record keeping management for medical practicesOne of the essential skills that your team should work on to support medical billing for ENT practices is record-keeping management. Having clear and accurate records can help to support clinical decision-making and improve patient care across the board. Otolaryngology management billing and coding are crucial to help keep your medical practice profitable, which ensures that you will be able to increase care opportunities and provide better services for patients. Working with a healthcare consultant service like MD Pro Solutions offers training and support opportunities for all staff members to ensure better record-keeping skills and clinical coding optimization.

Do It Now – Not Later

One of the best tips that you can get to improve record-keeping management is to get in the habit of documenting each patient interaction as soon as possible. This helps maintain the integrity of the patient’s record and allows practices to streamline the process and eliminate end-of-day tasks to ensure that file notes are complete and accurate. Many time-wasting activities that are common in medical practices involve putting off tasks to the end of the day or week. Remember, patient records can be used as evidence to defend your ENT practice in the event of a complaint or a claim. The sooner you and your staff document their notes; the more complete and accurate they will be when you need them the most.

Improve Patient Services

Changing the way you and your staff address record-keeping management can also help to improve patient services. Complete records that are entered accurately and legibly can remind physicians about what happened during a consultation, phone call, or emergency visit. With so many things going on in the office each day, it pays to write everything down right away before seeing the next patient. Quality records will help you remember the actions and steps that were taken, as well as the outcomes and any follow-up work that was done. Good records can help colleagues who see the patient in the future to ensure comprehensive care services that go above and beyond basic requirements.

Tips for Recording Patient Information

Your patient files should include a wide range of information, both on the patient and their insurance provider, as well as notes about consultations, visits, diagnoses, treatments, and ongoing support. Any relevant history and exam findings, decisions made and actions agreed to by the patient, information provided, treatment options, concerns expressed by the patient, and any drugs prescribed should all be noted in the file. Any investigations or referrals made to other physicians or clinics, as well as complete dates, times, and supporting information for each interaction, should be included in the file. Telephone conversations, video or phone consultations, discussions with third parties, test results, photographs and X-rays, referral letters, and any related surgical records should also be present in each file.

Integrity is Essential

Medical professionals are acutely aware of how important it is to preserve the integrity of records to support patient care. Medical billing for ENT practices and other types of record-keeping management training focuses on making and retaining comprehensive notes with supporting dates, times, and additional related information. All of this work will assist your billing department in providing support for clinical coding optimization to ensure proper payment for services. Your notes should be an accurate reflection of what took place during an office visit, and all relevant information should be included in the patient’s record.

Create a Professional System

One of the best ways to make sure that everything is accurate and complete is to have a system of checks and balances in place. Double-check to make sure that you create notes in the correct patient record, especially if the patient has a common first or last name. For patients with multiple family members who visit the same office or clinic, an extra check to ensure that the correct patient notes are in the right file should also be performed. Keep all comments and notes professional, avoid any type of personal or humorous statements that could be taken wrong when reviewed by a third-party. Your practice’s credibility and reputation could be negatively impacted if the records are not created properly.

Contact MD Pro Solutions

Does your Otolaryngology management billing and coding department need training and support to improve record-keeping management skills or clinical coding optimization? MD Pro Solutions offers a wide range of services based on your unique needs and requirements. Contact our team directly by calling toll-free 1-800-853-6110 to speak with one of our representatives about your needs. We can perform a FREE billing review to help get things started to provide support services to improve medical billing for ENT practices and clinics.