Solutions

• Using an efficient method for record keeping can lower your stress and require less energy.
• Typing is efficient.
• Many clinicians type at 40-50 words per minute, especially with daily practice.
• Typing is a skill that can be learned.
• Dictation of your records can be accomplished at 80-100 words per minute using Dragon Naturally Speaking (obtained separately).
• These two methods have the necessary characteristics for rapid record creation.
• They offer a way out for the hard pressed clinician who needs to get his or her records done quickly.

What is needed for record keeping?

Clinical records aren't that complicated. They consist of the following:

• Contact information, signed releases, and insurance information for you or your billing assistant.
• Some kind of initial evaluation and treatment plan, whether organized by template or not.
• Dated progress notes.
• You may also want to keep some psychotherapy/process notes but to meet the "psychotherapy note exemption" of HIPAA they have to be in a separate file at the start.
• Treatment plans. Some clinicians use these. It is nice to have individual treatment plans so that you don't have to enter recurring data over and over again. Simply edit the one you created and send that in again.
• Outpatient treatment authorization requests if you work with managed care companies that require them.
  • Here too it is helpful to have individual files that can be re-edited and sent in again saving more time and effort.
• Information about dates of service, procedure codes, and receipts of money.
• A billing method and the data needed for it.
• Various forms and files you use in your work.
• Letters, reports, memos, and other written material.
  • This includes recurring things you may edit over time.
• A repository of incoming paperwork whether NP testing, psychological reports, lab work, etc.
• Finally for psychiatrists or those following medications some way of managing all that relates to medication management.
• Most of us don't have to be connected to a lab, a hospital, or other facility. Interaction with others is by phone, fax, and e-mail.
• You may have special needs with regards to software but most of what you need is here.

That's it! It really isn't so difficult to describe what is needed. The issue is how to organize all this and have it work efficiently.

Let me gently introduce a new idea here. We clinicians need a new method for record keeping. We need typing and a well organized computer program.

This combination can solve a lot of problems for the hard pressed clinician and can actually make things easier.

How about a few details of the tools necessary to achieve efficiency? Click Here