pasting overuse. I've never seen notes from a provider who does this regularly, who hasn't messed up (a lot). Some common issues include: gender
mistakes "his/her," incorrect animal names copied over, etc, etc. It's always a mess.
- Any notes that show other quick-select options. If your notes show other selections that you didn't select, you're signaling that you're using some form of digital, pre-fabricated template - awful!
We designed ChiroSimple to protect you from creating a note that mis-represents your competency. By choosing ChiroSimple and using it, you've got the best chance at
having defensible notes, without even trying.
We believe that's worth a lot. Just ask any of our members who've been through this nightmare...they'll agree.
