. The reception area need not be large, but it should always be cheerful and sunny, if possible. Furnishings should provide a warm, comfortable atmosphere. Soft background music is helpful for relaxation and to disguise conversations in other areas.Chapter 3:
Basic Office Policies, Procedures, and Systems
From R. C. Schafer, DC, PhD, FICC's best-selling book:
“Developing A Chiropractic Practice”
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.
All of Dr. Schafer's books are now available on CDs, with all proceeds being donated
to chiropractic research. Please review the complete list of available books.
This chapter describes fundamental office policies, procedures, and systems, and their role in practice planning and conduct. Basic systems are explained for telephone usage, the reception area, receiving and recording appointments, managing case and administrative records, and records maintenance. Common procedural pitfalls, mail and correspondence processing, personalized form letters, filing, reminder systems, follow-up systems, and typical reports are portrayed. Additional topics include basic office supplies, purchasing, inventory management, small business regulations, and basic tax planning. The chapter concludes with a description of optional equipment, office cleaning and repair services, periodic inspections, and how to make procedural changes.
The procedures presented herein are in use in offices throughout the nation and working well. They contribute to efficiency, enhance the professional image, and are appreciated by everybody concerned. Our objective has been to offer basic data that you can take and amend to fit your individual needs.
Most authorities feel that the general economic situation has only a moderate effect on health practice success. Some doctors have thriving practices in poor times, and some have meager practices in good times.
The business maxim is: "Get organized, or get ready for trouble."
The goal for both you and your assistant should be a smooth flow of patients with as little loss of time and effort as possible. Proper scheduling and planning help your practice and personal life (Fig. 3.1) to run smoothly with less possibility of omitting necessary actions.
When patients walk into a professional office, they expect to enter a calm atmosphere that is well managed. Services are expected to be efficient, punctual, and private. Regardless of the size of the practice, there is no more certain sign of inefficiency than a hectic office atmosphere. There is always danger in discouraging patients if they are forced to wait an unreasonable length of time. An assistant should also prevent patients from crossing each other's paths. Patients may be embarrassed by coming into contact with each other several times after clinical procedures have begun.
Whether a practice operates at a profit or a loss often depends upon the quality and reliability of assistance the doctor has. Assistants can frequently guide a discussion with a patient towards her belief in your skills and the principles of chiropractic, but assistants cannot act and talk intelligently unless they are thoroughly trained in chiropractic principles and office procedures.
It is important that your entire staff be professional and thorough in all clinical and financial matters. Encourage your staff to ask questions, and have appropriate training literature on hand. Each assistant should be well acquainted with their duties and responsibilities, your general office organization and routines, and how you expect patients to be serviced by personnel. This implies that assistants should be familiar with all office policies, instruments, equipment, and clinical procedures used in the practice. Responsibility should be delegated slowly and only after efficiency has been demonstrated.
Management and Delegation
Task plans eliminate confusion about who should be performing a specific duty, work schedules eliminate the question of what to do next, and planning eliminates the need to work beyond expected hours with the exception of an emergency situation.
A doctor should never be required to do an unlicensed procedure in the office that an assistant can do as well or better. Valuable clinical time can be wasted if you must answer routine telephone calls, make appointments, supervise patient flow, send out statements and reminders, file records, and tend to all the various duties necessary to administer and manage the business side of the practice.
To be efficient as a professional, delegate much of your authority and responsibility for many office details to assistants so that your time will be used optimally in doing that for which you have been specially prepared --helping the sick to get well and the healthy to stay well.
Practice Objectives and Philosophy
Office philosophy should always consider patient handling, patient control, and patient satisfaction.
Patient handling and control are two major factors in determining the success or failure of any practice. As professional competence should be taken for granted, patient satisfaction makes the difference between success or failure. These factors determine whether there will be a high or low patient return and a high or low referral rate.
Interest and warmth freely offered to each patient are excellent practice builders. Interest in a patient's progress, family, and hobbies is appreciated. Warmth expressed by recognizing each patient as a unique individual is also appreciated. These factors build patient satisfaction, reduce complaints, and encourage referrals more than many other "clever" techniques.
