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M*Modal

The long and short of it - documentation - all smiles

Posted: May 15th, 2016 - 10:34 pm In Reply to: Fellow MTs, QAs, QA for ILPs please help piece together - what has been happening

First, MT profession started because docs had to document, but nobody could read their writing (including themselves.)

So, MTs started transcribing their written word into type.

With the advent of hand-held portable recorders, heck, just dictate it.

Now we transcribe their mumble mush, because only people with lots of medical terminology and knowledge could translate that mush into a presentable, medicolegal record.

We got so darned good at it, without any degree or even any training (back in the 1970s), that corporate thought it didn't take much to do this work. So, heck, just hire somebody, give them a bit of training, and hey, why should they get paid like a professional? I mean after all, high school diploma making middle class income? What's up with that is what they were thinking.

Then came along insurance companies who scrutinized the documents to try to get out of paying.

NOW we were worth our weight in gold. Document correctly, warn the provider when they made an error that would cost them reimbursement, warn them when they forgot to dictate something that would also cost them reimbursement.

The insurance companies got smarter, the CEOs got smarter, and heck, they went right back to just train them right off the street, a few months to a year, and presto, you've got a highly valued albeit misinformed newbie.

Finally, most of the office visits and a lot of the hospital visits are just "routine" so develop a template, pull it up doc, and click.

Now the docs are right back to doing their own documentation!!

We went completely round the circle.

Problem is, one serious flaw can create one hell of a huge lawsuit.

I'll be long dead before the bean counters realize how much money it costs for one misplaced 0.

Remember the $140 million lawsuit over 8 units versus 80 units?

Problem is, (and as a former ancillary provider I've seen this), "All is well" is not valid documentation. In fact, it is pretty worthless.

The word I'm giving to everyone is, "Carry your own history, you own medication list, your own allergies, and for heaven's sake, your own list of providers with you. You just will not believe how little information your current provider can get and how much of it is simply inadequate or completely incorrect.

I'm not saying the MLS is making the error, I've heard dictators make serious errors that when it gets into the record is THE TRUTH.

I'm also telling people that because the documentation is not being checked by anyone but the person who created it (the provider), it could very well cost you.

Mostly, the click it and sign is really going to reduce everyone's healthcare to the lowest common denominator, and that is the most scary thing about it.

My doctor was insisting on referring me to a pain specialist to do an epidural until I brought him in the test showing a pretty bad bleeding problem and told him it is really dangerous to stick a needle there hoping I don't get a hematoma right next to my spinal cord.

I am really really glad I had that test in my home records.

Cookbook corporate medicine. Just click it.

Some day the bean counters will realize we saved them a whole lot more money than they ever ever paid us.



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