When I first began my career in O&P almost 19 years ago, I started in a catch-all type of role, as I assume most of us did at some point early in our careers. Clean the storage room. File paperwork. Sweep the shop. Clean the plaster trap. Bust up old molds. The cool kids would say, if you know, you know. 

During that time, I remember being handed a small accordion folder and was asked to file the dictations inside. I opened that folder to find hundreds of one-inch by eight-inch strips of paper. They were dictations from the 1980’s and 90’s, typed on sheets of paper via a typewriter, and cut into strips. My job was to pull the chart, flip to the back of the chart, find the appropriate time frame, and then tape the dictation into place. I remember reading them, most saying “Patient was seen today for (any given appointment type).  Will see back in two weeks for (next visit type).” Any additional information beyond those two lines was non-existent. Some clinicians might refer to those days as the glory days of documentation; others might cringe as they think back to the lack of documentation and information that was not captured. Either way, I say that story to remind us that, while we aren’t that far removed from those days, we also still have a ways to go in our collective documentation efforts.

Having been onsite to over 200 O&P locations, I can tell you with absolute certainty that we are far from standardized as a profession. We still have clinicians living in those glory days, providing one to two sentence dictations. Then we have others that have adopted to the use of EMR systems and create dictations that will win appeals with their eyes closed.

If you live somewhere in-between those two worlds, or you believe your practice can improve, there are several ways to do that starting today. First, conduct an overall assessment of your documentation efforts. Conduct a comprehensive chart audit review. While this is a time-consuming effort (and one you can outsource), you will find gaps in every aspect of your documentation process. I highly recommend a third-party audit; they are going to be non-biased and will already have a format to follow. Once you have your summary report, figure out what areas need to be fixed right away and find focused education to help train up your staff. 

Below we have outlined resources that can help you:

• SOAP Note Documentation: See on Amazon
  • This book should be a staple in your practice, especially if your clinicians struggle with not understanding what should be documented in each section of a SOAP note.
• O&P Insight
  • They are a great resource for chart audits and compliance recommendations.
• AOPA & AAOP both provide very targeted webinars that will enhance your standards of care.

While the idea of focused process improvement on documentation doesn’t appeal to most, those that have put the effort in know for certain they can bill with confidence. Getting and keeping your money doesn’t have to be hard, but if you only put forth effort in your practice to make standardized documentation a priority. 

Jessica Norrell, MBA, CPO

Written for the Q2 2021 SPS Xpress