Chapter 7: RESPONSIBILITIES OF AN ADMINISTRATIVE ASSISTANT
Chapter 7:
RESPONSIBILITIES OF AN ADMINISTRATIVE ASSISTANT



This is Chapter 7 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“The Chiropractic Assistant”


The following materials are provided as a service to our profession. There is no charge for individuals to copy and file these materials. However, they cannot be sold or used in any group or commercial venture without written permission from ACAPress.


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Overview 
  Opening the Office 
  Greeting Patients 
  Greeting Visitors
Telephone Duties 
  Words Reveal 
  Pronunciation Enhances Understanding 
  Voice Tone
Managing the Reception Room 
  Sound Control 
  Policy Announcements 
  Reception Room Literature
Successfully Managing a Professional Appointment System 
  Types of Appointment Books 
  New Patient Referral Follow-up 
  Unstable Personalities 
  "No Shows" 
  Delayed Doctor 
  Continuity 
  The Control Sheet
Appointment Scheduling 
Handling the "Demand" for an Appointment 
  It's Not Always What You Say, But How You Say It
Office Records 
  Chief Complaint 
  Past and Related Histories 
  Advice Restrictions 
  Required Reports 
  Consent and Release Forms
Office Filing Systems 
  Alphabetical Indexing 
  Numerical Indexing 
  Current, Active, and Inactive Case Record Files 
  Subject File 
  X-Ray Files 
  Tickler Files 
  Reminder Calendars 
  Follow-up Files 
  Filing Philosophy
Typical Office Equipment 
  Purchasing and Inventory Management
Handling Mail and Correspondence

Housekeeping and Equipment Service 
  Appearance Inspections 
  Safety Inspections 
  Policy and Procedural Changes
Business and Personal Duties for the Doctor

Understanding Professional Public Relations 


Chapter 7: Responsibilities of an Administrative Assistant

Proper scheduling and planning help any office function smoothly with less possibility of omitting necessary actions. The doctor in charge will identify each assistant’s duties and functions and discuss her responsibility for the performance of each assigned task. During her initial orientation and training, these functions may be subdivided into procedural steps necessary.

Task plans and work schedules eliminate the confusion of whom should perform a specific duty. It eliminates the question, “What do I do next?” Work schedules based on good planning eliminate the need to work beyond expected hours, except for rare emergency situations. Keep in mind, however, that a plan is not a permanent thing. As conditions change, the doctor must revise schedules, duties, and responsibilities to reflect changes. Flexibility is a necessary qualification for a chiropractic assistant.

Patient handling and patient control are the two major factors determining the success or failure of any practice. As professional competence should be taken for granted, patient satisfaction makes the difference in success or failure. This one factor determines a high or low patient return and a high or low referral rate.

This chapter describes common duties of an administrative assistant. In both the professional and business world, however, specific job descriptions vary to meet the needs of management.



     OVERVIEW

It is frequently stated that the doctor should not be required to do anything in his office that an assistant can do as well or better. Valuable clinical time would be wasted if the doctor had to answer routine telephone calls, make appointments, supervise patient flow, send out notices and reminders, type letters, make billings, file records, and attend to the various other duties necessary to administer and manage the business side of a practice. To be efficient in his profession, the doctor must delegate much authority and responsibility for many office details to his assistant(s) so that his time will be used optimally in doing that which he has been specially prepared—helping the sick to get well and helping the healthy stay well.

The extent of delegated administrative responsibility depends largely on the nature of the practice itself, the assistant’s experience and training, and the size of the administrative staff. In a small solo practice with one assistant, the assistant will be required to assume several small roles. In a large office with several assistants, the number of duties will be reduced, but their scope will be expanded for each assistant.

An assistant with knowledge in basic administrative procedures, office equipment, secretarial methods, and bookkeeping systems will find little difficulty learning to become a capable administrative assistant within a chiropractic office. Major tasks usually performed by one or more administrative assistants include directing the flow of patients, reception area supervision, filing and record keeping, appointment and scheduling control, billings, telephone responsibilities, typing letters, general office management, inventory control, computing patient’s fees, instructing patients to office policies, and record filing among other tasks. These duties usually concern the reception, business, dismissal, and communications areas of the practice.

A solo assistant will undoubtedly be involved in technical duties and responsibilities as well as administrative duties and responsibilities. These technical duties involve certain routine data recording, measurements, laboratory tests, x-ray procedures, administration of certain therapies and rehabilitation procedures, and other clinical aid. The extent of clinical assistance also depends on the nature of the practice itself, the assistant’s experience and training, the size of the staff, and pertinent state laws and regulations. The typical role of technical assistants is described in Chapters 13 and 14.

General Office Philosophy

As described in the previous chapter, health practice is a very human environment. With most patients, the initial office contact is by the telephone. Know proper telephone etiquette, be cheerful but not familiar, and sincerely want to help the caller. After the telephone contact, the next is with the patient is in the reception area. This contact also helps to establish the success or failure in patient satisfaction. In both physical appearance and mental attitude, assure that the office has a reception room and not a waiting room. A waiting room is the result of poor appointment scheduling, The patient new to the practice entering the reception area should be properly greeted, and the initial registration should be completed. The doctor may wish you to take some preliminary case history using a standardized form. If the patient is asked to record information, a clip board and pen should be provided. Conversation with the patient should be professional and cheerful. A sincerely interested, reasonably relaxed, politely inquiring attitude will elicit more information in less time than a hurried, tense questioning period.

Keep your personal and office problems to yourself. The patient is there to bring his or her problems to the office. Patients do not want to listen to the problems of others.

Showing interest in a patient’s well being, family, and outside interests is a good practice builder. Another key to successful administration of a practice is personal warmth that recognizes each patient as an individual. Such an attitude can produce more confidence, increase patient referrals, and reduce office fee complaints than any other personal attribute.

Before the doctor sees the patient, the doctor should be given a few moments to review the patient’s case records. When the doctor is ready, the patient should be introduced, “Doctor, this is Mr. Jones.” The continuing patient can be introduced, “Doctor, Mrs. Smith is ready.”

After the initial consultation, the doctor may wish you to help in the examination procedure or perform some basic tests and measurements. After the information is gathered, the doctor usually asks the patient to schedule an appointment for an evaluation of his findings. This evaluation is usually given verbally, but some doctors may also give the patient a written summary report for the benefit of an absent spouse or parent.

During the initial consultation, the doctor explains the need for suggested examination procedures. During the evaluation appointment, the doctor discusses his findings from the examination and his prognosis under a specified treatment program. This procedure is called obtaining informed consent. It means the doctor will describe the procedures necessary and receive the patient’s consent prior to any recommended examination or therapy. The patient will be informed of likely consequences, dangers, and other factors so that the patient’s consent is given with knowledge of inherent dangers or risks, if any, to which the patient will be exposed.


Aiding Professional Service

Definite office policies and carefully planned procedures are the prerequisites for running a smooth efficient practice. Keep in mind, however, that a definite policy does not necessarily mean a fixed policy. Periodic staff meetings are regularly used to analyze the different phases and procedures involved in the professional services offered, seek areas of improvement, and voice doctor and assistant expectations. Quality communications require understanding another person’s viewpoint and expectations.

Office policies and procedures are generally designed to support the doctor’s three major services:

(1) consultation,
(2) examination, and
(3) treatment.

Consultation and history are required to help the doctor determine the type of examination necessary to isolate the cause(s) of the patient’s complaint. They are also necessary to counsel the patient against harmful acts and toward healthy behavior. Examination is necessary to profile the patient’s structural and functional status to arrive at a diagnosis and prognosis under the recommended therapies. Treatment is designed to help the patient return to as near a state of health and resistance to disease or normal stress as possible.

The typical office will offer five different forms of health care depending on the case involved at any particular time:

(1) emergency,
(2) acute,
(3) chronic,
(4) rehabilitative, and
(5) prophylactic care.

Emergency care is that minimal care necessary to aid the patient until an appointment can be scheduled for more detailed consultation, examination, and therapy. Acute care usually concerns unanticipated situations such as accidents, strains, and sprains that, although painful, leave little permanent damage or predisposition to recurrence if properly treated. Chronic conditions are usually those that are long standing and therapy is used more to check progress of the condition rather than reversal of the stubborn disease process. Rehabilitative conditions are those of either an acute or chronic nature where the disorder has been checked and therapy is directed to return the patient to that state of health enjoyed before the onset of the disorder. Prophylactic care is preventive in nature, striving to maintain optimal health and resistance of the patient.

Remember that all office policies and procedures are designed and administered to aid the practice’s services and the types of cases seen. From the time patients enter the office until they leave, every procedure should be planned to support the best interests of each patient. By so doing, the best interests of the practice will be served. Patient handling, case management, and practice control are just different aspects of professional health care. Each aspect must run smoothly and efficiently in a well-organized manner.

Office policies, procedures, records, forms, systems, supplies, equipment, and furnishings are but vehicles to reach the goal of professional health care. They should never be considered an end in themselves. The assistant should be alert that systems originally designed to aid the practice, in time and habitual use, have a tendency to dictate to the creators of the systems. The patient is always more important than any procedure.

      OPENING THE OFFICE

Acting in the capacity of office manager, the administrative assistant should be the first person to arrive at the office each morning. She should immediately follow a daily routine of getting the office in order. Here are some of basic duties:

  1. Assure that all rooms are clean and neat.

  2. Check temperature. Set thermostat so that temperatures range between 70* and 75* Fahrenheit.

  3. Make certain there is proper ventilation and adequate fresh air circulation so that it is a pleasant and refreshing place to work.

  4. Develop a list of the day’s appointments that gives each patient’s name, time of appointment, and reason for visit. Using this list, pull established patient record cards from the files and prepare one for each patient new to the practice. This will help to ease pressure and maintain efficient patient flow throughout the day.

  5. Open and organize the daily mail. Do not open personal letters addressed to the doctor or staff.

  6. Complete tasks left over from the previous day.

  7. Double check the office environment, and attend to as many preparation details as possible before patients arrive.


      GREETING PATIENTS

In review, the patient received the first impression of the office by the telephone and the second impression by the physical appearance of the office’s exterior and receiving area. Now the patient is ready for the third impression. This is the point of contact when the patient is personally “approached” by an assistant. Depending on the quality of this approach, either positive or negative impressions will be made.


Importance of a Positive Approach

In marketing a product, authorities rate the “approach” as high as 80% in importance to all sales. As a health practice is not a business but a profession, the word “salesmanship” is a poor term to use. On the other hand, it is difficult to completely differentiate salesmanship, public relations, and common sense in human relations. Obviously, the approach in a chiropractic office to either a new or continuing patient is important to practice success. When poorly handled through a thoughtless act or a tactless word, impression of the doctor’s skills and professional service standards may be sharply minimized in the mind of the patient.

An assistant should greet the entering patient with a smile and cheerful welcome as if she were the hostess in her home, being gracious and pleasant to make the patient feel welcomed and at ease. The rules of courtesy, appearance, decorum, hospitality, and tack apply. A kindly smile (never forced) will do much to tell the patient in distress that he or she will be served with consideration. Your words, voice tones, facial expressions, gestures, grooming, posture, and carriage are important parts of making a positive approach.

First words as first impressions are important. Phrases such as “Good morning,” “Good afternoon,” or “May I help you?” are warm opening remarks. Avoid stern expressions as “What can I do for you?” or “What seems wrong?” These openings often frighten the timid patient. It is good policy always to use the name of the patient in the opening statement if it is known, but do not ask, “How are you today, Mrs. Smith?” This may invite a problem.

After the patient is made comfortable in the reception room, inform the patient, “Dr. Jones will be with you directly, Mrs. Smith.” This is better than “Dr. Jones will be with you in a few moments” because the latter implies uncertainty. The word “directly” in the first statement implies a short wait, yet it is noncommittal.

If a patient enters the receiving area while you are on the telephone, acknowledge the patient with a smile and friendly nod. If you are busy at the desk, stop momentarily to greet the patient and exchange a few words. Suggest a magazine if you will be a few moments. Always be friendly and interested, but avoid excessive socializing even if you know the patient well. Avoid selective favoritism to any patient.

It is a rare patient who enjoys a long wait in a reception room. To many, it’s annoying. All patients deserve a courteous explanation of why a long delay is necessary. When a patient has been waiting a considerable time beyond the scheduled appointment, the assistant should re-enter the room and graciously apologize for the delay: “We’re sorry, but an unforeseen situation arose that delayed our schedule a little.” Never let the patient remain in the reception room well past the appointment time without an explanation. It is discourteous and unprofessional behavior. Nothing less than good social conduct should be the guideline of a hostess.

Proper atmosphere and patient contact are two major points in a proper approach. The assistant holds the responsibility for developing a receptive patient attitude before the patient meets with the doctor. In its simplest terms, the goal is to have the patient like you, the doctor, and the professional services. Your initial smile and friendly greeting are much more than a rule to be memorized. They set the stage for all that follows.

When the patient new to the practice is greeted for the first time, show where coats can be hung, and then obtain the basic office information. Be sure to offer extra special assistance with clothing of the elderly, crippled, or painfully distressed.

When patients enter the practice, basic information must be obtained such as patient’s name, home address, residence telephone number, occupation, business address, employer if not self-employed, business telephone, marital status, how the patient was referred to the office, health insurance information, and how the patient wishes to pay for the doctor’s services. If the patient is a woman, further information about the number and ages of children should be recorded. This basic information is often recorded on an index card and kept on file for administrative reference. In many offices, the doctor also desires the assistant to take some basic case history data such as childhood diseases, surgical history, accident history, disorders under treatment by another doctor, and other facts. A standardized form is usually provided.

If the doctor desires, record the pre-examination history for the patient new to the practice. Prepare a folder for the patient, insert history and other data obtained; and then prepare an office visit slip, and attach it to the folder. Mention the doctor’s time schedule (on time or delayed). When the doctor is ready, escort the patient to the consultation room and introduce the patient to the doctor.

      GREETING VISITORS

Every office, be it business or professional, has a regular stream of salesmen and solicitors calling. Many are important to the operation of the office. Others are unproductive or unnecessary time-consuming callers. The handling of nonpatient visitors is a matter that you and your employer should discuss early in your association. Together, you can set a firm policy in dealing with them. Many professional men and/or assistants designate specific hours or days solely for meeting with solicitors and salesmen.

In handling these callers, it is important to remember that your office may need the service or product offered. You must have good equipment, supplies, and service to run an office efficiently and profitably. Therefore, do not be abrupt with salesmen. Give them the attention and courtesies deserved. Do not discriminate against them provided they follow established office policies. Salesmen are not only your best source of information, they are also carriers of good will or ill will. Besides, salesmen and their families need chiropractic care too. Avoid the attitude that all callers other than patients are nuisances.

If a salesperson should call at the office without an appointment, request a card and the purpose of his visit. Tactfully find out if the subject is important enough to be called to the doctor’s immediate attention. After talking to the salesman, you may decide that he has something of interest for your office. It is then up to you to schedule an appointment with the doctor when the salesman can present full information on his product or service. These people will often leave some literature for the doctor to review.

Although most doctors do not want to be pestered with insignificant decisions and details, they do want to make major decisions. The extent of your ordering and purchasing will depend on your experience, the policy characteristics of your office, and the specific faith and authority given to you by your employer.

If the visitor is another doctor, by-pass all waiting patients and escort him to an inner room. Then notify the doctor. Such visits are usually for a specific purpose and can be handled quickly.


     TELEPHONE DUTIES

Attitude

The ring of the telephone should spur your sincere interest, helpfulness, and empathy. Your tone of voice should reflect a friendly professional attitude. No matter how busy you may be at the moment, take a slow deep breath, put a smile on your face, and let the caller know you “care.” The caller must be convinced through your tone that the office has people who are courteous, efficient, concerned, and eager to help.


Technique

Telephone technique is expressed in voice quality, volume, pitch, clear pronunciation, and rapidity of speech. A good telephone voice reflects sincerity, warmth, friendliness, professionalism, graciousness, and understanding. Volume need be no different from that of an in-person conversation. Don’t yell; don’t mumble. While callers cannot see your hand gestures and head nods, they will “feel” your smile. A pleasant well-modulated voice shows your response is free from strain and tension. Voice quality alone may calm or reassure a nervous patient.

Because the telephone is a low-fi instrument, many overtones and undertones witnessed in personal conversation are lost. Therefore, it’s often helpful to pitch the voice slightly lower than normal. If you have a high-pitched voice, speak slower and lower. Transmission is best when the mouthpiece is held about one inch directly in front of the lips.

Here are some simple rules in developing good telephone technique:

  • Smile, greet the caller pleasantly, and listen attentively. Visualize the caller. The caller will form an image of you through your voice and manners.

  • Answer promptly, on the first ring if possible, but once you pick up the phone, assume an unhurried manner. Before you speak, clear your mind of previous tasks.

  • Hold the mouthpiece about one inch from your lips and speak softly and clearly, avoiding monotones. Don’t use slang, “mod talk,” or professional jargon. Keep personal chatting to a minimum.

  • Record name (and often telephone number) immediately. Take notes, request necessary spelling and use phonetic spelling if necessary.

  • Don’t put the caller on hold if you expect a long delay. If you put the caller on hold, quickly return to the person and explain any delay.


      WORDS REVEAL

Words come from the mind, but the way they are spoken reveals your heart. When you meet someone face to face, you can express your cordiality by a smile, a nod, or a wave of your hand. But over the telephone you must find other ways of transmitting your feeling of friendship. Over the telephone, the smile, the nod, the wave of the hand, can only be shown by what you say and how you say it. You can sound uncertain, abrupt, bored, or irritated. Or you can be confident, courteous, sparkling and friendly. You can make yourself a real person instead of “just a voice.”

All appreciate a person who speaks over the telephone clearly and pleasantly, not too fast or too slow, neither too loud nor too soft, with a careful enunciation of each word and syllable. A pleasant voice is an asset —not only on the job but in everyday life. It saves time and avoids confusion. It makes friends and wins promotions, and it dissolves resentment and reveals culture. It invites opportunity and secures a cordial relationship.

The way your voice rises and falls, the way you show what is important by proper emphasis, the way shades of feeling appear in your voice—these give vocal color and help make it pleasing and convincing. For example, the way you say the words you use in answering a call is important. Suppose they are “Dr. Smith’s Office.” In these words you can accomplish much. By a pleasing tone, you seem to ask, “Is this the office you are calling?” By the helpful expression in your manner, you ask, “What may I do for you?” You imply that you are pleased to receive the call. All that—in just three words!