Policies and Procedures
Even if an office is ideally designed, it cannot function to its potential if the people in it do not. Practice objectives provide overall direction for making decisions, and office policies and procedures serve as mechanisms for their accomplishment. Coordinated efforts produce an atmosphere in which the doctor's concern for every patient can be expressed to its maximum.
Definite office policies and carefully planned procedures are the prerequisites for running a smooth and efficient practice. Goals, however, cannot be achieved solely by establishing rules. You and your team must make them happen. Sound policies and procedures can relieve you of mundane decision-making chores so that time is available for more pertinent tasks.
There is a distinct difference between an office policy and an office procedure. A policy is a basic statement, principle, or predetermined guideline covering a limited area on which the practice operates and serves to achieve its objectives. A procedure is an even more specific method or system, limited in scope, by which a policy will be administered. It describes how particular activities are to be conducted. For example, a credit policy establishes whether cash-only payments will be accepted for services or if credit will be extended and under what circumstances and limits. On the other hand, a credit procedure defines the methods and systems by which the credit policy will be executed such as how charges will be recorded, how and when statements will be mailed, how records will be filed, how overdue accounts will be processed, and other such management and administrative methods.
Office policies vary widely depending on the size of the practice, staff abilities, and the personal philosophy of the doctor involved. Each doctor selects those policies and procedures that lend themselves best to the doctor's training, time, and work habits. In addition, a policy appropriate for a large firmly established practice may be far from ideal for a small recently established practice.
Upon employment, each assistant should be made aware of what is established in the way of practice policies and employee policies. Practice policies relate to those nonpersonal policies such as office hours, billings, collections, inventory control, etc. Employee policies concern personnel policies such as working hours, duties and responsibilities, salaries, overtime, holidays, vacations, sick leave, insurance benefits, etc.
To assure efficiency, each phase of your practice should be planned in detail and the phases coordinated with your overall objectives (Fig. 3.2). Once objectives, policies, and procedures are established, the entire practice is in a position to be managed and periodically evaluated. Checkpoints, inspections, and assays will be crucial to your evolving planning process.
Types of Planning
There are two basic types of planning processes: by induction or deduction. Inductively, you can build up short-term and intermediate goals into long-range objectives. This method focuses on the immediate problems at hand, but growth tends to develop in a patchwork fashion. Decisions are made according to problem priority that may be disjointed with overall objectives. Perception becomes shortsighted ("brush-fire" management), and the emphasis is on procedures that are designed to safeguard survival. An overall plan may be vaguely acknowledged, but it is usually so general that it provides little direction in daily affairs. Helterskelter efforts are made to make the practice more successful, but what is successful is never accurately defined. You cannot score a touchdown if you do not know where the goal lines are.
Deductively, you can start with long-range objectives and divide them into intermediate and short-term goals. This takes considerable discipline in time management (critical paths) if the long-range objectives are given a specific deadline. This method is much more restrictive, yet it assures achievement in the shortest possible time by preventing distractions. Emphasis is on policies that assure steady growth. This is by far the better approach for the careful thinker for you know exactly where you are headed because success is specifically defined.
Obstacles to Planning
The main barriers to good planning are myopic conceptions, fear, lack of flexibility, lack of time, and lack of knowledge. If a clear vision of what the practice is and where it is headed is not at hand, it is impossible to plan or achieve a course of action. Without a clear overview, the solution to today's problems may be the cause of tomorrow's problems.
Subconsciously, many fear making specific plans. They feel that if plans are not made, discouragement can be avoided from failing to meet deadlines and expectations. No goals, no deadlines, no failure! Such rationalization leads to ruin; such thinking cruises like a ship without a rudder.
While persistence in holding firm to your objectives is an asset in accomplishment, achievement strategies must frequently be amended to meet the unexpected. Plans must be continually revised and updated. Contingency plans should be at hand to meet uncertain effects.
Time is always a problem. Time must be allotted to achievement planning and actions. This takes discipline because life presents many distractions and invitations to procrastinate.
