I started my private practice with a hurried, do-or-die approach.  I wouldn’t advise this knee-jerk approach as a general rule, but having had the brain injury just months before, it was a way to stay afloat and still make my clients’ needs a priority.  Think: small, low overhead with a manageable case load = sanity intact.

When considering how the years ahead would roll out, the mandate to keep client records available for 6+ years loomed a bit large.  Staff at my former group practice had struggled with the unwieldy volumes of  chart hard copies which had been stored in what now was an unworkable format; the owners had not yet established a digital record keeping format and so were keeping every chart in its entirety.

The same unwieldy room of paper threatened to follow me to the end of my career.  So a year of so into my practice, I scanned every single piece of paper in my office, and set up a DIY format for future case note entries.  I bought a Brother all-in-one and started to acclimate to the learning curve of all things digital.

I researched clinical billing/documentation software, but found it expensive.  This made me question the cost vs benefit of investing in a pre-packaged computerized system to manage clinical documentation and billing data.  I didn’t question that a software writer could invent a way to chart and bill better than I could, but there were aspects of these software packages that seemed limiting.  The case notes sections had point and click options to streamline the job of charting, but did I really want to describe clinical interventions by selecting from a series of multiple choice options?  I boldly set about inventing a rudimentary, but workable, system, using the software programs I already owned.  I used  Scansoft to convert scanned documents to PDF, a universal file type that could be easily transmittable and accessable through the years.  (Scansoft was included with my All-In-One software, so it was a useful freebie.)  I jumped on Open Office (a freeware word processing program) when I noticed it would support note-taking during client appointments without distracting me with the bells and whistles so prominent in Microsoft Word.  Quicken was the workhorse which downloaded and tracked business-related finances and produced reports for my billing service.

This took some doing.  Sometimes I was still glued to the computer when Anani arrived to clean the building–and he works late.  But my time investment has paid off in spades.  I built an affordable system that I can continue to tweak as my practice grows and shifts, and most of the time I find computerized record-keeping fairly effortless.  And it’s given me the extra time to write this blog.

How about you?  Have you resisted the digital trend or jumped on the HIPAA bandwagon to rethink your old pen to paper routine?  How do you organize those important records of yours?  Do you fax directly from your computer, or do you still feed documents into your fax machine?  Write and let me know if you could make use of a blog entry about the strategies I’ve invented.

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