      PRONUNCIATION ENHANCES UNDERSTANDING

To be easily and accurately understood, it is necessary, of course, to speak clearly and distinctly. Pronounce carefully, giving proper form to each sound in every word. Try this: Open your mouth slightly and while hardly moving your jaw or tongue speak a few sentences. You have heard people speak that way and probably had trouble in understanding them. They are suffering from stiff jaws, lazy lips, sleepy tongues. It’s no wonder their words sound mumbled, shut in, or “swallowed” instead of being nicely formed and directed. It should be obvious that chewing gum or eating should be avoided while using the telephone since they interfere with distinctiveness.

It’s more important to speak unhurriedly and distinctly over the telephone than when face to face. That is because the listener cannot see the changing expressions of your face. Without distinctiveness, other good voice qualities will be lost. You can frequently tell whether your voice is easily understood by noticing the number of times others ask you to repeat what you have said. Experiment until you have reduced these requests to a minimum.

If you cannot hear the caller clearly, use extra tact and courtesy. Never say, “I cannot hear you,” or “I can’t understand you.” Rather, say that it seems you have a bad connection and ask the caller to speak a little louder or slower.

      MONITOR YOUR RATE OF SPEECH

A moderate rate of speech is important. Sometimes you may be tempted to talk too fast over the phone because you are busy and believe you are saving time. If you speak too rapidly, however, the chances are you won’t be nearly as well understood and you must use valuable time repeating. It pays to take time for courtesy too.

Telephone conversation should neither be too fast nor too slow. If too fast, words are jumbled and parts of words are lost to the ear. If too slow, words seem disconnected and lose meaning and interest. Ordinarily, the very act of speaking clearly will tend to prevent talking too fast.

      VOICE TONE

Be as sincere and natural to everyone over the telephone as you are face to face. If your voice loses its natural tone, try to determine why. Is it due to a monotone or mechanical way of speaking? If so, put more expression in your tone by varying phrases. Perhaps you are speaking too loud or not loud enough. Ask a friend whether your telephone voice resembles your natural voice.

Care in using correct mouth action for any sound will assure that the sound is formed rightly and clearly. You’ll be astonished at the variety and importance of mouth action required to form different sounds. To sound any particular note on a musical instrument requires a special position or action such as pressing a violin string at exactly the right point and drawing the bow correctly. So too there is a special position or action of the lips, tongue, or jaw for every sound used in speech. The lips sometimes close or take a slightly parted or rounded shape; the jaw moves up and down; the tongue moves to certain positions. For a pleasing tone, drop your jaw so that there will be sufficient space between the teeth.


Answering the Telephone

In review: Try to answer each call as promptly as possible. If other lines are used, politely ask the caller to hold for a moment while you respond to the other call and return as soon as possible. Offer to return the call if you feel the delay will be longer than one minute. If the party on “hold” is there longer than anticipated, take their name and number and have the call returned rather than leaving them “dangling” on the phone.

Most doctors will have set policies for handling routine and emergency calls. For instance:

Rapidly identify the office.   For example, “Good morning! Suburban Chiropractic Clinic. This is Miss Anderson speaking. How may I help you?” Never just say, “Hello,” “276-5834,” or “The doctor is busy!”

Quickly determine the reason for the call.   If in doubt, ask a tactful question. For example: “Yes, Mr. Brown?” This infers that you are ready to hear why he called. Visualize the caller while speaking and listening.

Accurately gather the facts of the call.   Obtain the caller’s full name with correct spelling and phonetic breakdown, reason for the call, and final disposition. Recap this information to the caller to verify the facts before you hang up.

Be friendly.   If you are acquainted with the caller, let him know that he is recognized. For example: “Hi, Mr. Peterson. It’s good to hear from you.” To be sure of the name of the caller, repeat it during the conversation. People like to hear the sound of their name.

Although most calls will be for an appointment, many new patients will ask to speak to the doctor directly. Your “How may I help you?” will usually resolve this problem. Or you may say, “If you wish to make an appointment (or reserve time for consultation), I can help you as I have the appointment book here at my desk.”

Avoid direct answers to specific questions regarding the doctor’s fees or professional procedures. Give a polite general answer to the effect that the doctor’s fees and procedures are usual and customary in the area and that a personal visit with the doctor would be necessary to discuss specifics as each patient requires individualized attention. The caller may ask, “Do I have to be x-rayed?” Respond that all patients do not require films but the necessity must be discussed with the doctor in the light of each patient’s individual needs.


Calls the Assistant Can Resolve

Don’t feel that your function is to “screen’ calls from the doctor. Such an attitude appears to separate the doctor from his patients. Your function is to handle those calls you can so the doctor’s clinical time will not be reduced. An able assistant can manage calls about appointments, taking messages, answering questions about third-party claims, receiving a favorable progress report, answering requests for general information, requests for a housecall, complaints or misunderstandings about a bill, calls from sales people, and nuisance calls.

Sometimes a caller refuses to identify himself. This may be because the caller is a “skeptic,” has been recently mistreated by another practitioner, or is “shopping around.” Most people with legitimate motives will identify themselves and their suspicions. If a mystery caller demands to speak directly with the doctor, ask for their name and number so the call may be returned or suggest that a letter be forwarded. Be polite, even in the most demanding situation.

Sometimes a relative or neighbor of a patient will call seeking information. Unless you are sure the caller is a parent of a minor, remember that all information is privileged information and that a release form is necessary before any information can be communicated—even to the point that the person in question is a patient of the doctor. Speak in a way that others nearby will not hear the conversation; especially other patients. And never discuss a call with other patients or they will suspect that you do the same thing about their calls and conversations.

Following are two common examples of routine questions:

Question:   Is Dr. Smith a good back doctor?

Answer:   Yes, Dr. Smith is an excellent chiropractic physician. He offers professional health-care service.”


Question:   How much does he charge?

Answer:   How long have you had this problem?

After further discussion of the patient’s complaint and without mention of fees, state: “Dr. Smith will be happy to discuss fees with you. If you would like to arrange a private consultation before a regular appointment, he can see you either next Monday at 10:15 in the morning or Wednesday at 3:45 in the afternoon. What is the best for you?”


Calls the Doctor Must Resolve

While the assistant should give the impression that the doctor is always readily available, she should not put calls through to the doctor unless she feels it is totally necessary. If in doubt, place the caller on hold and brief the doctor of the problem. It’s important not to interrupt a doctor’s rapport or procedure with a patient being treated unless it’s vital or an emergency. Most calls that must be handled by the doctor can be noted by you so the doctor may return the call between patients or after the last patient of the session has left.

If you have a question, message, or special caller on the phone, there are ways to inform the doctor. You may use some predetermined buzzer or light signal indicating the doctor is wanted, in which case he could excuse himself from the patient for a moment. Another procedure sometimes used is to write a note and personally take it to the doctor. Place it so the doctor can see it at a glance without it being visible to the patient. He can then do whatever is necessary without the patient being aware of the delay or annoyed by the interruption.

Always knock before entering a private office or examination room. Be careful not to walk in on a patient unannounced while he is unclothed or in an otherwise potentially embarrassing situation.

If the doctor is available but speaking on another line, inform the caller that the doctor is speaking on another line. Ask if the caller would rather wait or have the doctor return the call. If the doctor’s current conversation is extended, return to the line and explain the situation: “Dr. Jones is still on the telephone. I’m sorry. Would you prefer to hold or may I ask him to call you back?” Never say, “The doctor is still talking” or “I’ll have him return your call.” Rather, say, “Dr. Jones is still in conversation” and “May I ask Dr. Jones to return your call.”

When the doctor is busy but wishes to speak immediately to certain callers, be sure you know the names of such callers. In such situations, say, “Dr. Jones is expecting your call. Please hold, and I’ll see if I can get Dr. Jones on the line for you, Mrs. Peters.”

If the doctor is out of the office, be tactful and factual. If he is out of town attending an educational program, say, “Dr. Jones is attending a special seminar (doing some graduate work) in Cincinnati this week.” Offering such information informs the caller that the doctor keeps abreast of the times. Avoid use of the word “Convention,” as it has negative connotations to many people. If the doctor is in town but out of the office, simply say, “Dr. Jones is out of the office and is scheduled to be back by 2 o’clock this afternoon.” Avoid statements that may be embarrassing to the doctor such as “He isn’t in yet!” (why not?), “I don’t know where he is” (golf?), “He hasn’t come in yet!” (tardy?), “He’s out for coffee” (no patients?), or “I don’t know where he is” (something secret?).


Call Records

A memorandum should be made immediately of every telephone call that needs the attention. This memo should contain date, time of call, name of person who called, telephone number of caller in case he is to be called back, the main points of the conversation, what the assistant did about the call, and, if necessary, some comments about the conversation.


Follow-up Calls

The assistant has many more duties besides the actual handling of patients face-to-face. An important function is the telephoning of patients for periodic spinal examinations or appointments that have been long standing. The doctor may also wish you to check the status of certain patients during the early stages of treatment. Patients often forget how long it has been between spinal examinations, or an appointment made several weeks ago may have been forgotten. Because people tend to forget and because “no shows” waste everyone’s time, a few minutes on the telephone confirming the next day’s appointments will keep office time productive. Thus, it’s helpful when recording a patient’s appointment that you also include the patient’s telephone number. When you do call, never “call to remind” the patient. This tends to insult a patient’s memory. Call to “confirm” or “verify” the appointment.


Outgoing Calls

If you must make several outgoing calls such as for appointment verification, allow about 5 minutes between each call to give a person who is trying to reach the office a chance to make connection. A constant “busy” signal may discourage a patient and cause him to call another doctor.

For frequently dialed outgoing calls, have a list of the numbers handy to your desk and keep it updated. It will save valuable time.


Answering Services

Many offices use some type of answering service or device when the office is closed. It is usually the responsibility of an administrative assistant to obtain the messages from the service—passing on urgent messages to the doctor, and responding to unessential requests personally. Often the assistant will feel she is too busy to respond to some calls, feeling that the service has told the caller when office hours begin and that the patient will call back. This is an error. Keep in mind that when callers receive an answering service, they already have suffered a “let down” in reaching the coolness of the service when in need of help. It creates a warm impression when the assistant replies to the call instead of requiring the patient to make a second effort to reach the office.

When an answering device is used, the assistant plays back the tape, notes the caller’s name, phone number, and a brief summary of the message. Calls are then returned to those who left messages.


Pressure Shows Your Personality

One test of a good assistant is the way she handles calls when under pressure and the last thing she needs is for the telephone to ring. A good assistant will be calm and courteous, doesn’t panic, and will not “take it out” on the innocent party on the line. You never know who that will be. It could be an important community leader, a colleague of the doctor, a patient in distress, or the doctor’s wife.


Summarized Highlights

While doctors of chiropractic rightly believe that clinical skills and services are the major factors in developing a successful practice, an assistant should realize that the psychologic impressions made on patients in their association with the office are equally important. Positive initial impressions and continuing impressions are an integral part of developing and maintaining a successful practice.

A patient is more than a sick body.   He or she is also a sensitive psyche. Each contact with the doctor or any member of the office team, no matter how minute, has one of two reactions. It either builds patients’ confidence, creates greater respect, and develops further appreciation for the doctor and what he represents, or it builds patients’ doubts and resistance, and lowers respect and appreciation for the doctor and what he represents. This action is not a sometime thing. It is constant. It begins with the first contact.

Visualize the new patient.   Before a new patient calls the office, it may be often assumed that the person is in trouble. He probably has had difficulty for a long time, even if “off and on.” He probably has run the gamut of self-medication and home remedies. He probably has been to one or more MDs or DOs with unsatisfactory relief. He has tried to follow the advice of well-meaning friends and neighbors with unfavorable results. It is even possible that he has been to another DC. Someone whose advice he respects has now suggested he try your office. He is skeptical but groping for relief. He has hope or he wouldn’t make the call. His optimism or skepticism will be enhanced by the first person he speaks to from your office and the continuing impressions he receives from the doctor and staff. The patient’s first impression of the office is usually by telephone. The second impression is usually his reception at the office. Both are likely under the control of a CA.

In closing a call, review the details.   Remember your “Thank you’s” and “I’m sorry’s.” Hang up gently; you can spoil a pleasant good-by by jarring the ears of the person on the other end of the line. It’s usually a good idea to allow the caller to disconnect first.

Keep personal calls brief.   Visualize the plight of the mother with a sick child who cannot contact the office because the line is busy. Frustrating! Limit personal calls during office hours to emergencies, and make such calls as brief as possible.



     MANAGING THE RECEPTION ROOM

First impressions are the strongest because they are the longest lasting. First impressions may be modified, but this takes a much longer time. Well begun is half done.

The receiving area is the second point of patient contact with the doctor’s practice. The call to set the appointment was the first point of contact. The patient’s susceptibility to impression continues in the receiving area. It is an important area as this is the first tangible evidence of the environment of the practice and possibly of the services to be received. Even before the patient has personal contact with an assistant in the receiving area, the external appearance of the office building and the receiving area itself has made an impression—adding to or subtracting from the impression created on the telephone.

From a clinical viewpoint, the reception room is a nonproductive area. Yet it is one of the most important rooms in the office. It is here that the new patient receives his first close impression of the doctor’s neatness, taste, consideration for detail, cleanliness, and patient comfort. It is here that the returning patient gathers his thoughts before he sees the doctor. The reception room can either enhance or deflate the doctor’s image and that of his services.


Overseeing the Receiving Area

The reception, dismissing, and business areas of the office are the chief domain of the administrative assistant. Before the first patient arrives, and throughout the day, observe these areas as if you were a patient. Periodically, check neatness of magazines, wastebaskets, lighting, ventilation, room temperature, general cleanliness, and tidiness. If the condition of the furniture, condition of wood and paint, color scheme, and furniture arrangement is not the best, feel free to call this to the attention of the doctor discreetly.

The reception area need not be large, but it should be comfortable, hospitable, and sunny if possible. Furnishings should be in good taste, coordinated, and chairs should have arms so patients with low-back disorders may arise without excessive strain.

      SOUND CONTROL

Rarely should the actual reception room contain a desk. Conversations with entering and leaving patients are private and should not be within the range of other patients. One exception to this pertains to the group practice of several doctors who share a common receptionist whose duties are solely those of a receptionist. When an assistant is seated within the reception room, conversations are not private, and much time can be lost in idle conversation.

Listen as you would if you were a patient. Are there annoying inter-office sounds from equipment, intercoms, voices? Are there extra-office sounds from street noise? Remember, once you become used to a certain environment, you automatically become unaware of visual and audio impressions witnessed by a patient new to the environment. Soft background music is often used to induce relaxation and cover voices from adjacent rooms.

Clocks, radios, and television sets have no place in a professional office. Clocks constantly remind the patient how much the doctor may be behind schedule and add to the irritation, Avoid radios and TVs because it is difficult to select a program that would not irritate somebody. Prized antlers or bear rugs should be avoided because many people are not interested in the doctor’s prowess as an animal killer, and they frequently frighten children. Care should also be taken in selecting pictures. What appeals to one may offend another. Seek to establish a pleasant atmosphere.

Several means can be used to reduce irritating noises. For inter-office noise, ceilings acoustically tiled, deep pile carpeting, snugly fitting doors, soft background music, conversations kept low, and especially noisy equipment placed in special sound-proofed rooms will be a great help. It is sometimes helpful to lower the ring of the telephone bell or use a phone chime in the business office. Street noise can be reduced by closing windows, providing windows with double-paned glass, covering windows with heavy drapery, and placing large shrubs near the windows. When appropriate, such suggestions will be appreciated by the doctor.

      POLICY ANNOUNCEMENTS

Sometimes it is necessary to post notices within the reception area that aid patients and procedures. Such signs should always be of professional appearance. If the sign is paper, place it under glass within a picture frame and mount. Never “thumb tack” it to the wall. Signs, usually of bakelite or plastic, announcing “Please Register” assure the assistant that no one patient in the reception area has not been properly greeted. Embarrassing situations regarding fee policy, payments for service, or check cashing can often be prevented by a small professional announcement near the business desk that describes office policies.

      RECEPTION ROOM LITERATURE

Reading materials should be neatly placed in a magazine rack. Topics should have a varied interest to meet the needs of patients with different preferences. The material should be patient oriented rather than office oriented. One exception to this is the office of the new practitioner who wishes to educate as many people as quickly as possible to the benefits of chiropractic health care. He may restrict literature to that of “chiropractic” and “natural health” publications. Professional journals and newsletters, however, should not be placed in the reception area. Health literature designed specially for lay people are welcomed in most reception rooms.

For some reason, many patients associate the progressiveness of the doctor with the type and date of reception room literature. For this reason, monthly publications should be removed when they are 2 months old; weekly publication when they are 2 weeks old.


Educational Literature

Either in the reception room or preparation rooms or both, an adequate supply of modern chiropractic educational literature should be on hand. When tactfully suggested by the doctor or an assistant, patients enjoy reading chiropractic literature. If they had little interest, they would not be in the office. If a patient casually mentions a friend or relative that has a health disorder and is not a chiropractic patient, you may suggest a specific piece of literature that the patient may wish to forward. Chiropractic educational material prepares the mind of a patient or prospective patient for further information.

The American Chiropractic Association has a variety of quality educational literature and supplies. An array of titles is available for general health education, children and classrooms, back injuries, safety, insurance, and career opportunities within chiropractic.


Reception Area Supervision

In most practices, an administrative assistant takes responsibility for housekeeping control. A schedule should be established for daily, weekly, semimonthly, monthly, and less frequent responsibilities for each assistant, cleaning help, landlord, and others involved. A messy office and dusty equipment can do more to discourage goodwill than things you or the doctor can say. Usually it will be the role of a technical assistant to supervise spotlessness of examination and therapeutic equipment. An administrative assistant should supervise business equipment such as typewriters, duplicating machines, Dictaphone equipment, files, etc.

Because it is one of the first impressions on the patient, the reception area requires constant attention. Its appearance reflects the personality and character of the practice. Because of constant patient flow, frequent attention must be given to scattered magazines, gum wrappers, arranging supplies, straightening files, and emptying wastebaskets. Any wastebasket that may receive food particles, moisture or liquids, discarded adhesive tape, etc, should be lined with a plastic bag. Daily dusting and sweeping is usually necessary, and special attention should be given to the tidiness and cleanliness of rest rooms. Heavy cleaning such as vacuuming, floor maintenance, window cleaning, and washing woodwork is typically performed by an outside cleaning service.

Check throughout the day to see that all rooms are well ventilated. Check heating and air-cooling levels, spray with air freshener when necessary, check lighting, pick up clutter, straighten furniture and magazines, restock literature displays, and oversee the neatness of all rooms. The bright, cheerful, well-organized reception area reflects a bright, cheerful, well-organized assistant.