Planning and time management are learned behavior patterns. Learning to plan effectively is not difficult, but it is time consuming. It is the price we must pay to assure our future. There are not instant formulas for success unless you believe in luck. Consistent achievers stack the odds in their favor.
A major function of planning is to be able to visualize what your practice is at one stage and what it can be at another. Thus, planning gives your efforts a road map bridging the gap from where you are to where you want to be. Good planning is essentially a problem-solving adventure where certain questions must be answered. It is important in establishing a practice, and it is important periodically after your practice has been established.
What is the status of your practice at this time? Obviously, the first step in getting ahead is to know what and where you are. This consists of an accurate picture of your present status. It serves as a framework for planning the future. An objective analysis should be made of your practice objectives, financial position, management capability, supervisory expertise, and personnel practices. In addition, such factors as your public relations program, patient indoctrination system, scope of clinical services, accounting system, and collection system should be appraised. Which systems are assets in their present form, which are liabilities? How will they fit with changing requirements? When these factors are analyzed, thought should be given to how and why they achieved their present status.
Where should your practice be at this time? Once you have accurately appraised where you are, you can realistically judge where you should be at a certain point in time. Are you on schedule or behind schedule? If on schedule, it will give you an opportunity to reinforce positive actions. If behind schedule, why? This will give you an opportunity to differentiate between reasons and excuses.
What will happen if no changes are made? Change is vital to alter a destructive course or limiting policy, but change solely to do something different can easily create instability. A procedure that is producing good results should never be boring. As there is always a degree of uncertainty when a change is made from established procedures, limit changes to those areas that distinctly warrant improvement. Avoid the temptation to alter a course of action that is on schedule in hopes that success will be more rapid through risky innovation. A good change is characterized by easy and rapid implementation, a lack of confusion, few effects on other procedures that are proven assets, and harmony with reality.
What do you want your practice to be in the future? Once you know where you are, what your status is, and what course you are on, the next step is to determine what can be done to improve your situation. Some facets of your practice will deserve revision and some will not. Is there good balance between gross earnings and net income? How much you make is not as important as how much you can keep.
Is there good balance between new patients and recalls? How many new patients you serve this week is not as important as how many satisfied patients you serve. Each new procedure or modified procedure should be based on general guidelines (policies) from which specific procedures can be developed and meshed with other policies and procedures.
POLICIES AND PROCEDURES
What new policies and procedures should be developed and implemented? Good plans are detailed programs that limit confusion of what should be done, where, at what time, and by whom. How severely will a modified procedure affect other procedures? Will a new procedure overlap with an established procedure and result in duplicated effort? Strive for more efficiency.
What controls must be established to assure success? An annual assessment is not a control, it is only a postmortem review of past accomplishments. Alert control requires periodic assessment via numerous checkpoints and frequent analyses. Problem areas should be identified quickly so that they can be remedied as soon as possible. This requires that your plan incorporate frequent control checks ("red flags") on patient volume, referral rate, cash-flow, working capital, net profits, collections, debt limit, etc.
Basic Areas of Financial Concern
The most common areas of concern are a low patient volume, decreasing working capital, reducing profit margin, and rising debt level. A combination of factors rather than a single factor is usually involved.
LOW PATIENT VOLUME
When patient volume decreases, operating expenses do not decrease proportionately. This results in a reduced profit margin. Warning signs are seen:
(1) when the average number of new patients to your practice declines or plateaus,
(2) when the average number of recall visits declines or plateaus,
(3) when the average number of direct referrals declines or plateaus, and
(4) when the patient complaints or signs of dissatisfaction become frequent.
If patient volume is below that forecasted, the cause can usually be attributed to unrealistic expectations, impersonal care, inattention to patient total needs, inadequate public relations, failure to incorporate efficient services, or poor training of assistants. Other common causes include poor clinical management, overly aggressive behavior by doctor or personnel, a poor recall system, or severely adverse local economic conditions.
Every practice requires a certain amount of working capital. It must be adequate in amount and liquid in nature to meet fixed costs, variable disbursements, and contingencies. Warning signs are seen when:
(1) current assets less current liabilities drop below forecasts,
(2) the ratio between account receivables and current liabilities is below forecasts,
(3) loan payments are above forecasts,
(4) bank balance drops below forecasts, and
(5) financial concerns take priority over clinical concerns.
