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Why documentation is important for Alberta's physicians | ClinicAid blog

The new Schedule of Medical Benefits that was released by the Alberta Medical Association and came into effect on April 1st, 2014 reiterated the importance of proper documentation for all patient encounters. It also added an extra rule that requires physicians to record the time spent providing time-based services for each day of service. This time log should be kept chronologically and be part of the physician's documentation of patient encounters.

Proper documentation is important for personal record keeping, but also for reviews conducted by the Alberta Health Program Monitoring and Compliance Unit. In order to keep sufficient documentation of patient encounters, try these tips:
  1. Purchase a small notebook and writing tool (pen/pencil) that can easily fit in a pocket. You should keep this notebook with you at all times to quickly record and track phone calls and encounters, as well as log time spent performing time-based services.* 
  2. Record how many times you are speaking with facility staff about a patient. These calls are often missed in charts and are overlooked.
  3. Record every patient encounter in the patient's chart. Include the visits that have been billed on a cumulative time basis, callbacks, or multiple encounters on the same day. EMR systems can be particularly useful for these records, as well as keeping time logs for patients. 
*Some physicians might find a time management app most useful for keeping track of time-based services. Apps that can produce printable or downloadable records are especially useful.
Proper record-keeping will be useful for billing purposes, but are also extremely important for any audits or billing reviews that may occur. Documenting patient encounters accurately should become second nature to a physician in order to ensure all details are provided, while also making sure billing opportunities are not missed. Claims that are often missed are for phone calls with patients.

More tips on documentation methods and specific requirements for time logs can be found on the Alberta Medical Association's website.

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