Vinyl or wood floors should be cared for daily. Wood furniture should be dusted, leather or plastic furniture should be cleaned with a damp cloth and saddle soap, and upholstered furniture should be brushed and fluffed. Dust and fingerprints should be wiped from desks and table tops. Lamps should be dusted and bulbs replaced as necessary. The magazine rack should be clean and well organized; discard old issues. Window shades should be adjusted and draperies straightened. Empty wastebaskets and replace liners. Check rest room soap, towels, and toilet paper.

Wipe dust from plant leaves and use leaf spray. Plants will require moisture and nutrition. Dead leaves should be removed, and the plants should be rotated for sunlight.

Periodically see that upholstered furniture is dry cleaned or shampooed, that lamp shades are cleaned, that desks and tables are washed and polished, and that the frames of pictures or paintings are polished. See that draperies are professionally cleaned annually. Upholstered furniture should be vacuumed weekly. Dust paintings with a soft dry cloth as necessary.


     SUCCESSFULLY MANAGING A PROFESSIONAL APPOINTMENT SYSTEM

The most frequent complaints from patients do not concern fees, health services, or house calls but rather the time wasted in waiting in the reception room when the doctor is behind schedule. Waiting complaints are heard twice as much as complaints about fees. It is natural for patients to become irritated when they have established a specific appointment time and are kept waiting a half hour or longer. Yet this is what happens in offices that are not run efficiently. This is poor management, poor human relations.

The doctor’s reputation and the practice’s image must be developed on an appointment system that is truly a system which does not deteriorate into a “catch the doctor when you can” procedure. Patients are people whose time and appointments are just as important to them as they are to the practice. Poor appointment management results in businessmen missing important dates, employees being “docked,” and the development of animosity rather than good will.

Many practitioners feel strongly that no patient should leave the office without an appointment. Such an appointment may be the next day, as with an acute situation, or several months ahead, as for a periodic examination.


Handling and Making Appointments

General community economics has little to do with the success of a practice. Some practices thrive in poor times; others flounder in good times. One imperative for a successful practice is a controlled appointment system. Such a system considers the best interests of the patient and the practice.

It is important then to allow enough time for each patient and their needs. Allowance also must be given to the examination or treatment that takes a little longer than anticipated. This takes experience by the assistant: knowledge of the doctor’s habits and knowledge of his patients. With experience, the alert assistant will judge fairly well what type of consultation, examination, or treatment will be necessary and how long such a procedure usually takes. Proper calculation of the time necessary for a patient’s appointment greatly reduces reception room waiting, improves the quality of care, and contributes to positive public relations. A free period (about 20 minutes) scheduled mid morning and mid afternoon allows for catch-up or to enter an unexpected emergency case.

To the doctor of chiropractic, the appointment book is his diary and record of activities. On it, he schedules his time. Thus, handling and making appointments must be done accurately and intelligently. Three basic points should be remembered:

  1. Assure that names, addresses, phone numbers, time of appointments, and spellings are correct before you enter them into the book. Repeat them to the patient for verification. There is no room for overlooked appointments or misunderstandings in a well run office. Open times in the appointment book are unproductive nonincome-earning periods. Crowded or duplicated periods in the appointment book are sources of dissatisfaction.

  2. If in doubt about an appointment, verify it. This will avoid an error and will aid you when you fear the patient might have overlooked the appointment.

  3. A record should be kept of canceled appointments made by phone or in person. This information is important when reviewing the work done that day and the work to be done in the future. The record also serves as a reference for charges and may have medicolegal implications. People are human, and humans make mistakes. When the patient enters, the appointment book should be checked to assure that the patient is not too early, not too late, coming at the right hour, or even arriving on the right day.

Even the best appointment schedules can be disrupted. First, tardy patients do happen. A very late patient should be asked to reschedule the appointment or wait until there is time in the schedule for him. This explanation must be tactful, never sharp or paternal. Second, sometimes it is difficult for the doctor to dismiss a talkative patient. When the assistant suspects this, it is not inappropriate for her to remind the doctor that the next patient is waiting. Third, occasionally a person may drop in without an appointment. If it’s not an emergency, schedule an appointment for the next day if possible. And fourth, emergencies happen that cannot be avoided.

Patients in severe pain take precedence over others with less priority. Most patients waiting will realize that they may be in same condition sometime and will require immediate attention. Explain the occurrence in general terms to waiting patients so that they will understand.

      TYPES OF APPOINTMENT BOOKS

The appointment book is a prerequisite of a good appointment system, and there are many types designed to fit a variety of needs. Some doctors with special needs have sheets printed to their specifications. Most books have a line for every 15 minutes and offer two columns: one for the patient’s name and the other for the services to be rendered. Some books allow one page for each day, while others show Monday through Saturday on two opposing pages, three days to a page. Most doctors and assistants prefer a large appointment book revealing the weekly schedule at a glance. Appointment books come either bound or loose leaf, and choice is a matter of personal preference.

While the 15-minute-line appointment book is the most common, many offices find this division impractical and prefer 5-minute or 10-minute intervals. This offers better accommodation for different types of consultations, examinations, and therapies. It is also more flexible for practices that require seeing more than four patients per hour on typical visits. Appointments must be scheduled according to services rendered.

      APPOINTMENT RESPONSIBILITIES AND TECHNIQUES

The doctor schedules appointments by day, but it is an assistant who is responsible for arriving at an agreeable time of day for the patient. Because this assistant has this responsibility, she must have the authority to control the scheduling.

Some doctors like to schedule all severe cases at one period during the day and check-up visits during another. Likewise, some doctors like to schedule all extensive examinations during one part of the day (mornings or afternoons), while others prefer them interspersed between regular appointments. This is a matter of policy determined by the doctor’s preferences.

In a busy office, it is rarely possible to give a caller an appointment at the exact time desired unless the appointment is being made far in advance. The assistant, however, should always let the patient know that the doctor is available and will see him as soon as possible. If a distressed caller is put off for several days, he undoubtedly will turn to another doctor who is more accommodating. Usually, a continuing patient not in distress or a new patient with a chronic condition will not mind if an appointment cannot be arranged for several days. Even in these situations, however, a 5-day wait is about maximum to suggest.

Appointments made by telephone are rarely forgotten by the patient as the patient has taken the initiative. However, appointments made in the office are apt to be forgotten, especially when the patient’s condition begins to improve and distress is not a constant reminder. For this reason, most doctors will have printed appointment cards as a reminder. If the appointment is for a period over a week, a telephone call on the day before the appointment is advisable to verify the appointment. Such a procedure helps to avoid “holes” within the appointment schedule because of forgotten appointments.

On the other hand, some doctors have the policy that an appointment should never be confirmed by telephone. Their reasoning is that calling patients to remind them of their time reservation often acts as an invitation to cancel or change the appointment. A patient may respond, “Glad you called. I was just going to phone you. It’s not convenient for me to come in tomorrow. I’ll let you know when I can make another appointment.” Thus, it is felt that the office should not be the stimulus for a cancellation or appointment change. As health processes may be involved that are unknown to the patient, nothing should be done to encourage development of a tentative health-care plan. As shown, there are many strong points on both sides. The final decision whether to verify appointments or not must be decided by the doctor.


Managing the Appointment Schedule

Each new patient should be informed of the office’s appointment policies when they are about to complete their first visit. This is usually at the dismissal desk. At this time, the assistant learns the most convenient time of day and days of the week for each patient and then tries to accommodate the patient’s desires as close as possible when making appointments. It is helpful to note such desires on the patient’s record for reference.

If the health-service program agreed to requires several visits a week for several weeks, the assistant should suggest blanketing a series of appointments for specific times during specific days in advance. This shows consideration for the patient’s desires, eliminates further conversation about appointments in the near future, and serves also to act as a commitment between office and patient.

Most doctors prefer appointments be scheduled at regular intervals if possible. When it is necessary for a patient to be seen three times a week for several weeks, schedule the patient Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday. Patients to be seen twice a week could be scheduled Monday and Thursday, Tuesday and Friday, or Wednesday and Saturday. Patients to be seen once a week or less frequent can be scheduled any time available.

      APPOINTMENT REMINDERS

As previously described, some doctors prefer patient appointments verified by telephone and others do not. Most practitioners, however, do prefer the use of mailed reminders when appointments are made far in advance. Thus, if an appointment is greater than 3 weeks in the future, notify the patient through the mail so that it arrives about 4 days prior to the appointment. Many offices use a fill-in printed type of appointment reminder for this. Such printed cards have spaces for the patient’s name and the date and time of the appointment reserved. If the appointment is made when the patient is in the office and not by telephone, the appointment is recorded in the appointment book in the presence of the patient and a note is made in a small tickler file to mail the appointment reminder.

It’s good psychology to offer a patient a choice of two different appointment times. This gives the patient an “either—or” choice and a sense of being in control rather than being dictated to by the assistant. On the other hand, rarely give more than two choices as contributes to the difficulty of a decision and wastes time at the appointment desk. By learning time preferences of various patients and recording this information within their records, you can conserve your time as well as that of patients.

      RETURN APPOINTMENTS

Many practitioners prefer that every patient leaving the office has a definite appointment and that the name be entered in the appointment book in the patient’s presence. Some doctors believe that a patient without a specific appointment will feel “discharged” if symptoms disappear and left to an unstable health-maintenance program. This would be an injustice to a comprehensive health-care service. Another reason is that if the doctor tells some patients to return in 2 weeks, they will often appear 2 weeks later when you do not have an opening. Thus, give the patient a specific day and time for the next appointment even if the appointment is 6 months in the future. If you are aware that the doctor has told the patient, “We’ll do another progress examination in 3 months,” note this in the appointment book so that adequate time will be allotted. Note any procedure you can anticipate if more time will be required than for a routine visit.

      FUTURE-APPOINTMENT REFUSALS

The doctor assumes responsibility for proper case management, but he cannot do this if the patient does not grant the authority to direct and schedule necessary appointments for care and evaluation of progress. In fairness to both doctor and patient, this policy must be maintained. A patient who refuses to accept a future appointment should understand that the doctor cannot be responsible for the consequences. When a patient refuses to accept a specific appointment, he assumes responsibility for the effects.

If a patient refuses to accept a future appointment after your tactful explanation, make a memorandum of the future appointment together with the patient’s refusal. Post the memo within the patient’s file. An accurate detailed record may relieve the doctor from responsibility for the patient’s condition if the patient suffers a relapse because of lack of treatment.

      COMPLETING INCOMPLETE APPOINTMENT SCHEDULES

A tactful administrative assistant can efficiently control the appointment schedule by manipulating appointment times to suit practice needs and individual patient demands without disrupting the cordial doctor-patient relationship so necessary in health care. It is her responsibility to see that the appointment schedule is as complete for every practice day as possible.

After a practice has been operating for several years, it is possible to have the appointment schedule productive in advance 95% of the time. This is achieved by referring to the periodic examination list and developing a recall list. If, for example, today is Friday and you note three openings for next Monday, check the appointment book for patients scheduled to come in later next week for a periodic examination. Call these people, and ask if they would mind coming Monday rather than the previously scheduled Wednesday, for example. Most patients who have not been to the office for several weeks or months usually do not mind such a slight appointment change. If this procedure fails, call “once a month” patients who are scheduled later in the week and attempt to move them to Monday. “New patient” calls and emergency calls will usually fill openings created by changes necessary to complete Monday’s schedule. Monday is probably not the best day to use as an example because patients have a tendency to overextend themselves on the weekend and the telephone is usually quite busy early Monday morning.

Patients who admire the doctor and respect the services readily cooperate with tactful requests. The objective is to see that each practice day represents a minimum of lost production time. When using a system to complete incomplete appointment schedules, note each patient’s cooperativeness in their record file. Avoid requesting the same patient to change his time reservation on consecutive occasions, and avoid asking patients to change their time reservation if previously they appeared uncooperative or annoyed during the request.

In newly established practices, it is difficult if not impossible to maintain a completely full schedule for the simple reason that patient volume has not been developed to that point. In such situations, group appointments as close as possible to each other. Rather than allowing four 15-minute openings in an afternoon, it is better for the doctor to have an open hour at the beginning or end of the afternoon for correspondence, reading, case study, or personal business.

      NEW PATIENT REFERRAL FOLLOW-UP

It is important when making an appointment for a patient new to the practice to ask who referred him to the doctor. If it was another doctor, record this fact as it is customary that a report of your doctor-employer’s findings and recommendations be sent immediately to the referring doctor. If you learn this on the telephone, try to arrange an appointment for the patient at the earliest opportunity as a professional courtesy.

Obtain the patient’s name (correct spelling), address, telephone number, the condition for which be is being referred, and possibly the length and type of treatment he has received. This will help you prepare initial records, offer the doctor an overview of the situation, and save time for all involved. If the referred patient lives many miles away, consider travel time and possibly lodging arrangements.

If it is found that the entering patient was referred by a patient of your office, the referring patient should be sent a “Thank you” note or letter. Some doctors use a printed fill-in-type card. However, most doctors believe that a printed card is too impersonal and prefer an individually typed letter be forwarded. Many offices have on file several numbered “form letters” of this nature that can be personalized. Several are necessary as patients who refer usually develop a history of referring several people to the office. When numbered “form letters” are used, note in the referring patient’s file the letter’s number so the same letter is not sent twice to the same patient. If it is, the personal touch will be lost and feelings may be injured.

      APPOINTMENT BOOK RESPONSIBILITY AND AUTHORITY

As one assistant should have the responsibility for appointment scheduling and control, the book must be considered her personal domain. Most doctors will respect this assistant’s authority. She alone should make and change all appointments. It is also her responsibility to write clearly and accurately so that others can easily read her entries and notations.

If one assistant has the responsibility for the smooth functioning of the appointment schedule, she must have absolute authority to control it. There are two major reasons for this. First, the doctor who makes an appointment for a patient without informing the assistant is committing a definite breach of professional taste. Second, appointment book problems are multiplied in the two or more doctor office that has several staff assistants. Everyone is tempted to make appointments. If various doctors and assistants make appointments, disorganization and chaos follow.

On the surface it may appear that anyone can look at the book, see an opening, and insert a name for the time reservation. Such a policy does not consider the problems involved. For example, the assistant supposedly in charge of the appointment book has just spoken with Mrs. Anderson and told her that next Monday at 3 pm would be open for her daughter Mary. Mrs. Anderson says that’s fine but she must check with the school to see if Mary can be excused early that day, and that she will call back in 20 minutes. Meanwhile, when the assistant is away from her desk for a moment, the telephone rings and is answered by a doctor or another assistant who schedules a patient in the apparently open 3 pm spot. A few minutes later, Mrs. Anderson calls to confirm the 3 pm appointment. Tempers flare that could have been avoided if the caller who telephoned while the assistant was away from her desk was informed that the assistant in charge of appointments would return her call shortly.

      NECESSARY INFORMATION FOR MAKING ADVANCED APPOINTMENTS

Put as much information as possible in a small space in your appointment book. For example, if a patient is scheduled for an extensive examination, noting this allows for proper time estimation as well as alerting the staff of necessary preparation. Most offices code standard procedures; eg, diathermy (D), x-ray (X), traction (T), spinal manipulation (M), physical examination (P), ultrasound (US), urinalysis (UR), and so forth. With experience, you can judge how long each procedure usually takes and schedule the appointment accordingly.

Obviously, a patient requiring several procedures will need a longer time reservation than a patient requiring one to two procedures. An entering patient requiring extensive examination will need a longer time reservation than a patient for a routine progress evaluation. A patient suffering a severely painful disorder probably will require more time than a patient suffering a minor acute disorder. Different procedures and different situations require different time requirements. Even age is a factor. A senior citizen will usually require a longer time reservation than a teenager suffering the same complaint. If the assistant must control patient flow with maximum efficiency and minimal effort, she must be able to see at a glance why the patient is scheduled.

When setting advanced appointments, mark holidays observed by the office. Also cross out all days when you know the doctor will not be in the office for such reasons as seminars, conventions, vacations, and other predictable absences. This prevents errors requiring many telephone calls and apologies to change scheduled appointments.

Your employer may be an examiner or a consultant for an insurance company. If an examiner, the company will refer applicants for life insurance to your office for examination prior to approving the policy requested. When this happens, be sure to obtain the name of the insurance company since it will be they who are responsible for the bill. If the company requires certain laboratory tests, note this in the appointment book. The doctor will inform you how long an average insurance examination will take. Note this for reference.

If your employer is a consultant for an insurance company, one of his roles will be that of reviewing claims. If the volume is extensive, he may wish you to allot several hours a week in the appointment book to review claims.


Handling Difficult Appointment Requests

An administrative assistant frequently receives some unusual appointment requests. Mental and emotional balance is the key in handling such situations. First, remember that a health practice is a service operation. Its primary goal is to help people in need. Second, office policies must be guarded. If there are too many exceptions, satisfying the needs of a few patients may be detrimental to the needs of the majority. By keeping in mind the needs of individual patients and the needs of the practice as a whole, logical decisions can be achieved.

Telephone requests for a definite appointment time can be a problem. If the time requested is available, reserve that time for the patient. If the requested time is filled, offer two alternatives as near the request as possible and say something to the effect: “What is your second choice, Mr. Brown? I probably can be more helpful then, and, if there is any change in the schedule, I’ll call you immediately.” Intelligent patients will appreciate this consideration. Even if no change in the schedule occurs to satisfy the original request, telephone the patient and say, “Sorry. Mr. Brown, but there has been no change in our schedule so I’m verifying your second choice at one o’clock Wednesday. If a change does occur, and I’ll do my best to help you, I’ll call you immediately.” This again reassures the patient of your personal interest and enhances office good will. Good will is the essence of practice security and growth.

Telephone requests for an immediate appointment are handled in the same way as requests for a definite time. We are not referring here to the emergency call, rather the call for an immediate appointment because of impending travel or personal convenience. If the patient should call and request an appointment for later that day, make the appointment if an opening is available. When you do, say, “You’re very fortunate, Mrs. Kingsley, it just so happens that we just had a schedule change.” Never say, “We just had a cancellation.” Patient attitude should be developed to the effect that a cancellation never occurs. Patients should be educated that cancellations are not permitted.

The continuing or entering patient who enters the office without an appointment and requests immediate service requires tact. Explain office procedures, yet comply with the request if the patient can be worked into the schedule without too much confusion. Here again, we are not referring to what would be called an emergency. Avoid the word “cancellation” and say, “Because of a recent change in our schedule, the doctor can see you soon.” Then have the patient seated in the reception room and begin the entering patient process. These occurrences test the efficiency and tact of the assistant in charge of appointments. By being interested in patient’s needs and without disrupting good practice management standards, everybody benefits. Such situations, however, should be rare for any one patient.