When working capital deteriorates, the cause can usually be traced to accumulating operational losses, poor collections, excessive payroll expenses, or unusual disbursements (eg, unexpected legal expenses, repair costs). Other common causes include expensive equipment purchases by cash and investments in unprofitable equipment.
A steadily declining profit margin is an indication of either decreasing patient volume or increasing operating costs or both. The major warning sign is seen when net profits before taxes decrease below forecasts.
Decreasing profits can usually be traced to increased operating costs, outdated fee schedules, inefficient scheduling, mounting interest on loan payments, or poor time management. Other common causes include inefficient personnel, waste, poor security from theft or fire prevention, and improper equipment maintenance.
LEVEL OF DEBT
Almost every practice carries some burden of debt, but the level must be kept within reasonable limits. Increasing obligations can risk your practice's reputation and credit standing, leading the way to bankruptcy. Warning signs are seen when debt exceeds forecasts, supplier relations become strained, or when funds are not available to take advantage of an opportunity requiring cash.
Steadily increasing levels of debt can usually be traced to decreasing patient volume, poor collections, low profit margin, increasing expenses, or overinvestment in fixed assets. Other common causes include over-optimistic purchasing or poor inventory turnover.
Office hours should be carefully charted. The number of days your office will be open each week and its number of operating hours each day must be carefully considered. While community standards are important considerations, they should not be the sole factor to consider. For example, evening hours may be a benefit to the new practice even if few doctors in the community provide such a service.
Strive for a balanced day where, for instance, you are not idle in the morning and overworked in the afternoon, or vice versa. This will avoid stress and inefficient services. Know your own pace and capabilities, as well as those of your staff. In addition to the priority time for patient care, time should be allotted for necessary paperwork, planning, problem solving, research, study, emergency situations, community relations, and relaxation.
Regardless of size, every office has daily routines that must be conducted at the proper time so that the practice will run smoothly, efficiently, and professionally. Procedural routines guard against forgetfulness, and most routines can be delegated to well-trained assistants.
Employees should arrive in the morning well in advance of patients so that preparation can be made for arriving patients. Many tasks can be accomplished at this time that would be difficult when rushed. For example, proper lighting, air conditioning, and ventilation can be checked. The various rooms can be prepared for patients, telephone answering service messages can be recorded, and equipment checks can be made. In addition, office correspondence can be opened and classified, case files should be pulled in the order of their appointments, and minor tasks left over from the previous day can be completed.
The cleanliness and organization of all rooms should be frequently checked. The reception area, preparation rooms, and treatment rooms deserve particular attention, as these will have the greatest traffic. Clinical instruments should be disinfected after each use.
An assistant should have the task of seeing that the office is properly closed at the end of each day, even if you remain for some reason. Patients unable to be reached earlier may possibly be contacted late in the day. Wastebaskets should be emptied, supply shelves should be restocked, and special equipment necessary for the next day should be checked. All equipment should be wiped or dusted, and appropriate instruments should be placed in a sterilizer. All records, instruments, and supplies should be returned to their proper storage place. Anything that requires repair or servicing should be noted.
Work stations should be cleared or organized for the next day. Petty cash should be placed in a safe, and all necessary vaults, cabinets, desk drawers, and files that have locks should be secured. All windows and doors that exit to the outside should be locked. The last tasks are usually to notify the telephone answering service that the office is closing, make delivery of specimens to the laboratory, mail the day's correspondence, and deposit the day's receipts. These are also tasks that are usually delegated to an assistant.
Duty Schedules and the Procedural Manual
The daily routines just discussed are a good example of task planning. For a smoothly run practice, a duty schedule allows each employee to know work expectations and responsibilities. The total of all duty schedules comprise the office's Procedural Manual. The object is for an assistant to know what the doctor expects and what to expect from the doctor. These guidelines ("the office bible") become the basis for all routine task planning and employee training. Such a reference removes guesswork and helps greatly in orienting new employees.
