Keeping Medical Records With A Laptop Computer

KEEPING MEDICAL RECORDS WITH A LAPTOP COMPUTER

My use of the laptop had a painful birth. I had a lawsuit against me from a patient whom I had operated. I was at a seminar in Montana. At the end of one particular day of lectures, my own attorney (who frequently came to podiatry seminars) cornered me under a staircase. Fortunately there was nobody else around. He BERATED me for my terrible office chart. My ears turned red and I ground my teeth. I was furious and terribly embarrassed. Up to that time I kept my records by handwriting them. They were not very good. I was forced to admit it to myself.

In the early 80’s computers were nothing like they are now. Very few laptops existed and they had very limited memory. Still, I resolved to TRY to do something about it. I knew that at that time I couldn’t afford to retire, so I’d be in practice for many more years. My poor records would haunt me and create misery for me in the future. I purchased a small Radio Shack Model 100. It was the start of a wondrous change in my career, my practice, my ability to defend myself and miraculously, my income. The last thing that I expected from this was an increase in my income, but it happened. I have some ideas how and why, which I can go into later. Every several years I purchased other laptops as they improved and become more sophisticated. I took it with me everywhere.

I am a very good typist. But I knew a number of podiatrists who are not. They still find the laptop the very best way yet to type their notes. Even the cheapest modern laptops have huge memory and marvelous resources. Their screens are bright, easy to read and reliable. Some of the more expensive ones are very light and easy to carry from room to room. Avoiding transcription costs are a very attractive way to save money. The laptop is also an excellent practice management tool. You can download your patient’s telephone numbers into it and easily call them at home at night to find out how they are doing after their surgery.

CANNED FILES:

CANNED FILES ARE FILES YOU MAKE UP FOR LATER USE. They are “generic” and allow you to generalize, but add specific patient information at a later time. They save an enormous amount of time and effort. Very long and complex statements and forms can be put under a patient’s name with just a few key strokes. Type them once. You’ll never have to type them again!

1. I have created several dozen surgery reports of operations. They have several things left out blank that can be easily put it for each separate case. I can create an op report in about 3 minutes, a nail surgery report in about 1.5 minutes. 2. I have routine post operative visits recorded, with the opportunity to “personalize” them to each patient. Add a few words, and the post op note becomes a personal record for that patient. 3. I have several history and physical canned files. Some for biomechanical exam, pre- surgical, new patient, hospital admit, surgical center admit, etc. All the “basics” are there, and the files can easily be “personalized” by adding their specific medications, allergies, etc. 4. I have several model “routine foot care” files recorded. Some for thickened nails, ingrown nails, fungous infections, skin infections, etc. 5. I have excellent post and pre operative instructions, instructions for patients who have post op infections, pre-surgical appointments, etc. 6. PODIATRY ALGORITHMS: These are a set of notes that explain your approach to various conditions, like painful heels, hammertoes, bunions, post operative infections, etc. Please look at our website for podiatry algorithms to see how they can be used. Having them already prepared as a canned file allows you to insert them anywhere you want in a patient’s chart and their chart notes. 7. Your own “pet files” for practice management and “defense” of yourself through the power of excellent chart notes! 8. You can keep special canned files for nursing home visits that allow you to insert a detailed note into your record of a nursing home visit. This allows you to keep your OWN detailed records of nursing home visits in addition to the ones at the nursing home. You can mail them to the nursing home and ask them to place them into the patients’ charts. If they forget, or if they’re lost, no problem, you have them ALL home in your OWN file cabinet!

YOUR CHART NOTES:

Simply start each day with a date and a patient’s name: ------2/2/2002 Margery Morningstar

(Canned file)

Mrs. * comes into the office today with the chief complaint of thickened, fungoused nails. She has adequate dorsalis pedis and posterior tibial pulses, which are palpable. There are corns on the ______toes, which we trimmed and debrided. We placed soft pads on each and instructed the patient to return if there are any problems with her feet.

(added typed note)

Also noted was the inflammation of the 5th toe right foot, which might be a bursal sac that is red and sore. We padded this carefully, but made an appointment for next week for discussion of a possible surgical correction on this painful toe. We took AP's and Laterals of that foot. At that time we will discuss the podiatry algorithm for painful toes with corns with her.

HERE’S AN EXAMPLE OF A CANNED PRE-OPERATIVE HISTORY AND PHYSICAL FOR A SURGICAL CENTER ADMIT: PRE-OPERATIVE AMBULATORY SURGICAL H & P FORM

DATE: NAME OF PATIENT: NAME OF SURGEON: (Your name here) NAME OF ANESTHESIOLOGIST: local or regional by Dr. Yourself DIAGNOSIS: ANESTHETIC: local ASSISTANT SURGEON: none PROCEDURES:

CHIEF COMPLAINT:

PERTINENT HISTORY:

ALLERGIES:

MEDICATIONS:

PAST HOSPITALIZATIONS:

PERTINENT FAMILY HISTORY:

PROSTHESES:

PERTINENT OTHER NOTES:

------

PHYSICAL EXAMINATION

BP: PULSE: TEMP: RESP:

NORMAL: (MARK X) SIGNIFICANT FINDINGS

HEART:

LUNGS:

ABDOMEN: ENDOCRINE:

EXTREMITIES:

MUSCULOSKEL:

NEURO *(deferred) RECTAL*(deferred) PELVIC*(deferred) LYMPH*(deferred) ONLY)

This file was totally pre-typed and was just copied over. It took less than 10 seconds to access it and bring it here. Now, just fill in the blanks!