A patient who habitually enters the office without an appointment and requests immediate attention or the patient who frequently calls late for a time reservation must be discreetly educated to the necessity of adhering to office policy. It’s only policy because it’s in the best interests of all patients. Some patients feel that while the doctor prefers appointments, they are not absolutely necessary, at least not for them. An attitude as this soon grows to a lack of respect for the doctor because the assistant was not in control of the situation. Yes, some patients will bully assistants.

Tourists.   Offering service to tourists is often a perplexing problem for the doctor. On one hand, he is faced with a person in need and it is his professional obligation to help. On the other hand, because he lacks experience with the patient, a thorough history and examination is necessary to provide competent care. Few tourists are willing to go such an expense when they know they will be leaving town soon. The doctor can suggest two things: Either perform the necessary examinations and tests, or telephone the patient’s hometown doctor (at the patient’s expense) and see what he suggests. The patient must decide what course of action he prefers. First aid is always extended on request, however.

A practice operating on office hours rather than an appointment system requires a different approach. Prior to World War II, most doctors treated patients during certain hours rather than giving each patient a specific appointment. The appointment system has since slowly gained in popularity and is now used by most practitioners. In the office-hours system, patients are seen in the order they arrive. It is important for the receptionist to record each patient’s name in their order of arrival. This serves a threefold purpose: it avoids questions about who sees the doctor next, provides a record of patients the doctor has seen that day, and allows the assistant to gather in sequence patient files.

The major disadvantage of the office-hours system is that most patients tend to come about the same time. This means the office and doctor may be idle at some hours and then be forced to handle a large volume of patients at other times. This situation can be avoided, however. If, for example, office hours are from 2 till 6 o’clock, tell half the patients to come between 2 and 4, and the other half between 4 and 6. Experience will tell the alert assistant the best way to manage the particular practice philosophy of her employer.

Handling several progress reports or inquiries by telephone may dominate lines needed for appointments. If the practice manages many acute disorders, the doctor may ask patients to report their daily progress. Patients, on their volition, may call the doctor’s office to report their progress or to ask questions regarding their condition. Such calls may be routine for the practice. Abuse of the telephone is seen in the patient attempting to obtain detailed professional counsel or a diagnosis over the telephone. These abuses are often called “nuisance” calls as they interrupt the doctor when he is in consultation with another patient. Many practitioners feel that legitimate progress reports and inquiries should be encouraged.

To avoid “plugging” lines during peak office hours or interfering with a doctor-patient relationship during care, practices having many of these calls can set aside a special time each day during which patients can reach the doctor by telephone. This special time, a “Telephone Hour,” is sometimes printed on the office’s stationery, sometimes it is posted in the dismissal area, or both. When a telephone hour is established, it is usually placed at the beginning of the day. If placed at the end of the day, conflict may arise because of an extended schedule accommodating drop-in patients or emergencies requiring an immediate appointment.

When a telephone hour is specified, office policy usually requires that telephone appointments will not be scheduled during the telephone hour or will progress reports or inquiries be accepted at times other than the telephone hour. As always, controlling policy requires tact by the assistant so that no patient will feel that they are being “victimized” by an office policy. And, of course, there will always be justifiable exceptions.

Problems arise in housecalls that are different from those of office visits. Out-of-office visits are usually made for one of two reasons. Either the patient is bedridden because of an acute condition and the doctor must afford enough relief so the patient can come to the office for thorough care, or the patient is bedridden because of some chronic degenerative condition. For whatever reason the doctor makes house calls, the assistant should schedule them to the mutual convenience of the doctor and patient in the most efficient manner.

Because of unforeseen delays resulting from case management, traffic conditions, or climate, it will be impossible to give the patient anything more than an approximate time for the doctor’s arrival. When scheduling the appointment by telephone, ask what major streets or landmarks are near the residence and note this for the doctor. Check the address in your city directory, and see to it that the doctor’s bag contains a city map. If the doctor makes a regular round of house visits, prepare a routing list so he need not crisscross the town after each visit. The list should be prepared considering both the location of the patient’s residence and the urgency of the visit. A copy of the list should be at the office so if the doctor needs to be contacted you will have an approximate idea where be will be at any time.

A record of out-of-office visits can be handled several ways. For example:

  1. When the doctor returns, the assistant can note on her copy of the routing list the services provided, the fee involved, whether the fee was paid or charged, and other points the doctor wishes recorded. These points are then transferred to the patient’s record in the office file.

  2. The doctor may carry a pad of printed housecall slips that he fills out at each residence visited. When he returns to the office, he gives these to the assistant for processing.

  3. The doctor may keep a small pocket notebook using two facing pages for each day’s entries. Patient names, addresses, and approximate appointment times are entered on the left-hand page. Notes about services provided, patient’s condition, charges made, and payments received are recorded on the right-hand page directly across from the patient’s name. Such a ledger is usually kept at the appointment desk so that the assistant can schedule the out-of-office visits efficiently. The doctor picks up the ledger as he leaves the office and returns it to the assistant when he completes the calls. Data from the ledger are transferred to permanent patient records in the office.


Appointment Planning Influence on Case Management

The efficiency of almost the entire office can be aided greatly through a well-planned appointment schedule. Good planning maintains an even patient flow through the office and avoids idle time. As time means money, planning affects practice economy. Orderly scheduling prevents overcrowding and allows patients to be cared for in an unhurried manner. Thus, good planning has a direct relationship to both the clinical and psychologic atmosphere of the practice.

Only in slipshod helter-skelter offices will appointments be considered just names in the appointment book. The assistant should never enter an appointment unless there is reasonable assurance that the appointment will be kept. Each patient must be educated to the importance and seriousness of the time reservation with the doctor. When the assistant recognizes the seriousness of efficient appointment planning and respects the authority and responsibility the doctor has given her, patients will reflect this attitude. On the other hand, if the assistant assumes a lackadaisical attitude in appointment planning and is unimpressed with the importance of efficient scheduling, patients will reflect this attitude. This would be detrimental to a good doctor-patient relationship.

Good planning means to live in reality—to face situations of the practice as they are and not as we wish them to be. Office policies are not laws; common sense and good judgment are needed to know when it is logical to bend the rules and when it is not. We must have administrative mechanics, but people are not machines that can be operated with simple push-button controls. Living in reality, the wise assistant anticipates some appointment changes, tardy patients, broken appointments, last minute cancellations, times when the doctor will be late, and sensitive, irritable, and demanding patients.

Besides the concerns described, patient relations can suffer if the following situations are not well planned in patient scheduling.

      PATIENTS WHO COMMUTE

A patient may live several months in Arizona during the winter, reside in Minnesota during the summer, and vacation on the coast. The doctor recommending a comprehensive health plan must adapt the ideal to anticipating many appointment irregularities in routine. Either the ideal must be amended or the doctor must restrict his care to prophylactic care until the patient can be convinced it will be necessary to reside in the doctor’s community for a longer period than originally planned. While several doctors in different areas who practice closely alike may cooperate on a case of a commuting patient, it is difficult. In any event, it is important that the assistant ask how long the patient expects to be in the area when planning appointments.

      SHIFT WORKERS

Employees working in factories requiring a rotating shift pose a problem in maintaining a regular appointment schedule. Entertainers presenting both matinee and evening performances also have difficulty. Before accepting a patient under these conditions, the doctor must educate the patient on the importance of following the case plan, and the doctor and patient must agree on ways to correct irregularities to the recommended schedule. It would be folly to embark on a comprehensive program for a serious condition if it is felt that adherence to a schedule could not be made. If ways to correct expected irregularities can be found and agreed to, this information should be passed on to the appointment assistant and recorded in the patient’s chart. If the doctor and patient cannot agree on a logical method to establish an effective appointment routine, it would be better to postpone the recommended service until a satisfactory schedule can be maintained. Policemen, firemen, nurses, and others on rotating shifts present similar problems.

      UNSTABLE PERSONALITIES

The more unstable the patient’s personality, the more important it is that the patient be educated and periodically reminded of appointment policy. Skeptical, high strung, overemotional, flighty, severely neurotic, or unstable patients need constant guidance and reinforcement. If such patients fail to profit by the advice, the doctor may be forced to postpone further service until full cooperation can be obtained. If the recommended case program cannot be followed, the patient is wasting money and the doctor is wasting time that could be better spent with more cooperative patients.

      ADVERSE TRAVELING CONDITIONS

Patients living many miles from the office may be subjected to bad driving conditions, inclement weather, undependable transportation systems, and other unpredictable problems that place a severe hardship in maintaining appointment regularity. Here too, attempts must be made to find a logical solution.

      SALES AND SERVICE PEOPLE

Some types of sales or service positions and truck drivers require extensive traveling to meet customer needs. This may involve a multicounty route or unpredictable service calls to remote areas from the home community of the doctor and patient. It is important that anticipated irregularities in the recommended appointment schedule be explained to the patient and means sought to protect regularity.

The doctor can examine a patient to determine the cause of a health disorder. He can recommend to the patient a plan felt to be the best method to correct the disorder in the shortest possible time, if it is possible. When the patient accepts the program, he can expect that the doctor will do everything possible to see that the plan is carried out. Likewise, the doctor must expect the patient to cooperate to the fullest in following recommendations. But the doctor cannot do it alone.

Returning a sick or disabled person to health is a difficult enough task without adding to it the negative influences of broken appointments, changed appointments, cancellations, and other irregularities to the recommended schedule. Barriers to offering the best professional service possible must be identified as early as possible, and attempts must be made to eliminate them. To do less would be an injustice to both the patient and the doctor.


Handling Broken, Changed, or Late Appointments

Patients who cancel or change appointments without due notice or justification must be tactfully reminded of office policy else the assistant contributes to the patient’s delinquency and helps to establish a negative habit pattern. The patient should be made to feel, in a polite way, that the doctor’s treatment plan has been greatly inconvenienced by the schedule being disrupted. The assistant might say, “Mr. Jones, you realize that a time reservation has been personally set aside for you. When so many people want time to see the doctor, it really isn’t fair to the doctor or your health. I know you will see that it won’t happen again.” When a patient did not have the courtesy to call to change or cancel an appointment, a letter can be sent to the patient who does not have a telephone.

      UNWORTHY PATIENTS

If the patient habitually misses, cancels, or changes appointments without justification, he must be considered an unworthy patient. If the case program is being affected, the doctor must have a heart-to-heart talk with the patient on the importance of regularity. If this fails, steps must be taken to postpone further service until cooperation can be given. This may not be possible in the newly established practice where every patient is important to the practice’s economic stability. Nevertheless, a practice cannot be controlled or a professional health service provided if it is based on uncooperative patients who are unworthy to both the practice and their health needs.

      “NO SHOWS”

Chronic “no shows” must be handled in the same manner as that for patients who habitually cancel appointments without due notice or justification. Such unworthiness suggests a profound lack of appreciation of the doctor and his services. This lack of respect may be the result of the patient’s personality, negative environmental factors, or negative conditioning.

The cause also may be within the doctor’s office. Was the first telephone contact handled effectively? Were first impressions of the office positive? Did the assistant who first greeted the patient present a warm and professional approach? Were the history taking, examination, and case presentation conducted professionally? Does the staff maintain the highest professional standards, and do their attitudes reflect sincere concern for the patient’s welfare? Was the patient adequately educated to office policies, and were appointment policies stressed? An objective analysis of the important phases of patient contact will often spotlight weaknesses in the office system.

      TIME RESERVATION CHARGES

If a patient cancels at the last moment or fails to notify the doctor that he’s not coming in, some doctors feel the time reserved should be charged. This, of course, is strictly up to the doctor. Doctors who charge a fee usually do not like to charge a patient for the first offense. For the patient who habitually cancels, the charge serves to motivate regularity. Some doctors post an announcement in the reception area that appointments not rescheduled within 24 hours of the time reserved will be charged a fee for the time reserved (eg, $15).

While a charge for a broken appointment is legal in most states, many doctors feel that the procedure is psychologically unsound except in special situations. The basic problem requiring correction is education of the patient to the need for regularity.

Several canceled appointments will severely affect office economics. Most doctors base their fees on anticipated patient volume and projected expenses. To the practice with a tight schedule, cancellations and “no shows” represent a drastic influence on practice stability. If the office is open 200 days a year and if the doctor charges $20 for a standard office visit, one broken appointment daily represents a $4,000 annual loss; three broken appointments a day, a $12,000 deficit.

      PROBLEM RESOLUTION TECHNIQUES

Several methods in handling canceled appointments are used. One common method applied when a patient calls to cancel an appointment is to suggest another time immediately. If time allows, the CA can then call a patient who desired an earlier appointment but was unable to obtain one.

With a “no show,” the assistant should initial the notation of the missed appointment. With the patient’s file folder on her desk for reference, the assistant can telephone the patient and say: “Hello, Mr. Smith, this is Dr. Godfrey’s office calling. Dr. Godfrey was sorry you missed your time reservation this morning and asked me to phone and arrange a visit this evening —or would tomorrow morning be better?” Calls to “no shows” should be made approximately a half hour after the patient was due. The goal is to arrange another appointment as soon as possible so the patient’s schedule will not be too upset.

There are three main reasons for a “no show”:

(1) the patient forgot the appointment;
(2) the patient feels so good that he feels future appointments are unnecessary, or
(3) the patient feels worse and is discouraged in continuing treatment. These reasons deserve further explanation:

  1. If the patient simply forgot the appointment, there usually is no difficulty in quickly arranging another.

  2. If the patient says he feels so good that he doesn’t feel an immediate appointment is necessary, the assistant should respond to the effect: “It’s wonderful you are feeling so much better, Mr. Smith. Dr. Burton will be glad to hear that because that is what he has been working toward. Let’s arrange an appointment for Thursday or Friday so that you can discuss this with Dr. Burton and avoid any recurrence of the problem. Which would be better, Thursday at 10 am or Friday at 3:15 pm.” If the patient still refuses your suggestion for an appointment, let him know that you will give the doctor his message and that the doctor may want to call him. Depending on the circumstances of the case and your report of the conversation, the doctor may wish to call the patient to explain the difference between the relief of outward symptoms and achieving as much of a permanent correction as possible.

  3. If the patient says he feels worse, is discouraged, and doesn’t wish to continue treatment now, the assistant can comment: “Mr. Smith, it’s only human to get discouraged when response isn’t as fast as desired. However, the fact that you haven’t responded suggests further treatment is necessary to get you well. Dr. Burton would not have asked me to call if he was not thoroughly convinced that further therapy is necessary. Let me arrange an appointment for you Thursday morning at 10:30 or Friday afternoon at 2:15. Which would be better for you?” If the patient still refuses an appointment, let him know that you will pass on his message to the doctor. Again, depending on the circumstances, the doctor may wish to call the patient to attempt to re-establish rapport.

In essence, the effectiveness of any appointment control system (or any office system for that matter) depends primarily on the doctor. If the practitioner is lackadaisical, deficient in professional deportment and authority, does not take time to adequately train his assistants or supervise their performance, he will find that patients reflect this attitude in their attitudes toward the recommended appointment schedule. If either the doctor or assistant hesitates to tactfully discuss appointment irregularities with lax or uncooperative patients, they cannot expect to maintain control of the appointment schedule. Poor consequences are inevitable.

      TARDY PATIENTS

Patients late for appointments cause another type of problem. Because people meet unsuspected problems, occasional tardiness must be accepted as part of life. On the first offense, the late patient only needs to be reminded that he is late and that the doctor will see him when possible. Whether the patient will receive the total service scheduled will depend on the type of service specified and how tight the appointment schedule is. The habitual late patient is a more serious problem. With tact and sympathy for the patient’s excuse for being late, the assistant should arrange a new appointment if the schedule would not easily allow him to be worked in. Patients with undependable appointment habits must be educated to the importance of their time reservations. This is only logical, however, if the doctor and the staff are punctual.

      DELAYED DOCTOR

Patient irregularities are not the only reason schedules get disrupted. The doctor may be late in arriving at the office. If patients are waiting, the assistant should inform the patients the reason for the delay. If the doctor is extremely delayed, new appointments should be made for those patients who do not wish to wait.

Sometimes situations arise when the doctor must cancel one or more appointments. Bad weather, emergency professional meetings, and other unforeseen situations may require several appointments or even the entire day’s appointments be changed. When this happens, patients should be notified immediately by telephone, telegram, or mail—whichever is the more appropriate. When the schedule is changed, another appointment should be offered at the same time. When changing a patient’s appointment, the assistant should tactfully offer a reasonable explanation why the appointment must be changed. Avoid such abruptness as: “Mr. Jones, this is Dr. Carey’s office. We must cancel your appointment for next Wednesday. Could you come in Friday?” Such a cold approach would be received by most patients as an indication of little concern for patients’ interests and personal problems. A better approach would be something like this: “Mr. Jones, this is Dr. Carey’s office. Dr. Carey must attend a special meeting in Capitol City at your appointment time. He asked me to call and extend his apologies and asks if we can arrange a convenient time for you—like next Monday or Tuesday? In this instance, you have used tact, appreciated the inconvenience to the patient, and offered the patient a choice in selecting the new appointment.


Handling Emergency Situations

While emergency situations are not everyday happenings, it is important that you know what to do. There are two basic types of emergencies: those that happen when the doctor is in the office and those that occur when he is not.

When the doctor is in the office, any emergency should be brought to his attention immediately. If he is out of the office such as at his residence, at a meeting, or out socially, you should know where to reach him. Your employer will have a personal calendar that lists his engagements. If the doctor is out of town or unavailable for emergency needs, he will have arranged with another doctor to cover patient needs. Be sure you know who this substitute is and where he can be located during your employer’s absence.

If a telephone call reports an emergency, keep calm and in control. Be careful to write clearly and accurately the necessary information of who, what, when, and where. Most emergency situations can be handled quickly and efficiently if you are calm, cool, and collected. After noting the important information, retrieve the patient’s file and bring both the file and your notes to the doctor. If you are communicating with a substitute doctor by telephone, relate from the patient’s file the patient’s history, working diagnosis, and other points questioned.

The following usually indicate emergency situations:

Severe pain
Unusual swelling, edema
Difficult breathing
Inability to move, paralysis
Dizziness, vertigo
High fever
Fainting, unconsciousness
Sudden visual disturbances
Anuresis (inability to urinate)
Bleeding of any type
Severe vomiting
Cyanosis, jaundice, pallor (turns blue, yellow or grey)
Convulsions, seizures, delusions.