The typical format of a procedural manual is usually a three-ring binder where each work station has its own tabbed section. For quick reference, sectional data are filed alphabetically according to subject and listed within a general index in the back of the book. Some large offices have a manual for business functions and another for clinical functions, while smaller offices just separate these functions by a divider in one book.
What is included in each book and each section depends upon your preferences. Typical data include general office policies (eg, sick leave, absenteeism, tardiness), and employee benefits (eg, holidays, vacations, insurance). Job descriptions should be included that specify requirements, responsibilities, regulations, normal working hours and station, and promotional guidelines. Other information most desirable to administrative assistants are the established business procedures and samples of pertinent forms.
The typical subjects covered are:
Record processing and maintenance
Incoming and outgoing correspondence procedures
Correspondence formats and styles
General filing procedures
Tickler filing procedures
Patient reminder and follow-up procedures
Supply storage, ordering, and purchasing procedures
Office subscription handling
Equipment service procedures
Doctor's fee schedule
Credit policies and procedures
Accounts receivable procedures
Billing and collection procedures
Banking and depositing procedures
Accounts payable procedures
Tax record procedures
Answers to typical problems.
Other information most important to technical assistants are the established clinical procedures and samples of pertinent forms. Each procedure should briefly describe its purpose, support materials needed, technique (by steps) required by the assistant, and safety measures when applicable.
The typical subjects covered are:
Case history procedures
Clinical file flow and processing
Examination assistance procedures
Film processing and filing procedures
Laboratory procedures and profiles
Disinfectant and sterilization procedures
Supervised therapeutic applications
Clinical report processing.
The impressions made upon patients over the telephone are lasting impressions. Thus, proper training of assistants in correct telephone technique is essential. The points made within this section will help you train your assistants in professional telephone procedures.
Although clinical skills and quality services are the foundation in developing a successful practice, the psychologic impressions made upon patients in their association with the office are almost equally as important. Positive initial and continuing impressions are an integral part of developing and maintaining a successful practice.
Health practice is a very human situation, and the initial contact with your practice will usually be via the telephone. The ring of the telephone should be answered with sincere interest, warmth, courtesy, helpfulness, and understanding. A smile cannot be seen over the telephone, but it can be felt.
A patient is more than a sick body; he or she is also a sensitive psyche. Each contact with a doctor or any of the office team, no matter how minute, has one of two reactions. It either builds a patient's confidence, creates a greater respect, and develops a greater appreciation for you and what you represent, or it builds a patient's doubts, resistance, and lowers respect and appreciation for you and what you represent. This reaction is not a sometime thing. It is constant. It begins with the first contact, which is usually the initial telephone conversation for an appointment.
One test of a good assistant is the way she handles calls when under pressure, when the last thing she needs to hear is the ring of the telephone. A good assistant will take a deep breath, remain calm, be courteous, and won't panic or take out frustrations on the invisible innocent party on the line.
Assistants should be thoroughly trained in proper telephone etiquette, cheerful but not familiar, and sincere in wishing to help the caller. What is said and the way it is said is representative of you and your practice.
An assistant's voice that is calm, clear, and distinct naturally rises and falls and emphasizes important words. This is a great asset to any office. Voice tone should reflect a friendly, alert, professional attitude. The "I Care" message must be conveyed.
Proper telephone technique is expressed in voice quality, volume, pitch, pronunciation, rhythm, emphasis, and rapidity of speech. The caller should be visualized when the phone is answered. Volume need be no different from that of an in-person conversation. Because the telephone is a low-fi instrument, many overtones and undertones appreciated in direct conversation are lost. Thus, it's helpful to pitch the telephone voice slightly lower than normal. It also helps to speak at a slower rate. Telephone transmission appears to be best when the mouthpiece is held about an inch directly in front of the lips.
A pleasant, well-modulated voice indicates freedom from strain and tension. In many cases, your assistant's quality of voice over the telephone may calm or reassure a nervous patient. The common errors to avoid are mumbling, monotones, and slang.
