The benefits of Allied Health clinical note taking

Allied Health is a business where your patients always come first. Treating and resolving patient issues is the reason you chose the profession. When you think about treating your patients it’s the work that you do in practice, directly with your patients, that comes to mind.

What doesn’t come to mind is taking notes.

It’s no accident that the About page on your web site doesn’t mention “great at note taking”. What is valued by patients and practitioners is the effectiveness of the treatment you perform and the manner in which you interact.

This leads many in the profession to treat note taking as a cost that must be borne because the regulators require it, rather than an activity that will enhance your practice.

Effective clinical note taking will enhance your skills as a practitioner, reduce risks & drive efficiency for your practice and lead to better patient outcomes.

Better patient outcomes drive practice revenue

Patient well-being is the reason you are in Allied Health. Remembering and understanding each patients history is key to providing effective and successful individualised treatment. The only sure way to provide continuity of care, and ultimately a better outcome for you patient, is to record detailed and accurate notes of every consultation.

Regulators know this which is why they publish guidelines on effective clinical note taking.

No matter how good your memory, it simply isn't possible to remember how you've treated each patient in every consultation. Patients can’t be relied on to remember this clinical information either. If a patient doesn't come to see you for an extended period, you need to know that you can look at those records and be sure of how and why you treated them all those months ago.

There are direct follow on effects flowing from better patient outcomes to the success of your practice. Patients who have successful treatments are more likely to remain with you long term, either to improve their overall wellness or to return if they require treatment for new issues. Those same patients are much more likely to recommend you to their friends and family.

The result is a clear link between effective clinical notes and higher appointments and revenue for your practice in the future.

Clear evidence of your treatments reduces practice risk and cost

Effective clinical notes, particularly where they meet the regulators compliance requirements, provide clear evidence of the treatments you performed and the advice you provided for every patient consultation. The best notes explain why you acted the way you did.

Your notes become the first line of defence against several risks to your time and your practice.

Customer complaints, regulator audits or health insurance requests for information can all be a drag on your time. Effective notes reduce the time to respond to any requests to a couple of minutes, rather than the days or weeks it may take to bring everything up to scratch.

You've heard the stories, Health Insurers are becoming more aggressive around auditing their payments to Allied Health professionals and the quality of note taking is a clear target. Health insurance agreements generally require you to provide your notes on request for any patient that is claiming for your services.

In Australia, there have been a number of cases where Health Insurers have involved the regulators with claims of poor record keeping. At best this has resulted in a requirement to undertake training and further education on record keeping requirements. At worst the Health Insurers have threatened to reclaim insurance payments from the Allied Health professionals involved.

Complaints from patients to the regulators have also resulted in training and further education requirements for individual health professionals. It's wasted time and effort for you which you could spend on helping your patients, growing your practice, or spending time with friends and family.

When you want to focus on your current patients the last thing you want is to have your valuable time taken away. Having to pull together notes from memory or otherwise update them so they can be understood is dead time that benefits no one.

Effective clinical notes, with clear evidence of all your treatments, is your best defence against the risk and cost of third party requests. For a little regular effort you will massively lower your risks if something goes wrong. Collecting a patients history is as easy as clicking a button.

It’s just not worth leaving yourself exposed by not recording effective notes.

Linking notes to your reception drives efficiency

Effective clinical notes, especially where they are designed to capture the right information and link seamlessly into your operating processes, will drive additional revenue and decrease administration costs. This allows your notes to have the dual purpose of recording clear evidence of your treatments and advice, as well as driving valuable actions within your practice at the same time. This additional benefit is a pure side effect of recording effective notes.

Capturing patient treatment schedules, and providing the detail to your reception staff, will drive up appointment bookings. If a schedule outlines exactly how many times a week a patient should be treated then the reception can book out future appointments with confidence and you will have a fuller appointment book. Matching those schedules with appointments already booked can massively speed up the process of filling in the gaps, rather than starting from scratch after each consultation.

With the right scheduling process you can drive this even further to match a patients plan against their actual consultations. If a patient is falling behind their schedule it will be clear to both you and your reception staff so that additional appointments can be booked to bring the patient back in line. More revenue for your practice with the additional benefit of improved treatment outcomes as the patient comes back to their plan.

Recording the products you prescribe will drive up incremental sales. If your reception staff have access to the list of products you have prescribed then they can pick them right off the shelf and provide them to the patient before they leave your practice. The revenue will flow to your practice rather than a pharmacy or other business.

Referrals become much more efficient where they are recorded during note taking and reception staff have access to them. Referrals become clear and unambiguous. Reception staff can prepare documentation for a patient without practitioner interaction and without relying on a patients memory. Patients get accurate referrals with less chance of costly mistakes.

Messages recorded during a note can add many possible patient interactions which provide value to both them and your practice. Instruct your reception staff to book appointments with a practitioner of another profession, like a massage therapist, and increase revenue for your practice. Note that a patient is on holiday soon and reception can check that overlapping appointments are moved, reducing no-shows.

There are real benefits in clinical notes

As you can see, for practices that take clinical notes seriously and work through the best way to approach them, there can be significant revenue, risk and cost benefits.

The key is to make sure your clinical notes are effective when recorded and leveraged when needed.

We have mentioned effective clinical notes are number of times, and we will have much more to say about how to make your notes effective in future articles.

Want to learn more

This article is part of the series “Effective clinical note taking for Allied Health practitioners”. Please see the other emails in the series for further details and recommendations. If you were sent this link directly and want to subscribe to the whole series, please sign up.