Legitimate telephone requests for emergency attention of an established patient must be given priority appointment time even in a full schedule. Specific procedures for coping with these situations depend solely on the doctor’s practice philosophy and state legal requirements. Time must be borrowed from other patients—usually prophylactic or unworthy patients.

Experience shows that the emergency patient should only receive services solely of an emergency nature. If an emergency patient new to the practice is accepted and extensive examination and therapy are provided during a full schedule, a poor precedent is established with that patient. In addition, it is unfair to those patients scheduled who were inconvenienced by the emergency.


Maintaining Appointment Continuity and Control

      CONTINUITY

Log patients on regular appointment schedules at the same hour whenever possible. It helps to establish a habit pattern. Likewise, when the schedule is known for several weeks in advance, blanket these appointments in advance. On the other hand, if a patient is accustomed to a specific time and day for his appointment cannot be allotted that time, inform the patient immediately.

      CONTROL

Appointment schedules should be arranged as far ahead as possible to suit the patient’s convenience. However, the patient should not be allowed to determine the interval between appointments. This is a clinical judgment. When the patient makes such a decision, the doctor is no longer in authority of the case. If the doctor is to be responsible for case management, he must have the authority to direct the quantity and quality of service.

While the assistant should be specific in the patient’s appointment day and time, she should not mention the specific length of time reserved for the patient. Never say, “We’ve scheduled you for a 15-minute reservation next Friday, Mr. Johnson.” When the day of the appointment arrives, different patient conditions and situations may develop that require a shorter or longer visit than originally anticipated.

Some CAs handle this by scheduling three or four patients simultaneously followed by a break. This allows flexibility needed for patient care, makes fullest use of examining and treatment rooms, avoids delays for the doctor while patients are being prepared for examination or treatment, and helps handle the problem of the tardy patient.

The office appointment book must be considered restricted property and its schedule confidential information. Never allow a patient to view the appointment schedule. The volume of patients scheduled for any one day or the openings present are the business of the appointment assistant and the doctor; no one else.

Policy should be explained in detail at the dismissal desk following the first visit. A good explanation here will do much to minimize the possibility of future changed or canceled appointments. Also, the assistant is in a prime position to reinforce the doctor’s concern for “case control” and the value of regularly scheduled check-ups in preventing relapse. A doctor’s staff can do much to create an impression of punctuality, concern, efficiency, and cooperation in the minds of patients by rigidly setting a positive example.

      THE CONTROL SHEET

A practice in control operates efficiently without unnecessary open time in the appointment book, without rush periods, and without seasonal trends. This takes patient education to the value of health services, preventive measures, and the value of health maintenance. However, before anyone can be educated, there must be a desire to learn. Desire is based on need, admiration, and respect: human relations.

The efficient office has a minimum of unproductive time. This requires few broken appointments, changed appointments, and tardy patients else the practice is not in control. A control sheet is helpful in analyzing problem areas. It is a sheet on which each patient scheduled for the day is listed followed by several columns to indicate the patient’s next appointment, a broken appointment, a canceled appointment, a changed appointment, or if the patient was a new referral.

The exact scheduling of the patient’s next appointment is important to patient control. No practice can be considered under control when patients are allowed to arrange their next appointment on their volition. For all practical purposes, a patient without a scheduled appointment must be considered lost to the practice because it cannot be assumed that the patient will return.

From both a human relations and an economic viewpoint, it is important to record the number of cancellations and the reasons for the cancellation. From a clinical viewpoint, the doctor is interested in cancellations and appointments changed to a later date as such changes may affect his prognosis. It is also an indication that the patient is assuming responsibility of the case and is directing his appointment schedule. When a patient assumes such control, there is a breakdown in the doctor-patient relationship allowing the patient to question the doctor’s authority and sincerity.

A control sheet allows the doctor to analyze the quantity of these occurrences. When the number of new referrals does not exceed the number of patients lost to the practice, the practice is not growing; it is diminishing.

There is nothing unprofessional about an assistant calling a patient to determine the reason for not meeting a scheduled appointment. If the appointment was scheduled for the patient’s welfare, no inquiry suggests lack of the doctor’s interest. The reason may be a simple oversight, or it could mean a breakdown in communications. Obviously, if the practice does not show interest and concern for the patient’s welfare, the patient will lose interest and concern for the doctor’s services. If a patient becomes discouraged or has a complaint, the doctor must know this to analyze it and keep similar situations from recurring. For his sake and the patient’s, the doctor is obliged to determine the reason behind cancellations.

A cancellation may be the result of a death in the family. If so, the doctor will have an opportunity to forward an appropriate sympathy card. Whatever the reason, communications must be maintained so that positive action can take place. Professional conduct should never be less than good social conduct. Communication of sympathy, congratulations, and the like cannot be expressed if the facts are not known. This takes follow up. Intelligent patients appreciate this consideration.

Obviously, all legitimate reasons for cancellation are excusable. Yet even with justifiable excuses, the patient must be impressed with the necessity of maintaining the treatment schedule. If appointment changes are not justifiable, office policy must be reaffirmed to the patient through education and motivation. The results of these conversations should be noted in the patient’s record.

It cannot be overemphasized that the office’s concern with cancellations and changed appointments reaffirms in the patient’s mind the importance of office policy and the staff’s interest and concern in the welfare of the patient. When the patient is thoroughly impressed with the seriousness and importance of the appointment, there is greater desire by the patient to see that there are few appointment irregularities.


     APPOINTMENT SCHEDULING

The appointment book is the place of battle against time. The entry system must be unified and informative. Entries should be made in pencil so that changes, cross-outs, and erasures can be made neatly. During late afternoon or early evening before the day in question, many offices telephone to confirm appointments for the next day. This may be in addition to reminder cards that were given to the patient when he was last in the office or those mailed several days before for a time reservation made by telephone.

Patients sometimes make appointments for friends and family members—in person or by telephone. Determine if the appointment is for a patient new to the practice or an established patient. Record as many important data as possible such as the full name, complete address, telephone number at home and at work with extension, and family name when different from patient’s name (eg, married daughter).

Try to determine why the appointment is being made, and ask the age of the prospective patient. Is there an urgency to the appointment? Try to find the needs of the patient, how long the disorder has existed, or if the patient has been to another doctor for the condition or is under care of another doctor for another reason. Determine what specific instructions the person might need (eg, forms to be prepared prior to the visit).

You can measure your success at the art of scheduling two ways:

(1) when patients come to the office confident that they will see the doctor without unreasonable delay, and
(2) when the doctor and staff are productively occupied with neither too few or too many patients. If the doctor has recommended a future appointment but the patient fails to make arrangements, the reason should be noted in the patient’s record. A “Will Call” must be considered the same as a cancellation and treated with appropriate follow through.

As referrals are the life-blood of the practice, human relations factors must be considered. The foundation for most entering patients will be referral from current patients. Surveys conclude that most patients new to the practice will be referred by active patients. No practice can survive or grow if it depends on referral by location, the yellow pages, or other external influences. When one realizes that 94% of new patients are the result of direct patient referral, note the importance of recognizing and thanking each patient for each referral. Printed “fill-in” cards are not recommended as they lack the human, personal touch. Human relations cannot be mechanical.

Human relations and patient control are analyzed by noting factors such as patient load, the number of patients with a definite future appointment, why some patients do not have a future appointment, and the quantity of cancellations and the reasons offered. The number of changed appointments, the quantity of new patients admitted, the services rendered, collection difficulties, and other facts offer helpful “trouble shooter” information.

When the appointment book shows an insufficient number of patients scheduled to maintain full production capabilities, a system of recalls should be considered. In this procedure, the doctor reviews his files and selects several patients that do not have scheduled appointments, are considered worthy patients, and have not been to the office for several months. Such patients have not been educated by the doctor on the importance of preventive or maintenance care.

Studies show that for every eight patients telephoned, five will accept an appointment. Patients are contacted each day until the appointment schedule is filled to a desirable degree, allowing for new patients and emergencies. Never attempt to “pressure” a patient into a return visit.

      HANDLING THE “DEMAND” FOR AN IMMEDIATE APPOINTMENT

An assistant’s judgment must decide whether a patient’s urgent request for an appointment is a true emergency or not. If in doubt, ask the doctor. Frequently, however, answers to tactful questions provide the information necessary to arrive at a competent judgment whether the patient should be “squeezed” into a full schedule or put off until the next opening.

In asking questions about a patient’s symptoms, never “play down” the patient’s problem. His complaint is very real to him, while you are looking at the situation from an objective viewpoint. The patient should feel you are genuinely interested, as you are, and allow him an opportunity to air how he feels and what is happening. Most patients will be more receptive to suggestions after they have expressed themselves than when you first answer the phone.

If the patient persists that an immediate appointment is necessary, politely explain that the schedule is full and the doctor is running late. If he feels he cannot wait until tomorrow, say that you will be happy to work him in. Remind him that the doctor could only take a quick look at his condition today, and you would rather give him an appointment tomorrow when the doctor will have more time to thoroughly investigate the problem. As few patients want a hurried visit when not necessary or enjoy waiting a long period only to be rushed in and out, most patients, after discussing the problem with you, will ask what time the doctor can see them the next day. However, never refuse an established patient emergency care when requested—it could constitute malpractice.


      IT’S NOT ALWAYS WHAT YOU SAY, BUT HOW YOU SAY IT

A CA should never let a patient browbeat her (eg, for the sake of economy or expediency) to do anything that would not be ultimately in the patient’s best interests. Actions should be designed to enhance the doctor-patient relationship and support the doctor’s authority in case management.


Semantics and Case Management

During the course of treatment, never ask a patient, “How do you feel.” If the patient does feel better, fine; if he does not, you invite a complaint. It is better to greet returning patients with a positive question such as, “What improvement have you noticed so far?” This suggests to the patient that it takes time for the healing process but improvement is expected. However, if you can see obvious improvement, there is nothing wrong in mentioning it to the patient. In fact, it is positive reinforcement.

Patients rarely leave a practice because they have a complaint. They leave when people involved do not listen. Any patient complaint, no matter how seemingly casual or trivial, should be taken seriously. Evaluate every comment, and follow with appropriate comment or action. During acute illness, complaints may come from family members who are apprehensive about a loved one. Do your best to ease their fears or they may be passed on to the patient, but never infer a “promise” that could be mistaken as a guarantee.

You will occasionally be exposed to a sensitive human-relations situation in which a patient mentions that another doctor or a member of the immediate family disagrees with your doctor-employer’s opinion. When this happens, maintain professional poise, be courteous, and disagree friendly. Indicate that while you respect the other person’s opinion, your employer has a fine reputation for having excellent judgment in such matters. Build the doctor without tearing down another person.

Help the patient recognize that the doctor is not a magician. The patient must assume a share of responsibility in the healing process such as following the doctor’s advice and recommendations. The doctor’s role includes teaching the patient certain preventive practices, explaining methods to enhance the healing process, educating the patient in certain dietary habits and therapeutic exercises, or recommending acts such as more rest, staying home from work, and activity changes. A patient’s recovery depends a great deal on active participation in the health program. The chiropractic assistant serves the patient’s and the doctor’s best interests when she encourages the patient to become actively involved in the health plan.

Only a fraction of lost customers can be attributed to death, moving, unadjusted complaints, lower prices, or better services in the business world. The majority of customers lose interest because of personnel indifference or disinterest. A breakdown in human relations is the major cause of clientele loss. There is no reason to think this is not also true in health practice. Patients who are responding well and those who are not will remain in the practice if they feel the doctor and assistant are competent and interested in them as individuals. They leave the practice when interest is not continually reinforced. This interest is maintained by having single-minded focus on the patient, his condition, and his problem.

Both doctor and assistant should leave all thoughts of family problems, organizational interests, and other personal concerns aside during office hours. Energies must be concentrated on and directed to the most important aspect of the practice—the patient. Every thought or act that is not patient oriented distracts from the quality of the practice. If thoughts of the staff are filled with patient concern, the practice will maintain positive momentum.

Periodic tests and examinations, comparative studies, and progress reports indicate to the patient the doctor’s thoroughness and concern. The assistant must be aware of the purpose of these procedures so she can reinforce their need and benefit whenever the opportunity arises.


Semantics and Patient Relations

Many expressions mean different things to different people. The effects of semantics on good human relations are difficult to overemphasize. Technical words between doctor and assistant often become matter-of-fact among the staff, but we should remember that chiropractic terminology is often “over the head” of the average patient. When patients are exposed to confusing terms and do not understand them, they can feel “put down,” uneducated, and alienated. When you see that “gazed, confused” look, respond with, “In other words, ....” Look for signs of poor understanding or unfavorable connotation when explaining routine consultation, examination, evaluation, laboratory and therapeutic procedures, and fee arrangements.


     OFFICE RECORDS

The typical chiropractic office requires a variety of records. In this variety, there are two basic classifications: administrative records and clinical records.


Office Records and Functions

Administrative records aid scheduling, financial control, analyzing practice growth, and recording information for business and tax purposes. Examples include entering patient data forms, daily record sheets, permanent ledger, petty cash record, appointment book, and patient financial records. Examples of administrative support records are excuses, authorizations, form letters, collection systems, request forms, various types of memos, and other support records and forms. Clinical records concern the health-care aspects of the practice. Examples include patient history forms, examination and case history forms, case progress records, and laboratory and radiographic records. Entering patient data, patient history, and initial examination findings may be recorded on one comprehensive form. However, for ease in comprehension, we will describe them in this chapter as if they were separate records. Financial records will be explained in the Chapter 8. Any employee involved in the preparation, organization, or filing of records should fully understand how they are to be processed efficiently. Neatness, accuracy, and completeness are not only clinical and administrative requirements, they may also be legal necessities. When assistants are delegated the responsibility of gathering information from a patient to be entered in case records, accuracy and completeness must be above criticism.


Typical Office Records and Communications

Good records protect the interests of both the doctor and patient. Accurate information helps the doctor provide quality services, helps in the continuity of patient care, and serves as a clinical and legal history of the relationship between doctor and patient.

Printed forms save preparation time as well as indicate a well-organized office system. The type of records and reports necessary depends on the nature of the practice and is determined by need. Yet, this is often a problem. Some burden time and result in poor control. Too many increase “red tape” in patient handling and practice control. The ideal would be an inventory of records and forms offering the least number of items in stock that would allow the simplest and most efficient method of practice management. Necessary paper work in health care is large.


Common Record Flow

At this point, it is helpful to explain the flow of records within a typical office.

  1. Initial telephone Contact. An assistant puts basic information on a card at the time of appointment scheduling and held in a “Future Appointment” file. It will be reconfirmed by the assistant on the patient’s arrival, and additional information and case history will be added.

  2. Established and new records are made ready for the day’s patients. The doctor will likely want to quickly review each patient’s file before he sees the patient.

  3. During the visit, the doctor will enter notations concerning case actions and progress, and note on the visit slip the services rendered.

  4. When the doctor dismisses the patient, the patient presents the visit slip at the check-out desk. An assistant totals the slip, determines how fees will be paid, and enters the completed visit slip in the record. The patient’s next appointment is scheduled.

  5. Appropriate entries are made for recall, thank-you letters, etc, and entered either in the case record or another file. If laboratory work is necessary, an assistant makes necessary arrangements and offers the patient appropriate instructions. If vitamins or minerals are dispensed or if rehabilitative equipment is been loaned or rented, entries are made within the records. If the office has a lending library, books leaving the office should be noted.

  6. When it is known that the patient is scheduled for x-ray on the next visit, note this in the record so that an identification marker may be prepared before the appointment.

The flow of records within an office is determined by office policy. The above list offers a general system that must be amended to fulfill the needs of a particular practice.


Emergency Telephone Numbers

Although dire emergencies are rare in a chiropractic office, they do happen and the entire staff must be prepared to act calmly and decisively. People can have strokes, heart attacks, and seizures in a chiropractor’s office just as they can have them anywhere. This requires established policies, procedures, and training. A log of important telephone numbers will save time and eliminate confusion.


Closing the Communications Gap

Even in a small practice, a communications gap can exist between doctor and assistant. The best preventive is to remember, “If it’s worth remembering, it’s worth a written notation.” A written record eliminates guesswork and avoids the chance of forgetting instructions or patients’ comments. Even the best of memories may fail at the most inopportune moment. In times of personal sickness or vacation, written records will carry on in your absence.

When patients telephone progress reports, note their comments in their records and date of the call. When information is passed verbally to the doctor or another assistant, record a reminder for reinforcement. Be brief, but be sure to include the necessary facts of who, what, when, where, and why if known.

All correspondence should be copied. Memos given to patients are best made in duplicate so a copy can be placed in patient files.

In larger practices requiring several assistants and possibly more than one doctor, a clinical routing slip is helpful when several people are involved during a single patient visit. This routing slip enables each staff member to initial services as they are completed. This can avoid an oversight.

Purchase orders facilitate both record keeping and inventory control. The office copy of a purchase order will automatically file information about the name of the supplier, what was ordered, the quantity, the cost, and the order and expected delivery date. Standard forms can be obtained at an office supply store or from mail-order catalogs. The doctor’s name and address can be imprinted on the POs or rubber stamped at the office. They can be obtained prenumbered if desired.


Standard Operating Procedures

An office run in a business-like manner should contain a procedure notebook or file incorporating office policies, standard procedures, and doctor-assistant relationships. The assistant should know what the doctor expects of her, and the doctor should discuss what the assistant can expect from the doctor. A procedural reference, often called the “Office Bible,” should include statements regarding office regulations, employee duties and responsibilities, employee benefits, growth opportunities, and serve as a compilation of rules and systems that allow the practice to run smoothly. Whenever a policy is changed, a notation should be made within the notebook or file folder. This reference removes guesswork and helps in orienting new employees to office policies.


Entering Patient Data

When patients new to the practice enter the office, they are typically greeted, seated comfortably, handed a clip board to which a card, slip, or sheet has been attached, and requested document some basic information. Usually, the first entry is the patient’s name and address. Date of birth is a more courteous request than age, and it provides information that can be transferred to a birthday record book if the office sends cards. A space will be provided in which the patient is asked to briefly describe the chief complaint. For legal and insurance reasons, it is good policy to have this description in the patient’s handwriting. Marital status is commonly requested, as is the number and ages of children, if any. This offers the doctor an overview of the family environment. Date of marriage will be asked if the office sends out anniversary cards. Employer and occupation information is requested. This is necessary if the case is (or may be in the future) an industrial accident. Occupation data is necessary if the work activities of the patient must be controlled. If the patient has been referred by a patient or doctor, a space will be provided to enter this information. This is important so proper acknowledgment may be sent to the person referring the patient. Space also will be provided for the entering patient to list health and accident insurance data. The form usually concludes with a statement of office policy concerning payment for services rendered by the office such as “Payment is expected at the time of visit unless other arrangements have been made in advance.” Whatever office policy is, the patient should be informed as soon as possible. After the patient completes the form, the assistant should check it to be sure all appropriate blanks are filled and that the writing is legible.