Each call should be answered promptly by an assistant. The office and the person receiving the call should be identified immediately. For example, your assistant can answer the ring with, "Dr. Johnson's office. This is Miss Andrews. May I help you?" Care should be taken that the phone is answered calmly and distinctively. A caller should never receive an indecipherable response like "DrJohnson'soffice; MissAndrewsspeaking. MayIhelpyou?"
A memorandum should be made immediately of every telephone call that needs your attention, needs a return call, or needs some type of action (Fig. 3.3). This record should contain the date, time of call, name of caller, caller's telephone number, the main points of the conversation, what your assistant did about the request, and other vital facts. Spelling should be clarified when necessary. To be sure of the name of the caller, your assistant should repeat it one or two times during the conversation. People like to hear the sound of their name. They also like to hear several "Thank you's." To impress an appointment on the mind of the caller, your assistant might say: "Fine, Mrs. Andrews. I've entered your name on my calendar for a time reservation at 10:30 in the morning on next Tuesday. Would you mark us on your calendar too?"
A person in distress is not always able to speak clearly or convey information accurately. To assure the facts before closing, all data submitted by the caller should be recapitulated before the conversation is ended. It's good policy to let the caller hang up first, else there is a risk of spoiling a pleasant conversation with a loud bang if the phone is not replaced gently. Your assistant should speak in such a manner that others nearby will not hear the conversation, especially other patients. Nor should a patient's call be discussed with other patients.
Placing Calls on Hold
When a caller must be placed on hold while your assistant gathers some information, the assistant should always request permission to do so and state approximately how long it will take. Any holding delay should be short. If a long delay is anticipated, the assistant should offer to return the call. Upon return, the caller should be thanked for waiting.
The term "routine calls" is really a misnomer. There are no "routine" calls in good human relations. Each call is something special to the caller and should be handled as such. To appreciate this, the person answering the telephone must consider the outlook of the caller. Every call is different in some way and important to somebody.
Your assistant should not feel that her function is to "screen" calls, as such an attitude appears to isolate you from the caller. Rather, the assistant's function is to handle those calls she can so your clinical time is not reduced.
CALLS YOUR ASSISTANT CAN RESOLVE
Your office will receive many calls that do not require your personal attention. It has been estimated that about 50% of office calls will be about an appointment with the doctor. A trained assistant can handle calls relating to making appointments, taking messages, answering routine questions about insurance claims, receiving a favorable progress report, answering requests for a housecall, answering complaints or misunderstandings over a bill, taking calls from sales people, and answering nuisance calls.
Your assistant should strive to take care of most phone inquiries. Following are some examples of typical questions that can be resolved by an alert assistant:
Assistant: How may I help you?
Caller: I would like to speak with Dr. Smith.
Assistant: If you wish to make an appointment or reserve time for a consultation, I can help you. I have Dr. Smith's appointment book here at my desk.
Caller: Is Dr. Smith a good chiropractor?
Assistant: Yes, Dr. Smith is a very fine chiropractic physician. He offers professional health-care service.
Caller: How much does the doctor charge?
Assistant: How long have you had this problem?
Caller: It's been getting worse over the last 2 weeks.
Assistant: Dr. Smith will be happy to discuss fees with you. If you wish to arrange a special consultation prior to your appointment, he can see you either next Monday at 10 o'clock in the morning or Wednesday at 3 o'clock in the afternoon. Which do you prefer?
Note: The assistant should avoid direct answers to specific questions regarding office fees or professional practices. She should inquire into the general history of the case to show sincere interest. A polite general answer can be given to the effect that your fees and procedures utilized are usual and customary in the area and that a personal visit with the doctor would be necessary. A choice of two appointments should be offered so that thought will be directed to when rather than if an appointment will be made.
Caller: Do I have to be x-rayed?
Assistant: All patients do not need to be x-rayed, but the necessity must be discussed with the doctor in light of each patient's individual needs.
CALLS YOU SHOULD RESOLVE
Each doctor has preferences of what type of calls should be handled by an assistant and what calls the doctor wishes to take personally. Most doctors prefer to take calls concerning test results, clinical findings, unfavorable progress, and therapeutic reactions personally. Other calls that should be referred to you are calls from other physicians, calls about emergencies, calls about home treatment, calls from concerned relatives, and calls from your family.
