Perhaps one of the most transformative and useful changes in health care has been the transition from using paper medical charts to electronic health records.
Electronic Health Records are the digital method of recording a patient’s medical history such as their medications, surgeries, allergies, and history of present illness during their doctor’s visit. The charts also contain vital information such as blood pressure, weight, vision, and eye pressure. The vitals in each chart vary by the kind of healthcare services the specific doctor provides.
Some of the common electronic health record systems for occupational therapy include Systems 4PT, InsightEMR, TheraOffice, and My Clients Plus. The Electronic Medical Record system that current clients of KLN Professionals use is WEBPT. It is one of the best EMR systems available for Physical and Occupational Therapy billing. However, KLN Professionals provides services for all EMR systems.
The earliest versions of electronic health records were used from 1971 to 1992. Most of the early EHRs were developed on large, standard computers with limited storage. In order to properly store all the patient records, the computers would have to be equipped with removable disk packs or tape for extra storage. Some electronic health records were created on minicomputers.
The Institute of Medicine pushed for widespread use of EHRs in the 1990s, but their attempt was unsuccessful. Providers did not adopt EHRs due to reasons such as errors in data entry, high costs, and lack of incentives. The value of EHRs first became widely recognized in the 2010s. The American Recovery and Reinvestment Act of 2009 provided doctors and hospitals with financial incentives to adopt electronic health records in their practices.
Electronic Health Records play a crucial role in provider billing. The evidence needed to prove a certain service was either rendered or medically necessary lies in those health records. KLN Professionals deals specifically with Occupational and Physical Therapy billing so it is important to understand the medical charting process used in those fields.
Physical Therapists have a specific protocol they must follow when charting the examination for their patients. If it is the patient’s initial consultation, the physical therapist must perform a physical therapy evaluation which is divided into three steps. First, the doctor or technician must take the patient’s medical history. The second part of the exam is to perform a systems review where the physical therapist will assess the musculoskeletal, integumentary, cardiovascular/pulmonary, and neuromuscular systems for any health issues. The therapist also evaluates the cognition language, communication ability, and learning style of their patient during this visit. The final part of the evaluation involves performing tests that are designed to “rule out” or “rule in” any functional limitations, to establish a diagnosis/prognosis, and then develop a treatment plan for the patient.
The medical chart has historically been documented using the “SOAP” format. The “SOAP” format divides the chart into a subjective section and an objective section. Reports that came from the patient themselves such as the history of present illness are included in the subjective findings. The actual tests performed and the review of systems is included in the objective section of the chart. The “A” in “SOAP” stands for assessment which includes the prognosis or diagnosis section. Finally. The therapist’s treatment plan or plan of care stands for the “P” and is the final section of the medical chart.
Medicare and other major insurance companies require the provider to have their patients return for a follow-up exam so they can record the progress of their treatment plan. Most physical therapists are mandated to re-evaluate the patient and write a progress note at least every 30 days.
All physical therapy medical charts must quantify the patient’s function. The goal of physical therapy treatment is to maximize the patient’s motility and function and enable them to be more independent. Eliminating the patient’s pain can be a goal as well, but the most important goal is to make sure the patient can function (with or without pain),
There are several benefits to using electronic health records as opposed to paper medical charts:
Truly, Electronic Health Records have gone a long way since they were first created. They were not widely accepted at first, but are now used by most providers across many different fields of healthcare.
Contact KLN Billing Professionals to get started! Give us a call at 678-549-1794 to schedule your free consultation.