Entering patient data are often called patients’ personal or statistical data. Besides the entries described above, this information should contain the parents’ or guardians’ names if the patient is a minor, the name of the person to be billed, the patient’s home and business telephone numbers if applicable, and mailing address if different from that of the residence.


Patient History Form

After this initial information is obtained, the next data-gathering step is to obtain a record of the patient’s health history. In many offices, either an administrative or technical assistant may be responsible for collecting some of this information. The history records why the patient is consulting the doctor, when present symptoms first appeared, how long the disorder has existed, what the patient has done about the condition, and other facts helpful to case evaluation by the doctor. The data gathered by an assistant are usually restricted to the patient’s chief and minor complaints, the patient’s medical, surgical, and obstetrical history; and family, social, and accident histories. This information serves the doctor as clues to a crime would serve a detective. Therefore, although an assistant may take some basic in formation, the doctor will review each point in greater detail with the patient.

Case history forms come in a variety of sizes, shapes, and styles. There are small cards, large cards, double cards, sheets and multiple sheet forms. The nature of some practices requires modest information while others need extensive information. Styles range anywhere from a 6 X 9-inch card to several 8-1/2 X 11-inch sheets. Although professional printing houses have a large selection of case history cards and sheets to choose from, many doctors wish to personally design them to meet particular needs.

To save patient and office time, some doctors use a form requiring only a simple “Yes” or “No” answer that can be checked or encircled by the patient. These forms are usually designed so that a group of questions relates to a specific system of the body.

      CHIEF COMPLAINT

The chief complaint data gathered here are an elaboration of those recorded on the entrance form. The chief complaint is the primary motive for the patient seeing the doctor—why the patient is seeking help. Although a patient may present several complaints, one will usually stand out as chief among the group. In cases of an acute and chronic complaint, the acute situation would usually be the chief complaint. If a patient complains of a chronic cough and of being overweight, the cough would be the chief complaint. The chief complaint will usually be the most painful, severe, potentially dangerous, or urgent complaint.

      PAST AND RELATED HISTORIES

The patient’s medical history records serious past illnesses, operations, miscarriages, births, drug or food sensitivities, congenital difficulties, and past medical and chiropractic care and the results obtained. Family history concerns the health status of siblings and parents, which may offer clues regarding possible hereditary influences. The patient’s social history relates to where the patient lives, marital status, number and ages of children, type of work, work environment, smoking and drinking habits, and similar activities. The history of accidents and their effects are also recorded. If present complaints appear to have resulted from an accident or work-related injury, details of how, when, where the accident occurred is important.

The patient’s history, the doctor’s diagnosis, the therapy recommended, and the patient’s progress record form the patient’s case record (chart). Without this record, few doctors could remember from one visit to another what was previously learned. Such records must be referred to (often for many years) whenever the patient visits the office.

If an assistant is responsible for recording some of the patient’s history, absolute privacy must be granted the patient. Such confidential information is not for the ears of strangers, friends, or even relatives except for a minor patient in the presence of a parent. If a patient appears to feel embarrassed to tell an assistant necessary information, the assistant should be tactful and memo this to the doctor. The matter should not be pressed.


Examination and Case History Form

The doctor’s examination begins with the patient’s history. During consultation, he will probe the information acquired and arrive at a judgment of what type examination procedures would be best suited for the particular complaints involved. Where the assistant has left off, the doctor will explore deeper and conduct more intimate questioning if necessary. A comprehensive patient history can offer most information necessary to arrive at an accurate diagnosis.

At the completion of the consultation, the doctor proposes the type and scope of the examinations necessary. With patient agreement, the examination proceeds or another appointment will be scheduled for the necessary tests. After examination, the doctor records or dictates the results of his physical examination, orthopedic and neurologic tests, spinal analysis, x-ray findings, laboratory findings, and other data necessary to profile the patient’s condition.

In a simple acute case, this whole procedure may be completed in a matter of minutes. In a severe chronic condition of an obscure nature, the process may take from several days to several weeks before a diagnosis and prognosis are determined. Regardless, after the examination and evaluation of the patient’s history and examination findings, the doctor will meet with the patient to discuss the recommendations for treatment, risks involved, and options, or referral to another practitioner.

Some doctors do not like the restriction of a standardized format. They prefer to develop case histories in their own way for each case. Some doctors prefer to dictate case histories and have them later typed on plain white bond. Such typing should use headings so that review can be made easily. X-ray findings and laboratory reports also should be included in the case history along with the physical examination findings, results of the spinal analysis, and other test results.


Case Progress Records

Once a patient enters therapy at the office, each time the patient returns on subsequent visits or the doctor visits him at the patient’s residence, the patient’s condition is recorded, together with changes in treatment or changes to previously given instructions. Progress notations are a permanent record of what was done and offer a chronological patient status. While the patient’s history shows the patient’s status at the time of the initial visit, progress records show the patient’s state of health at subsequent points in time.

Once a therapeutic program is established for a patient, subsequent care should be handled smoothly in a well-organized manner. Only minimal verbal instruction among staff members is necessary if procedures are firmly established. Patient progress records should indicate the date of each visit, therapies offered (type, strength, distance, pressure, duration, special instructions, etc), type of service the patient is to receive on the next visit, necessary diet menus, supplements, exercises, supports or braces, home therapies, and new instructions and changes to previous instructions.

The doctor should initial all entries made by himself. The assistant should initial all entries made by herself. If the doctor dictates notations, the assistant’s initials should precede the doctor’s initials (entered after review and approval). This review guards against an inaccurate entry. It is especially important in offices where several staff members make entries on a patient’s record. If the assistant is new to the office, it also differentiates her entries from those of her predecessor.

Brief, accurate, and neatly prepared case histories and progress reports help the doctor to help the patient. Such records can supply data for chiropractic clinical research, and they can be used as evidence in lawsuits. If the patient moves or changes doctors, copies will likely be forwarded to the next attending physician. Thus, the need for accuracy and detail should be obvious.


Legal Considerations

Medicolegal considerations are subjects explained in Chapter 12. However, a few points will be summarized here as they pertain to the need for accurate comprehensive clinical records.

Medical histories, progress reports, and other patient records are “privileged communications” that always must be treated as highly confidential records. They are protected by law as such. Office records belong to the doctor and must never be copied or information from them disclosed without express authorization from the doctor and the patient. If these records are needed by others and authorization is not given, they must be subpoenaed. The doctor and chiropractic assistant are equally bound by this principle of secrecy.

Case histories and reports are legal documents that may have to be produced in court as evidence. This is especially true in accident cases involving suits for damages where the doctor’s testimony would be required. This again underscores the necessity for accuracy, neatness, legibility of handwriting (if not typed), completeness, and dating and initialing of all entries. The quality of patient records may mean the difference of winning or losing a legal case.

      ADVICE RESTRICTIONS

There are times when an assistant must discuss certain confidential information with a patient. At these times, the assistant must be alert that she does not transgress the Chiropractic Practice Act by directly or indirectly offering information that might be construed as recommending a type of treatment or making a diagnosis. These are the sole prerogatives of a licensed practitioner. For instance, if a patient asks whether to continue a certain type of home therapy recommended by the doctor although the treatment is increasing the patient’s discomfort and the assistant is aware that such side effects are quite common, she would be in error to tell the patient either to stop or continue the procedure. To say, “It’s okay, many people have such symptoms at the beginning of treatment” would be a serious medicolegal error. If the patient’s condition becomes worse, the doctor might be liable and the assistant charged with practicing chiropractic without a license. Also, if a patient asks the assistant, “I have a ‘slipped disc,’ don’t I?” and the assistant responds with a casual remark, “Well, it seems like it,” she would be in an embarrassing position if the doctor arrives at a different diagnosis. The assistant also should be aware that a doctor’s “working (tentative) diagnosis” may be different from his final diagnosis.

      REQUIRED REPORTS

There are various instances, especially in communicable diseases, where the doctor is legally obligated to report to certain authorities. Usually, it is the local or state Department of Health. It’s often the assistant’s responsibility to complete forms from information given by the doctor and see that the doctor signs the report before it is mailed. Births and deaths are probably the two most important events that must be registered in every state. Only in a few states do doctors of chiropractic practice obstetrics. However, in a growing number of states, chiropractic physicians are authorized to sign death certificates.

Other situations that may require reports to authorities are cases of criminal assault, venereal disease, drug addiction, child beating, abuse of the elderly, and blindness. In these instances, state laws vary considerably and the assistant must be alerted to legal requirements and informed of changes in requirements. According to local needs, the assistant should see that a proper amount of necessary forms is on hand in the office at all times and that such reports are processed promptly.

      CONSENT AND RELEASE FORMS

As the number of lawsuits for damages against doctors has increased in recent years, the use of consent and release forms has increased to protect the doctor from an unjustified malpractice claim. Pertinent forms are commercially available, or the doctor or doctor’s attorney may design a form and have it printed locally. When a rarely used form is needed, the assistant may type it as needed or keep a few on file. A carbon copy should never be used as an original, however.


Referral List

Each doctor develops a list of particular specialists to whom he or she refers patients for specialized attention. This should be kept handy for immediate reference.


Other Records and Forms

A variety of office forms and records were described in previous chapters, and several are explained in this chapter. In Chapter 8, regarding office economics, the functions of patient receipts, charge slips, daily work sheets, petty cash slips, financial arrangement forms, expense records, patient statements, collection systems, financial account records, permanent ledger sheets, financial authorization forms, daily control sheets, payroll records and time cards, and other subjects of this nature will be explained. In Chapter 14, concerned with the duties of a technical assistant, laboratory request slips, radiology record forms, x-ray ID cards, dietary instructions, corrective exercise forms, and patient instruction sheets will be described. Chapter 11, which concerns insurance and other third-party relationships, offers descriptions of health insurance claim forms and worker’s compensation forms.


     OFFICE FILING SYSTEMS

An efficient filing system should provide for at least three basic types of records:

(1) patients’ case histories and financial account records,
(2) correspondence, reports, reprints, documents, etc, and
(3) record books, inventory sheets, personal notes, etc. Some records are designed to hold more than one set of information and others require new folders for the data. That is, some records are designed to incorporate history, examination findings, progress reports, laboratory reports, and similar data, while others require a separate document.

An office may use different filing systems for different categories of patients. Some offices use the same file, but folders are color coded to show the appropriate category. An increasing number of offices use color coding to provide subdivisions within a particular major category to differentiate cases; eg, Medicare, Medicaid, Worker’s Compensation, Health Insurance, Accident Insurance, and other types.


Basic Filing Requirements

Most offices file strictly alphabetically by the patient’s last name in clinical files or subject of the topic to be filed in nonclinical files. In large volume practices where several patients may have the same name, patients’ records are filed by case number and each patient’s number is cross-indexed to an alphabetical list incorporating the patient’s addresses. It is not unusual in large practices to have several patients with the name Mary E. Smith or John J. Jones. Despite the system used, guides should be used to divide the file drawers into appropriate sections, and patient folders or pockets should be used to hold all records of a patient or topic.

It is necessary to refer to a patient’s records on return visits, to complete insurance forms, to review case progress, and to supply a variety of information needed from time to time. Thus, prompt accurate filing is important. Besides patient record files, card files that can remind the assistant of important dates and matters to be taken up in the future reduce burdening memory with sundry details.


Pulling Files

The custom in organizing patients’ files is to place the newest material (that with the latest date) at the front of the folder with records running in chronologically. When records are pulled for patients with appointments, they should be placed on the doctor’s desk in the sequence that the patients are to be seen. The best time for initial organization is usually at the end of the previous day or in the morning before the first patient arrives.

For follow-up visits where a new record is not necessary and the appointment has been made for several weeks, records can be pulled once each week when reminder notices are sent. For patients new to the practice, however, entering patient data and history data must be obtained after the patient arrives, thus the file cannot be given to the doctor until just before the patient is introduced.


Safety and Security Considerations

If a patient’s record cannot be found, first look through the entire letter of the alphabet to see if it has been previously misfiled. Next, check the desks of other staff members where files are commonly placed when in transit.

Whenever any document is removed from a patient’s file, an “Out Card” should be inserted that notes what was removed, who removed it, and the date it was removed. This card should be placed in the position of the document removed. Such a record will save much frustration in locating missing documents.

Be cautious in keeping records out of sight of patients. Never leave them lying around or open on a desk. People are curious and can easily be frightened by what they read and misunderstand. All records developed at the office are records that belong to the doctor. You may have to tactfully explain this to patients. Use a release form, under the doctor’s and patient’s specific authorization, when there is need to send information to an insurance company, attorney, another doctor, or another third party.


Avoiding Space Waste

Several methods can be used in saving file space:

(1) Loose papers take less space than those having bulky fasteners, clips, or staples. Of the three, staples are the best unless papers must be separated.
(2) Transfer papers and records that cannot be destroyed, yet are rarely referred to, to other storage facilities. If the material is stored in boxes, label the contents of each box on the outside.

Federal and state statutes of limitations and the doctor’s desires determine what should be destroyed and what should be stored in active or inactive files. The doctor will usually wish to keep all case, legal, and financial records despite the statutes of limitations involved. However, with the doctor’s approval, grossly outdated correspondence, literature, and records no longer useful or pertinent can be destroyed periodically to save filing and storage space.


Filing Systems

Both efficiency and accuracy are the key words to remember in good filing.

Avoid accumulating charts to be filed by setting a certain time each day for filing. Take care to file charts in their proper order, and be alert to any name or address changes to maintain accuracy. Although a patient has been in the office before, verify the address, phone number, occupation, and other basic data periodically.

There are two general filing systems popular in chiropractic offices: alphabetical indexing and numerical indexing. Numerical indexing became popular shortly after World War II. In recent years, however, this system has been replaced by the simpler alphabetical indexing method.

      ALPHABETICAL INDEXING

The most simple alphabetical indexing method uses three units. Unit 1 is the last name, Unit 2 is the first name, and Unit 3 is the middle name or middle initial. There is little difficulty in assigning the correct alphabetical position in the file to each patient’s record when indexing is done in the unit method.


    Unit 1     Unit 2     Unit 3
    Jones      John         J.
    Jones      John         L.
    Jones      Mary         P.
    Jones      Mary         W.

A more detailed type of alphabetical indexing uses five units. Unit 1 is the last name in capitals, Unit 2 is the patient’s title, Unit 3 is the first name, Unit 4 is the middle name or middle initial, and Unit 5 is the nickname or name by which the patient prefers to be called.


    Unit1     Unit 2     Unit 3     Unit4     Unit5 
    JONES      Mr.        John        J.      Johnny
    JONES      Dr.        John        L.      Jack
    JONES      Mrs.       Mary        P.      Mary
    JONES      Miss       Mary        W.      Mary

Two difficulties sometimes arise within the three unit system. First, family chart errors are difficult to avoid; and second, confusion results when patients have the same last, first, and middle initials. The five unit system allows a married woman to use her formal name (eg, Mrs. John J. Jones), which would distinguish her from another Mary J. Jones. It also allows patient differentiation by title (Mr., Dr., Mrs., Miss), and shows the name by which the patient prefers to be called. This system greatly reduces the risk of having two files labeled identically.

It is often best to presort all charts to be filed before they are actually inserted into the filing cabinet. This organization saves time and effort by proper sequencing at your desk. Filing can be completed without going back and forth from drawer to drawer.

In alphabetical indexing, it is helpful to make a miscellaneous folder for each letter of the alphabet and place it behind the last name folder under the particular letter of the alphabet. File any material for which there is no separate name folder in this “Miscellaneous” folder. Filing should be done within this folder alphabetically rather than by date. Papers relating to a particular name or topic can be clipped together, and when they reach a logical number, a separate folder may be made.

      NUMERICAL INDEXING

In this system, numbers are used on file folders that are arranged numerically. The advantages of the system are those of fast and accurate refiling, the opportunity for indefinite expansion, and confidentiality.

Numerical indexing often is used in large practices conducted by several doctors and assistants. While numbers lead an illusion of being modern and concise, the system has several drawbacks. In the numerical indexing system, each patient is assigned a case number. The patient’s folder is labeled first by case number, and this is followed by the three-unit alphabetical system (eg, 1423 Jones, John L). A small cross-index card is also prepared that contains the same information in reverse (eg, Jones, John L 1423). This card is filed alphabetically in a separate file, and the patient’s case records are filed by number in the master file. Numerical indexing also requires a log book to be maintained that lists each number assigned so the same number will not be used twice. The extra steps involved in the cross-index card and the case-number log offer few advantages over the simpler alphabetical system.

      STANDARDS

Generally accepted rules of filing come from The Association of Records Managers and Administrators (ARMA), a recognized authority in the field of records management. ARMA guidelines have been developed over a 30-year period by committees of veteran records managers and file management professionals.


Types of Files

It should be recognized at this point that several different types of files are used in chiropractic offices depending on the nature of the practice, its size, and the personal inclinations of the doctor(s) involved. Current case records, inactive case records, a subject file, a correspondence file, tickler files, a public relations file, financial record files, and x-ray and microfilm files may be separate or filed within the same cabinet.

      CURRENT, ACTIVE, AND INACTIVE CASE RECORD FILES

Patients’ records should be separated into at least active and inactive files. Every office should have some cut-off point (eg, 3 or 5 years). Thus, if a patient has not visited the office in at least 3 years, his or her records can be changed from the active to the inactive file. The cut-off point is a matter of the doctor’s preference.

Many offices divide patients’ records into three distinct categories:

(1) active patients who are currently under care and patients who owe the office money whether they are under care or not,
(2) inactive patients who are not currently under care and do not owe the office money but are likely to return, and
(3) former patients who are not under care and do not owe the office money but are unlikely to return. The latter category is commonly used for patients who have not been heard from in 3 or more years, have moved from the community, or are deceased.

Active, inactive, and former patient files are usually placed in an alphabetic file where the folders are inserted behind alphabetic guides. When the files become crowded, they may be subdivided according to second letters (eg, Aa Al, Am Az). Subdividing enhances organization and rapid retrieval.

As the active patient file is under the greatest use, it should be placed in a convenient location as near to the pertinent CA’s desk as possible. The file is first divided by month. Next, the current month is set according to the days of the week beginning with the present date and following through to the same day 4 weeks from the present. When a current patient is dismissed and receives the next scheduled appointment, the assistant files the patient’s record in the appropriate divider for easy access.