Although your assistant should always give the impression that you are always readily available, she should not ask you to take the call immediately unless she feels it is absolutely necessary. If in doubt, she should place the caller on hold and brief you on the problem. She should realize that it's important not to interrupt the professional rapport or procedure between doctor and patient unless it's most vital. Likewise, most patients being examined or treated resent having the doctor interrupted or called away.
Most calls that must be handled by you can be noted by the assistant so that you can return the call between patients or after the last patient has left. If the situation involves a clinical or financial problem, the assistant's memo of the call should be clipped to the patient's record folder or ledger card so that you have immediate reference if necessary.
If your assistant has an urgent question, message, or special caller on the phone, there are a number of methods that can be used to communicate this to you such as a chime, a light system, or a polite knock on the door.
When you are available but speaking on another line, your assistant should inform the caller of the fact and ask the caller if he or she would rather wait or have the call returned in a few moments. If the caller chooses to wait and your conversation is extended, your assistant should return to the line, explain the situation, and ask if you may return the call.
If you are busy but expecting an important call, your assistant should be alerted to this fact. She should also have a list of certain callers that you wish to speak to immediately.
WHEN YOU ARE NOT IN THE OFFICE
If you are out of the office, your assistant should be tactful and factual. For example when you are out of town attending an educational program, the assistant might respond, "Dr. Jones is attending a special seminar in Chicago this week." Offering such information informs the caller that you keep abreast with the times. The word "convention" should be avoided as it has a negative connotation to many people.
If you are in town but out of the office, your assistant can simply state, "Dr. Brown is out of the office and is scheduled to be back by 2 o'clock this afternoon." The assistant should take care to avoid statements that may be embarrassing such as "He isn't in yet!" (Why not?), "I don't know where he is" (Golf?), "He hasn't arrived yet" (Tardy?), "He's out for coffee" (No patients?), or "I don't know where he is" (Something secret?).
The Mystery Caller. Sometimes a caller refuses to provide adequate identification. This may be because the caller is just normally a skeptic, recently mistreated by another practitioner, or "shopping." Most people with a legitimate reason will identify themselves and their suspicions. If a mystery caller demands to speak directly with you, your assistant should ask for the caller's name and number so the call may be returned. Politeness is necessary, even in the most demanding situation.
The Indistinct Caller. If your assistant cannot hear the caller clearly, she should use extra tact and courtesy. "I cannot hear you" or "I can't understand you" should not be used. Rather, it is better to respond, "There appears to be a poor connection. Would you mind speaking a little louder and slower?"
The Inquisitive Caller. Sometimes a concerned relative, neighbor, or coach of a patient will call seeking information. It may also be a call from an attorney or insurance examiner. Unless your assistant is absolutely positive the caller is a parent by voice recognition, she should remember that all information concerning a patient's health care or health status is privileged information. This includes whether or not the patient is a patient of the practice. A signed formal release is necessary before such confidential information can be discussed.
Note: As the doctor is legally responsible for the actions of his employees in the conduct of the practice, it is your responsibility to place specific limits on what an assistant may discuss with a patient, either directly or on the telephone. Some people can be very persuasive; thus, an assistant should have no doubt about what information can and cannot be given. Any discussion of a patient's diagnosis, therapy, or prognosis is strictly taboo for an assistant unless specifically directed to do so by you.
The "Nuisance" Caller. Abuse of the telephone is seen in the patient attempting to obtain detailed professional counsel or a diagnosis over the telephone. As these are impossible requests to fulfill, they are sometimes called nuisance calls.
One important function of an assistant is to telephone patients for periodic spinal examinations or for appointments that have been long standing. Patients often forget how long it has been between checkups, or an appointment made several weeks previously may have been forgotten. Because people tend to forget and because "no shows" waste valuable time, a few minutes on the telephone confirming the next few days of appointments will keep office time productive.
Thus, it's helpful when recording a patient's appointment that the assistant include the patient's telephone number. To be tactful when the assistant makes a follow-up call, it should not be "to remind" the patient, but to "confirm" or "verify" the appointment. It is good policy to have a running record of such calls (Fig. 3.4).