LAPTOP CHARTING IS FUN:

You will enjoy preparing your own pre-typed files. If you won’t want to type them yourself, you can scan files on a scanner and transfer them. Or, you could dictate files, have them prepared on a disk and just copy them into your laptop. Or you can have someone type them in on a disk for you, after you hand write them.

When we operated our Medicare Certified Surgical Center, we got our Center audited (including the charts), every 2 or so years. The auditors would appear at the door to our complete surprise, as they always showed up unannounced. They never suspected that we used canned files, since it was not at all obvious. The chart audits were very intense. We never failed.

WHAT WORD PROCESSING PROGRAM?

Most people use Microsoft Word. I used Microsoft Works, a program that is free of bugs and is completely reliable. I never, ever lost or had a corrupted file with Microsoft Works. It has many excellent features and is very inexpensive. By now, most word processing programs are very reliable and easy to use. You should use the one that you are most comfortable with. All of them have the ability to “mark” files to be transported and are easily “copied” and pasted. They list their files alphabetically, so they are easy and quick to locate. You can usually set up your “practice” files in a separate directory and keep them away from other “general” use files. Since you are used to word processing anyway, you’re almost all ready to start on your laptop.

VOICE ACTIVATED SOFTWARE:

I have never used this, but have been told that it is increasingly more reliable. It is certainly one option that those who are not comfortable typing should consider. You can transfer some canned files by the “traditional” method, and add dictation to those files you set up ahead of time. All voice activated software, no matter how efficient, has an error rate that requires proofreading. Proofreading dictated files at the end of the day is far easier than trying to do an entire day’s record keeping after you’re exhausted from a full day. Remember that all word processing and voice activated programs have their own dictionaries for your special “podiatry” nomenclature. After these programs “learn” the words, they will always spell them properly and pick up and correct any of your errors.

COMMERCIALLY AVAILABLE SOFTWARE PROGRAMS:

Any charting system you buy from a vendor will be computer based. All modern laptops have the memory and technical requirements to operate sophisticated software, including your proprietary one. It was not always this way, but it certainly is now. While I don’t have much familiarity with commercial podiatry record keeping software, it is designed by experts and is probably at least 50% better and more complete than what you are using now. Often they have excellent practice management sections of their software to help you expand your practice. Always get one that offers at least yearly updates and enhancements.

PATIENT REACTIONS:

Just enter the room with your laptop, sit down, put it on your lap, talk and type. Even though you will have eye contact with the screen periodically, I have never had a patient feel “abandoned.” Rather, they were complimented that “everything they said” was important. You might occasionally ask them to repeat something. Even better! On occasion you might be working on ANOTHER patient’s chart note. Naturally they think you are working on THEIR case.

PRINTING THE DAY’S NOTES AT HOME AT NIGHT:

I always printed my daily report and operative reports in the evening after dinner. It usually took less than 20 minutes. I printed three copies, one left at home, an extra one for the office, and a final one for the staff to snip and glue into patient’s chart with a glue stick. WE WERE NEVER BEHIND IN EITHER CHARTS OR OPERATIVE REPORTS. We usually had to include copies of op reports to send to insurance for billing. Because we were never behind, the surgery bill went out the very next day. It’s hard enough collecting from insurance. It’s even worse if the delay in your getting paid is your own fault.

THE HAPPIEST RESULTS OF LAPTOP CHARTING:

What did this do for me? I never had another malpractice case after I started laptop record keeping. That lasted for 10 additional years until I retired. I ran a Medicare Certified Surgical Center with my laptop. I could NEVER have done that without it. About 6 months after I started laptoping, I had a surgical patient get an infected 5th toe. He was uncooperative and threatened to sue me. He called me up one Saturday morning and told me he was going to an attorney. Naturally I was devastated. This was not my first lawsuit. I received the expected request for the chart notes from an attorney about a week later. I was painfully aware that some malpractice insurance companies were terminating podiatrists with too many lawsuits. It was a scary time.

About 2 months later, out of the blue, I got a call from his mother, whom I had never met (my patient was 29 years old). She told me (exasperated) that her son couldn’t find an attorney to take his case. The attorneys said my chart notes were “too good!” He had gone to three separate plaintiff’s attorneys, but to no avail. She was furious and told me she was going to request that the large group practice who referred him stop referring to me. As it turned out, I never got another referral from that group.

I never heard from him, his mother or any of his attorneys again. In fact, I never got requests for chart notes from an angry patient again.