Patients scheduled ahead for a longer interval have their folders placed in the monthly division They will remain there until their specific date becomes current. For instance, if today is January 9, and the patient is scheduled for her next visit in 2 weeks, the file will be posted in the January 23 location. However, if the patient is scheduled to return in 2 months for a periodic examination, the file will be posted behind the March tab. About 4 weeks before the March appointment, the folder will be placed under the appropriate day tab. This system is essentially a tickler file. When the assistant is ready to arrange the next day’s case records, they are already gathered and only need sequencing according to time of appointment.

Despite the system used, case records should be filed separately from other materials, preferably in a separate cabinet if not a separate drawer. If the patient’s chart is not a self-contained folder, a manila folder should be labeled for each patient according to either an alphabetical or numerical color-coded system. This case record folder should contain all pertinent history, examination reports, laboratory reports, progress records, and correspondence about the patient. Financial information may be included here or in a separate file.

When active patients can be designated as inactive or former, their records should be moved. Sometimes deceased patients or patients who have moved from the neighborhood are placed in a “closed” file. For storage economy, inactive and closed files can be placed in a distant storage room so valuable office space is not burdened.

The 15–28-inch four-drawer letter-size filing cabinet is the conventional style. This type cabinet also comes in two-drawer and three-drawer models. They occupy considerable room depth but not too much width. Another design has long shelves on which the folders are placed on end, tabs are easily read, and processing is rapid.

Few doctors destroy records—and for good reason. Regardless of statutes of limitation, a patient may return after many years or a patient’s children may be benefited from knowledge within a parent’s record. It is not unusual for a patient who has moved from the area to return many years later. When storage of inactive, former, and closed files become a problem, microfilming is one solution. Microfilm is being replaced with the increased use of office computers where data are stored on disks.

      SUBJECT FILE

When the subject is more important than the writer, the information is filed by subject in an alphabetical file. For instance if the doctor wishes to keep a technical paper on diathermy, it could be placed in a subject file rather than under the name of the author. Office nonpatient correspondence, however, should be filed alphabetically by author.

In a file arranged alphabetically by subject title, the basic file is arranged as follows:

(1) a durable separator with the letter of the alphabet in the left position,
(2) main subject guides with center tabs that can be labeled, and
(3) subheading folders with tabs in the right position. Papers within a subject folder should be arranged by date, with the most current date in front.

In typing labels for subhead folders, it helps in filing if you type the label with the main heading in capitals and the subhead in initial capitals. The subhead is usually typed on the first line, and the main heading is typed on the second line. A sampling of subject titles is listed below:

ASSOCIATIONS
BILLS PAYABLE
CONTRACTS
EQUIPMENT
EXPRESS MAIL ACCOUNT
FORM LETTERS
INSURANCE
POSTGRADUATE EDUCATION
SUPPLIES
TAXES

Invoices for office expenses can be filed under “Bills Payable” and then transferred to the “Taxes” file after they are paid. Before transfer, the date and number of the check issued in payment should be noted on the invoice. “Equipment” subjects would include purchase orders, related correspondence, descriptive brochures, and price lists. These files can be divided into “Office Equipment,” “Diagnostic Equipment,” and “Therapeutic Equipment” when desired. Similar information may be filed under a “Supplies” tab that may be subdivided into “Office Supplies” and “Clinical Supplies” sections. A file also can be made for each professional association of which the doctor belongs. And, if he is a member of certain committees or commissions, this file may be subdivided accordingly to accommodate this type information. Under the “Taxes” file, receipts for deductible expenses can be stored. An “Insurance” file can be subdivided to differentiate between “Office Insurance Policies” and the doctor’s personal and family insurance policies. The “Postgraduate Education” file should hold records of the doctor’s attendance.

It is advisable to maintain either an alphabetical list or a card index in subject filing to prevent filing material under a new heading when one already exists for the general subject. An alphabetical list is made by typing main headings in full capitals and the subheading in initial capitals. After each subheading, type in parentheses the main heading under which the subheading is classified. Sufficient space should be left between each item to allow for adding new subjects and to keep the list current. For example:

INSURANCE
INVESTMENTS
Itineraries (Travel)
Leases (Contracts)
MEETINGS
Minutes (Meetings)
PERSONNEL

In a card index, a card is prepared for each subject heading and subheading. In subhead cards, the main heading is typed somewhere on the card for reference. A card index is usually preferred in extensive filing systems because it is easier to keep current. It also allows for cards that cross-reference subject headings, subheadings, and synonymous titles.

      CORRESPONDENCE FILE

As most correspondence within an office concerns patients, copies of letters and reports about cases can be placed within patient’s case record folders. The general correspondence file refers to correspondence that does not specifically relate to a specific patient. This type of correspondence is filed alphabetically by the writer’s name or the name of the company, institution, organization, or agency from which the letter was issued.

Some offices divide the correspondence file into two sections: (1) incoming correspondence and (2) outgoing correspondence. Most doctors, however, prefer to staple the incoming letter and its answer together and file it under the name of the incoming letter’s author or company name. Generally, the assistant removes all letters at the end of the year that are over 3 years old. According to office policy, these are either destroyed or placed in storage.

      CROSS-REFERENCE SHEETS

Besides the cross-reference files needed for a numerical indexing system, other cross-reference files contribute to an efficient filing system. For instance, a letter received concerning several patients can be handled two ways. Either the letter can be copied and a copy placed in each pertinent file, or the letter can be filed in the records of the first patient named in the letter and a cross-reference sheet placed in the records of other patients with a note explaining where the original letter is and what it is about.

Whenever a document, letter, report, or form can be found under two or more names or subject titles, a cross-reference sheet or one or more copies should be made. Printed cross-reference sheets are available at most office supply stores. When they are printed on brightly colored paper, they are quickly noticed.

Cross-reference sheets are also valuable within clinical subject files. For instance, a report on “The Use of Diathermy in Osteoarthritis of the Shoulder” may be filed under “Diathermy” and cross-referenced under “Osteoarthritis” and “Shoulder Disorders.”

If you have only one main file that is set up by name and occasionally have material that should be filed by subject, or have only a subject file and have material that should be filed by name, you can combine such occasional folders in the main file. This is done by either (1) putting a cross-reference sheet under the name in the miscellaneous folder behind the alphabet letter that begins the name or (2) including a folder labeled with the person’s name (last name first), which would be a subject in a subject file.

      PATIENT RELATIONS FILE

Some offices wish to keep close account on patient relations. In this type of file, canceled appointments, broken appointments, and other data relative to poor cooperation can be filed. On the positive side, the names of patients who have referred others to the practice can be recorded so that appropriate thanks can be forwarded systematically.

      FINANCIAL RECORD FILES

An alphabetically arranged credit file contains cards for patients who have been extended credit. When a charge is made or a payment is received, the transaction is recorded first on the daily control sheet and then on the patient’s account card whose information is used in preparing statements. Colored tabs or small removable label signals are often used to distinguish delinquent account cards, with different colors identifying the stage of delinquency. Efficient financial record systems will be described in the next chapter.

      X-RAY FILM FILES

X-ray films are probably the only patient clinical records that are not filed with the patient’s case records. Because their size can be large (eg, 14 5 36 inches), films are filed in specially designed cabinets. The envelopes are usually filed alphabetically by patient name and sometimes cross-referenced by a x-ray film number.

      MICROFILM FILES

Microfilm was once the popular answer when storage became a problem. Local companies as well as Remington Rand and Xerox outlets performed this service. Sources were listed in the yellow pages of the telephone directory. Besides clinical records, microfilm was helpful in storing books and clinical papers. For instance, an 869-page reference book could be reduced to ten 4 5 6-inch cards occupying only 1/8-inch file space. Many outdated technical papers are only available on microfilm.

However, with the increasing popularity of office computers, microfilming is being replaced by storing data on computer disks (or DVDs today). Sheets are “scanned” by an instrument that sends a copy of the information to the computer. Some computer “hard disks” can store information in a quantity equivalent to over 100 books. See Chapter 10.

      TICKLER FILES

The need for an orderly reminder system is necessary as every assistant has the responsibility of seeing that certain things are done at some time in the future.

A well-organized tickler file is helpful in keeping special notations and memoranda in order. This system is usually a small file containing a card for each day of the year. Each morning, the card for that particular day is removed and reviewed. The information listed usually has approaching due dates for insurance policy premiums, taxes, withholding reports; subscription expirations; and other reminders of what should be done that day. Some doctors like to be reminded of personal anniversaries, approaching birthdays of family members, pledged charitable contributions, and other dates of approaching events. Patients’ birthdays and anniversaries may also be noted in a tickler file.

A small tickler file is helpful in preparing the doctor’s calendar. In this file is a tab for each month and 31 subtabs for each day of the current month. Notations are made on file cards, and the cards are filed according to the date the matter requires attention. If an item is recurring (eg, board meetings), the card is moved from week to week, month to month, or as necessary. It is obvious, however, that a tickler file cannot replace an appointment calendar, but it can serve as a reminder for many events.

      REMINDER CALENDARS

Reminder calendars serve a similar function as a tickler file. These calendars come in various sizes. Two common designs are the desk calendar and the portable type having a box by each date for recording events. The desk calendar and box calendar, however, limit the number of possible entries compared to a tickler file.

It is ideal when every member of the staff has a calendar of some type or a yearbook in which entries are made for important appointments, conferences, special dates, things to remember personally, and things to remind others about. Besides his regular calendar or yearbook, a doctor may carry a pocket memo book outside the office to jot down important items to be remembered and transferred to his calendar.

      FOLLOW-UP FILES

A follow-up file is a large type of tickler holding folders. It offers an excellent method to follow-up requests waiting an answer, matters that have been referred to others for action, orders for future delivery to receive or to place, items requiring periodic consideration, and promises made for future action. The follow-up system can be handled in one of two ways: Either the material itself is placed in the follow-up tickler file or a cross-reference sheet is placed in the tickler and the material is left in its normal file.

      FILING PHILOSOPHY

No practice or business can be operated successfully unless its key people can retrieve information quickly. Good practice management and control mandate more records and efficient filing of subjects than described so far. The number of new patients in a given period, the number of broken appointments in a given period, the number of x-ray and laboratory examinations in a given time, and other accounting are ways doctors have of objectively analyzing and controlling their practice. This is impossible without good assistance and adequate records.

Unfortunately, the average doctor is a poor businessman. He usually considers records and their maintenance a laborious chore and procrastinates and rationalizes at every opportunity in this area. Therefore, the importance of an assistant who is accurate, conscientious, and efficient in record and filing responsibilities cannot be overestimated. Studies show time and again that the doctor who has accurate and detailed records of important phases of the practice, and analyzes them carefully, is bound to be more successful than one who does not.

Accurate case records are as important to the patient as they are to the practice. Our legal system recognizes this. Judges may not accept verbal testimony if unsupported by documentation. On the human side, rare is the doctor who is thorough in record keeping who does not maintain strong doctor-patient relationships: a basic key of practice development.

The prime requisite of any good record system is accuracy, completeness, and immediate accessibility. No system is any better than the manner in which it is used. All systems require alert attention: no system will run itself. The major purpose of many records is to provide comparative information that is complete, accurate, and simple to file, pull, and analyze.


     TYPICAL OFFICE EQUIPMENT

Many offices will have the following business equipment:

Binding machine
Calculator
Desk organizer
Desk trays
Desktop computer
Dictation equipment
Duplicating machine
Electric letter opener
Electric stapler
Electric typewriter
Embossed label maker
FAX machine
Filing cabinets
Modem (computer)
Music system
Office inter-com
Paper punch
Paper shredder
Peg-board system
Pencil sharpener
Postage meter
Postage scale
Printer (computer)
Scanner
Tape dispensers
Telephones

The office will periodically receive mailed announcements of new equipment available. Although the office may not have need for such equipment at the time, it is often helpful to file these brochures for future reference when needs change. Whenever a new piece of equipment is considered, investigate different brands and types, and compare features, benefits, and costs. Maintenance and service considerations are just as important as initial purchase price. This research will help the doctor to arrive at a purchase decision.


Dictation Equipment

Some management consultants feel that, in the ideal situation, the office should have a central dictating machine with a microphone in each consultation, examination, and therapy room where the doctor might be. The person assigned typing duties should have a transcribing unit. Dictation immediately after consultation, examination, or therapy when recall is greatest is faster and more accurate for the doctor than writing reports long hand. Dictation equipment eases the chore of developing a referral letter, preparing a case report, creating general correspondence, entering reminders, making special notations within a patient’s file, and storing other information that should be recorded or processed.


Duplication Equipment

It is a benefit to most offices to have some form of copy machine so that duplicates of records can be sent to the doctor’s colleagues or a patient’s attorney or insurance company when authorized. Copying capabilities also allow patient’s financial records to be copied and used as an account statement at the end of the month.


      PURCHASING AND INVENTORY MANAGEMENT

Typical Business Office Supplies

In any professional practice, ordering of supplies must consider both quality and economy. Poor economic procedures in purchasing can place a hardship on the practice that hinders financial growth. If an assistant is given the responsibility of selecting and ordering office supplies, she should shop as she would for a personal purchase, keeping both professional quality and economy in mind.

An office will require an inventory of basic supplies necessary to carry out functions.


Ordering Supplies

Quantity purchasing and comparative shopping offer distinct savings to the office. When buying supplies that are used frequently in the office, check for quantity discounts. If three or four units are used each month, determine the price break on a dozen units. A rule is to order a 6-month supply. Less than that is usually poor economy. If you buy too far ahead, you burden office capital. You also may find that an item needed today will not be in the future because of changing policies, procedures, or systems. The doctor would not want a large quantity of something in stock when a new and better product is introduced to the market.

Many doctors will set up a system in which a specified assistant may order common supplies without his continued authorization up to a certain dollar amount of purchase (eg, reorders totaling under $100).


Checking Deliveries

Check ordered items on delivery. If something is delivered in an unsatisfactory condition or a mistake has been made, do not accept delivery. If damaged goods are not discovered until after delivery, call the supplier immediately and ask him to pick up the damaged goods when he makes delivery according to your specifications. Careful surveillance of ordering and receiving procedures will save the office time, money, and frustration.

The professional office is always quality conscious. Most doctors prefer quality bond letterheads, second sheets, envelopes, and statements that are coordinated. Cheap carbon paper will not give the clean copies desired or will it last as long as the higher quality grades. Because file folders are handled so frequently in the office, folders with reinforced tabs enhance durability. The better grades are of heavy material that adds greater life to the folder subjected to frequent use. Cheap typewriter ribbons, as carbon paper, are apt to be heavy and smudgy at the beginning of use but quickly result in faded copy. Silk or nylon ribbons are more expensive than cotton, but they give much longer wear. Carbon ribbons are the most expensive, have the shortest life, yet present the finest appearance.


Clinical Supplies

Unlike a commercial business office, the chiropractic office requires supplies over that necessary for the business side of the practice. Examination, therapy, laboratory, and x-ray facilities require basic supplies.

Representatives from vitamin/mineral companies and office supply houses may call on the doctor to keep him abreast of developments, leave pertinent literature, and take orders. Be courteous to these salesmen, check with the doctor to see if he would desire to meet with them for a few minutes, and advise them of the best time to see the doctor.


Inventory and Storage Considerations

A running inventory of supplies is the best procedure to assure enough materials are always available. A simple record can be developed by listing on a sheet of paper every supply item in the office. Record the date of the last order for each and the quantity ordered. After each month or sooner, count the quantity on hand. If you are low on any one item (eg, less than a month’s supply), reorder as indicated. This record will prevent running out of any one item and give you a good guide to quantity purchasing.

A central storage facility is more efficient than several storage cabinets scattered throughout the office. A central facility reduces both inventory time and duplication of paperwork. All items should be stored neatly in an organized manner so you can tell at a glance the quantity of each item available. For items requiring considerable time between order and receipt, be sure to note this on your inventory record. It is often helpful to note the reorder point for each item stocked.


     HANDLING MAIL AND CORRESPONDENCE

On or near each assistant’s desk and the doctor’s desk should be trays to receive incoming and outgoing forms, reports, and correspondence. Processing should be frequent, smooth, and alert to emergency situations. Filing, however, may be delegated to a certain period of each day, but carry-overs from day to day should be avoided.

Organization is the key to smooth function. The filing system should not only be one where you can retrieve material quickly, it also should be a file where everyone in the office can retrieve information quickly. Your work area should always be ready for “inspection.” By taking pride in your work, your methods, and your responsibilities, you will be happy and productive in your career.


Policy and Procedures

Every office receives a large quantity of mail each day: some of it is very important, some of it is of casual interest, and some of it can be classified as “junk” mail. In many offices, it will be the responsibility of an assistant to sort the mail, slit the envelopes, and stack them in an orderly fashion. To do this, the doctor must inform the assistant what he considers junk mail that is not to be forwarded to him, what incoming mail he wants to see, what priorities should be given to certain types of mail, and how the mail should be sorted and organized. Incoming mail marked “personal” should not be opened.

When incoming mail arrives, sort it into three piles: (1) letters requiring the attention of someone outside the office, (2) letters needing the doctor’s personal attention, and (3) letters requiring your or another CA’s attention. When opening mail and you notice a letter referring to an enclosure that is not there, note its absence on an attached slip before forwarding it.

If you attend to part of a letter before sending it to someone for further action, mark the paragraph that has had attention. Write the date and “done” or “noted” in the margin and initial. In opening mail, be sure to remove all contents from the envelope. Patients frequently insert small notes when paying bills. These can be easily overlooked and discarded if the envelope is not carefully inspected.

Although it is usually good policy to fold and insert approved letters in their addressed envelopes as they are prepared, do not seal the envelopes or attach the postage immediately. Wait to the time for mailing as you or the doctor may think of a necessary or helpful enclosure later in the day.


Daily Record

Keep a simple daily record of important mail sent from the office for action by another person. This is especially important in insurance records, reports, contracts, and other legal documents. Such a record serves as a check on the receipt and disposition of mail that gets misplaced and for follow-up if necessary.

Outgoing mail records are usually designed on three-hole drilled loose-leaf sheets for simple storage in a ring binder. Five vertical columns are titled “Date,” “Description,” “To Whom Sent,” “Action to Be Taken,” “Follow-up.” If you keep the record with a pencil or pen rather than with a typewriter, the sheets should be ruled. If typewritten, double space between each entry.

In the “Date” column, show the date the material was mailed. Under “Description,” note the date of the communication, the name of the sender, and the subject matter. “To Whom Sent” refers to the person to whom you addressed the material. In the “Action to Be Taken” column, the action checked on the transmittal slip or mentioned in a cover letter is noted. Write the deadline for disposition in the “Follow-up” column if it is necessary to monitor that proper action is taken. When follow-up confirms that the necessary action was taken, write “did,” the date, and your initial in the margin.


Transmittal Slips

Transmittal slips speed intra- and inter-office communications where there is no need for a journal record of the correspondence or for elaborate explanation.


The Doctor’s Correspondence

When giving letters to the doctor for his signature, separate those that he dictated from those that you or someone else wrote for his signature. Some doctors prefer that letters given to them for signature not be accompanied with the carbon copy or envelope.

Enclosures should be paper clipped to the letter, but this is not necessary if the enclosures are bulky. In all cases, however, the letter should mention the enclosures as a postscript notation.


Preparing Enclosures

When enclosures are approximately the same size as the letter, fold the enclosures, then fold the letter and slip the enclosures inside the last fold of the letter so when the letter is removed from the envelope, the enclosures come out with it. If the enclosures are smaller than the letter, they can be stapled to the back of the letter in the upper left-hand corner. If two or more enclosures are sent, place the smaller one on top. If enclosures are larger than the letter, either put the unfolded letter and enclosures in a large first-class envelope or affix the letter’s envelope to the face of a large envelope. An envelope with a letter (inserted or attached) must contain first-class postage. Large envelopes can be marked third-class when delivery speed is not urgent.


Organizing Incoming Mail

Doctors usually prefer their mail to be organized when placed on their desk. Following is a common priority order, from top to bottom:

1. Telegrams
2. Special delivery letters
3. Express mail
4. First-class clinical mail
5. First-class business mail
6. Third-class mail
7. Journals
8. Newspapers
9. Magazines
10. Catalogs

An assistant properly trained in screening mail will save the doctor a large amount of valuable time. In most offices, an assistant will process payments received, appointment requests or changes, and bills to be paid, and have the authority to discard mail that the doctor has classified as junk mail. In offices not using a purchase-order system, the doctor may wish to approve (by initialing) bills to be paid. An assistant may also be authorized to complete insurance forms for the doctor’s signature.


X-Ray Films

When your office receives x-ray films from another office, leave them in their mailing envelopes or tubes. You will then have the proper size envelope or tube if the films are to be returned. X-ray films (as patient files) are the property of the person or institution who makes them. When requested, return films to the sender when your doctor-employer has made his analysis. The longer they remain in your office, the more chance there is of being misplaced or damaged. This would reflect a poor image of your office.


Certified and Registered Mail

When certified or registered mail is sent requesting a return receipt, attach the returned receipt to the office copy of the mailing. This is proof that the letter was received by someone at the address (certified mail) or was personally received by the addressee (registered mail).


Letters Containing Checks or Money Orders

Letters containing checks needs special attention. Examine each check carefully. Be sure it is signed and that the date is appropriate. Banks will not pay, as a rule, postdated checks. Many banks will reject a check that is dated too far in the past (eg, 6 months old). Also review each check to assure that the written amount and figures agree. Improperly prepared checks returned from your bank cause confusion in the office’s bookkeeping system. When the check is properly made out, enter necessary data within your daily record, and assure that no errors have been made in transferring information.

Patients are humans who make both intentional and unintentional errors. When noted, the assistant should tactfully call this to the patient’s attention so a correction can be made. As some patients write checks with a minimum of funds in the bank, all checks processed in a day should be submitted to the office’s bank the same day received. First come, first served.

If a check is received marked “In full settlement of account” or “final payment on account” and the amount is below the account’s balance, discuss it with the doctor. Acceptance of the check may make it impossible to collect the full balance due.


Document Routing Slips

If several people should see correspondence, a report, document, or publication, routing slips can be used effectively. The originator need only write the sequence of the routing. Each person then initials and dates his review before forwarding it to the next person on the list.


Handling Mail in the Doctor’s Absence

If the doctor is scheduled to be out of the office for several days, the assistant should be informed of what mail she is authorized to respond to and what mail she should hold for the doctor’s return. Any mail you are normally authorized to process would usually be done in the doctor’s absence. However, there may be some correspondence that the doctor wishes you to acknowledge receipt with a note that he will reply on his return.

When the doctor is away from the office for an extended period and it is his habit to contact the office periodically, sort correspondence according to priority and note the essence of each letter so you can report to him quickly. Contact him immediately if his urgent attention is needed.


Holding File

Copies of correspondence requesting information that cannot be replied to immediately should be placed in a holding file. This file should contain a copy of the request until it can be fulfilled. A holding file is also a constant reminder of things to be done. Mail received during the doctor’s absence that requires his immediate attention should be banded, marked “Urgent,” and placed on his desk.


Postage Considerations

If most office outgoing mail is first-class, all you likely would need would be coils of stamps. Coils are better than sheets because they require less space, are easily stored, and easier to tear apart at the perforations.

As first-class mail rates are determined by the ounce, multiples of the same stamp can be used for mailings of over one ounce. However, if the office is required to send considerable third-class mailings or parcel post packages, a postage meter would be of benefit.


Postage Meters

If a postage meter is available at your office, certain precautions should be observed. Be sure to change the date on the meter the first thing each day. Assure the meter is set for the correct amount for each new classification or each different weight of mail. Make daily entries in the meter record book showing ascending and descending totals. If these totals do not balance, the machine requires immediate servicing. When the meter is refilled at the post office, take the record book with you. Purchase an adequate amount of postage so that trips to the post office can be kept to a minimum. If any mistakes have been made while metering, take the unused meter stamps with you to the post office to obtain a refund. If unfamiliar with the operation of a postage meter, ask your doctor-employer for detailed instructions or request that a company representative demonstrate its use.


     HOUSEKEEPING AND EQUIPMENT SERVICE


Cleaning Services

Heavy or specialized cleaning such as carpet cleaning, floor maintenance, window cleaning, furniture waxing, and wall and woodwork scrubbing are usually performed by a commercial cleaning service. When necessary, an outside service should dry-clean or shampoo upholstered furniture.


Equipment Service and Repair

Major equipment should have a maintenance checklist attached to assure that the manufacturers’ recommendations are followed. Periodic dusting, cleaning, and oiling (if necessary) add to the service life of clinical and business office equipment.


Periodic Inspections

There are two common facility inspections that should be made periodically: that of the office’s general appearance and that for its safety to patients, visitors, and staff.

      APPEARANCE INSPECTIONS

Patients tend to view professional offices with a critical eye. A carefully designed office with appropriately selected furnishings will not support the image or the impressions desired if the office become dusty, cluttered, or takes on an excessively worn look. Periodic office inspections, within and without, are required to see that the environment is maintained to the level of high standards. Even when cleanliness standards are high, negative impressions can result when leaves and papers accumulate in exterior shrubs or when wall hangings and lamp shades become crooked.

      SAFETY INSPECTIONS

Be careful that accidental shocks, cuts, bruises, slips, and trips are avoided. Frayed electric cords, electric cords coursing in traffic areas, sharp edges, wobbly furniture, supply boxes stored on the floor, slippery floors, loose carpets, loose grab bars and railings, and icy exterior walkways in winter are the most common hazards. Monthly safety inspections of the office are good insurance. The entire staff should have an emergency fire plan, and at least one good fire extinguisher should be centrally located.

      POLICY AND PROCEDURAL CHANGES

A procedure is a plan, and a plan is not a permanent order because conditions change with time, personnel changes, and growth of the practice. Likewise, a definite policy does not necessarily mean a fixed policy. Once patient volume substantially increases, it is not difficult to get so involved in practice routines that where the practice is headed fails to be recognized. The alert doctor must revise schedules, duties, and responsibilities to reflect necessary changes, as conditions evolve within the practice.

Office policies and procedures are the result of a series of development and modifications over the life of the practice. If the practice is growing, it is not the same today as it was last year or will it be the same next year. Periodic staff meetings should be regularly used to analyze the different phases, procedures, and control points involved in the services offered and to seek areas of improvement. This forces the entire staff to think creatively and regain a perspective of the practice as a whole.

The doctor is in the best position to appreciate his practice’s overall objectives; however, rational flexibility is essential because he is not directly involved in the detailed implementation of every item within the office’s procedural manual. As assistants must work with and integrate specific policies and procedures each day, they often can provide constructive suggestions. This could be done verbally, but placing your ideas on paper encourages each suggestion to be thought through from various viewpoints.


     BUSINESS AND PERSONAL DUTIES FOR THE DOCTOR

An assistant may have certain duties to fulfill for the doctor that do not specifically concern patient relations. Greeting nonpatient callers, making travel arrangements for the doctor, and helping the doctor in his organizational work are examples.


Nonpatient Callers

The assistant who serves as receptionist fulfills a responsibility to her employer first and visitors to the office second. Greeting patients of the office has been described. Here we shall explain how nonpatient callers can be handled efficiently.

While the doctor may instruct you how to treat specific nonpatient callers, many instances must be dealt with few specific guidelines. Regardless, you will be expected to greet any caller with good manners, determine the name of the caller, his company affiliation if any, and the purpose of the visit so you will know what to say and what not to say. When you know the doctor’s preferences, he may have you judge which callers he will meet during office hours, who he wishes to avoid, who should be seen by someone else in the organization, and who you should take care of yourself. You will be expected to tactfully explain to callers who the doctor will not see at a particular time.

Maintain the good will of the person by making his contact with the office both pleasant and helpful, while simultaneously controlling office routine. After you greet the caller, determine the purpose of the call, give the caller your prompt attention, display genuine interest, and express a helpful attitude. If the caller is to be introduced to the doctor, make the visitor comfortable during the waiting period.

Business calls with appointments produce few problems. However, there are certain instances that should be discussed with the doctor so you will be alerted to his policy. Here are a few examples:

– Callers soliciting a contribution
– Callers the doctor will see without an appointment
– Callers who are friends of the doctor
– Callers the doctor does not want to see
– Callers the doctor wants you to handle.
– Callers to be referred to others in the practice


Organizational Aid

Many doctors of chiropractic are active in professional and civic organizations. Related duties frequently require assistance of the doctor’s employees. For instance, he may ask an assistant to keep his calendar of meeting dates and a list of time/costs involved, and to alert him before an important event. An assistant may be asked to assume responsibility for paying dues, typing organizational correspondence, or taking minutes of a committee meeting.

A doctor participating in research or developing a professional paper will usually use an assistant’s services for typing a manuscript or report. She may be asked to help with editing and proofreading, and maintaining a list of individuals to whom original articles or reprints are sent. This subject will be described in Chapter 9.

You may find it helpful to keep a list that specifies:

– The name of each group
– The amount of dues and when payable
– The current office held by the doctor and date term expires
– Meeting dates
– How you can help (delegated tasks)

Doctors with heavy speaking schedules will usually assign an assistant the task of maintaining the calendar, seeing to it that speaking notes or slides are properly arranged, and handling correspondence related to public appearances. Many doctors keep a log of personal activities.


Meeting and Travel Arrangements

You may be asked to book transportation or to make hotel reservations for the doctor. When this is requested, you will need to know what persons to contact (travel agents, airlines, railroads, rental car agencies, etc) and their addresses and telephone numbers. Each doctor will have a personal preference to what type of transportation he desires. He also might have personal preferences to specific hotel or motel accommodations. Keep a list of preferred hotels/motels in frequently visited cities, their addresses and telephone numbers, and the price range for types of accommodations available.

Most doctors will use credit cards while traveling so an account of expenses can be readily determined. Know what credit cards the doctor has and record the cards numbers and the telephone number for the issuing company if a card is lost or stolen. Before making reservations, assure which cards the transportation carrier and the hotel/motel involved will accept. The same should be done for traveler’s checks.


Personnel Data

Another helpful log is that for personnel in a multiperson practice. This should include each staff member’s name, title, address, and telephone number in the event off-duty personnel must be contacted. Data concerning the doctor’s attorney, accountant, banker, insurance agent, and travel agent also can be placed on this list for ready reference.


Postgraduate Education Log

Most states have established specific continuing education requirements for annual relicensure. The number of hours required and the courses and seminars approved vary from state to state. Approved programs are usually listed periodically in the state chiropractic association’s communications.

It is helpful to develop a continuing education log, listing all educational programs attended by the doctor whether approved for relicensure or not. Programs not approved in one state may be approved in another in which the doctor holds a license. File and safeguard all certifications of attendance so that proper credit can be given.


     UNDERSTANDING PROFESSIONAL AND PUBLIC RELATIONS

It is a commonly held belief that doctors within the healing arts need better public relations. Perhaps this is because the scientific and technical aspects of practice are so emphasized in the educational environment. While doctors must to a certain degree be objectively detached in their clinical approach, the secret of building solid patient and public esteem lies in the individual physician living up to his concept of being a “good doctor.”

Be it good or bad, everybody has public relations. Positive public relations is that attitude and course of action taken by any individual or group desiring to identify its actions and goals with the welfare of the people to gain widespread understanding and good will. Public relations is not merely the propagation of favorable publicity regardless of merit. It is not phony promotions and cheap publicity stunts designed to manipulate public opinion.

Public relations is identification with the public welfare: education to mutual concerns, and operating in the public interest and communicating this performance. As the business world has learned that it can, and must, take a careful account of the attitudes and wishes of the public before it evolves its programs of action, so do health-care professions.

Public relations begins in the local community and takes shape through the contacts of individual people with one another. In both the business world and the professions, a good reputation is founded on good works communicated truthfully and candidly. It must be recognized that the modern doctor of chiropractic is a combination of scientist and healer. As a scientist, his powers of analysis and integration have led to growth from fixed orthodoxy and illogical traditions. As a healer, however, he also must be aware of basic psychologic and human relations facts contributing to the “art” of his profession.

Doctors and their assistants should never become so preoccupied with the “case” to the neglect of the person involved. It is unfortunate that many patients neither look for nor evidently expect to find in their doctor the same qualities of compassion, sympathy, and reassurance that were once taken for granted in the healing arts. But this attitude is held with reluctance. Patients would prefer a doctor who is more important as an individual than all his scientific skills and instruments. Patients would prefer a doctor who, in turn, rates the patient more important as an individual than the disease or disorder presented.

Poor public relations, ill-will, and resentment take place when either a doctor or assistant fail to put themselves in the patient’s place. Patients inevitably react negatively to a transaction in which they are expected to understand without knowing the facts as understood by the doctor and assistant. Thus, it’s the doctor’s and assistant’s responsibility to explain the facts to patients and the public in words that can be understood.

Public relations in chiropractic can be approached from both an individual practice viewpoint and a professional viewpoint—these are overlapping and indivisible functions. Such programs are but practical devices by which the profession may and does prove its devotion to the community.

Ethics, a service-oriented attitude, and high-quality conduct are the basis on which any public relations program must be built. What is good public relations for the doctor is good public relations for the profession, and vice versa. However, a well-planned, high-quality national or local public relations program will profit the profession little if the individual practice is not completely imbued with the attitude of positive public relations and the development of safeguards making poor public relations impossible.

Interpersonal relations generally involve the four steps of attention, interest, desire, and action. The goals of mass public relations and community relations programs are to gain public attention and interest in public health in general and chiropractic health care in particular. The development of patient desire and action is a function of the individual practice. Without patient interest and desire, there can be little practice growth.


Relating to the Public

The goals of chiropractic must be to strengthen weak spots in public belief. As early as 1910, Theodore N. Vail, then president of the American Telephone & Telegraph Company, said: “In all times, in all lands, public opinion has had control at the last word.”

Our presidents recognized the power of public relations. In one of his debates with Douglas, Abraham Lincoln said: “Public sentiment is everything; without public sentiment, nothing can succeed. He who molds opinion is greater than he who enacts laws.” And President Harry Truman once observed: “You hear people talk about the powers of the president. In the long run, his powers depend a good deal on his success in public relations.”

Most practitioners agree that a chiropractor’s public relations efforts must be directed toward obtaining favorable opinion. This is an educational process requiring a change in public attitudes, which comes about as the result of long-term exposure and influence.

Public opinion is but the concert of individual opinion. It is based on information and belief. If it is wrong, it is wrong because of wrong information and consequent erroneous belief. It is the obligation of everyone —those who meet the public—to see that the public has full and correct information, thus a positive image of chiropractic. When each practitioner and his staff realize that the power of public opinion is the supreme arbiter in public affairs, when they accept the thesis that opinion is subject to change, and when they recognize the basis of success is involvement in organized public relations activities, then chiropractic public relations, efforts of communication should and will follow.


Building Public Confidence

There is no doubt that public confidence is essential to public relations success. It is both cause and effect. Unfortunately, too often participants in a public relations program get overcome with the tools and tend to concentrate solely on the means rather than the end. Merely getting chiropractic’s name in the paper or a chiropractic spokesman on TV or being invited to speak before a meeting is not good public relations. The positive results that may or may not come from that exposure is. Thus, the amount of public confidence built into a public relations program becomes the determining factor of the soundness and effectiveness of that program.

It’s essential to understand that chiropractic does not merely want exposure. It needs positive exposure, well-timed exposure, and well-planned exposure that fulfills its role in a progress strategy. Exposure, any kind of exposure, therefore, is not the goal, as some would believe. Positive exposure that fits into the general plan and has a role in building public confidence is the key. It becomes necessary, therefore, that the techniques and approaches used in building public confidence should change from time to time and be influenced by current conditions. In this respect, a good public relations program builds on a foundation of previous campaigns but changes to meet new conditions, new opportunities, new challenges.

Public relations is not a cure-all nor should it be considered a one-treatment method for correcting a traumatic public opinion problem. In its most effective form, public relations is a preventive-health method of assuring public confidence. It requires defined objectives and consistency of purpose. In terms of involvement, it is a 12-month-a-year activity, year in and year out.

Like the health of an individual, public relations is in a state of constant flux. Therefore, it is foolhardy to assume that once a “healthy state” is achieved the job is done. Consistency is the only key to security. National, state, and local ongoing PR programs are essential if a positive image is to be achieved and maintained.


Media Action Projects

The American Chiropractic Association has available to the profession a comprehensive portfolio titled Media Action Projects Kit designed to help state and local chiropractic associations develop positive relations with radio, television, and newspaper personnel. The kit offers guidelines for strengthening media relations and improving public communication benefits. Projects concern radio and television public service time, press information, news releases, space announcements, health columns, techniques for dealing with controversy, and so forth. An abundance of how-to-facts, proven do's and don'ts, and a plentiful supply of samples and forms are offered.


Community Action Projects

The ACA also has developed a portfolio titled Community Action Projects Kit designed to help state and local chiropractic associations develop positive community relations. The kit includes the implementation of health and professional literature, posters, speaking engagements for the doctor, health fairs and exhibits, bumper strips, industrial safety programs, films, youth programs, billboards, and community service awards, along with political and educational involvement at the local level.

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