Another type of follow-up call concerns an acute case. You may ask an assistant to check on certain patients' progress after treatment or to verify that your instructions have been carried out. A list of such calls offers you an opportunity for a quick review (Fig. 3.5). Whenever patients report their progress via the telephone, their comments (dated) should be noted by the assistant in the patients' records. These memos should be brief but include the necessary facts of who, what, when, where, and why.
Frequent Outgoing Calls
If your assistant must make a number of outgoing calls such as for appointment verification, she should allow several minutes between each call so that a patient trying to reach the office has a chance to make the connection. A constant busy signal is quite discouraging and may result in the patient calling another doctor.
For frequently dialed outgoing calls, your assistant should have a list or rotary file of the numbers handy to her desk and kept updated. This will save valuable time. Following is a list of typical numbers to include:
Business office repair service
Clinical equipment and supply firms
Clinical equipment repair service
District Chiropractic Association
Doctor's home phone
Insurance agents (office)
Insurance companies (patients)
Medicaid (local office)
Medicare (local office)
Office equipment and supply firms
Staff home phones
State and National Chiropractic Associations
Telephone answering service
Welfare Department (local office)
Worker's Compensation (local office)
It will be helpful to you if your assistant organizes call slips into categories. For example, calls to patients should be separated from those to nonpatients. Calls requiring back-up information (eg, lab reports) should be separated from those that do not. Calls requiring immediate attention should be separated from those that are not urgent.
Patient Progress and Inquiry Calls
You may request patients with acute or rapidly progressing conditions to report their daily progress. In addition, patients of their own volition may call the office to ask a question regarding their condition or care. The majority of practitioners feel that legitimate progress reports and inquiries should be encouraged.
Handling several progress reports or inquiries by telephone may dominate lines needed to receive and schedule appointments. Thus, some offices have found it efficient to set aside an appropriate time or times during each working day for patients to call back or for the physician to return patients' calls. A "Telecommunications Hour," for example, is sometimes printed on the doctor's stationery, posted in the dismissal area, and explained during consultation.
When a specific telephone hour is established, it is usually placed at the beginning of the day. If placed at the end, conflict may arise because of an extended schedule to accommodate emergency cases or walk-in patients requesting an immediate appointment.
When a telephone hour is formally specified, office policy usually requires that telephone appointments not be scheduled during that time nor are progress reports or inquiries accepted at times other than that specified. This, naturally, takes considerable tact by the assistant in handling calls made at different times. Patients should never feel that they are being "victimized" by an office policy.
Primary physicians frequently refer patients to specialists. An assistant should be trained to arrange for these consultations with the appropriate specialist's appointment secretary. This will require knowledge of times most convenient to the patient and passing on the same data your office requires in scheduling an appointment.
Office staff should be trained to keep personal calls most brief during office hours. Visualize the plight of the mother with a sick child who cannot make contact with your office because the line is busy. Frustrating! Personal calls of staff should be limited to emergencies and made as brief as possible.
Telephone Services and Equipment
Telephone services and equipment have evolved rapidly during recent years. Services are available today for the small office that were unheard of even for large offices only a few years ago. There are single-line telephones that come in a wide variety of types, colors, and sizes, with either dials or pushbuttons. There are multi-button telephones, hands-free telephones, cordless telephones, remote speaker telephones, automatic dialers, repeat dialers for busy numbers, telephones with privacy buttons, mobile callers and radio pagers. Your local telephone company will be happy to discuss with you all options that are available.
Answering Services and Equipment
Most chiropractic offices use some type of answering service or device when the office is not attended.
Available answering services will be listed in the yellow pages of your telephone directory, and most can be contracted on a month-to-month basis. The services offered vary considerably, from simply relaying messages to electronic paging or two-way radio dispatching. Most services can answer the telephone in the doctor's name or name of the practice. Many local chiropractic organizations also provide answering services as well as referral services for their members.
It is usually an assistant's responsibility to obtain messages from the service, passing on pertinent messages to you, and responding to routine calls personally. It is an error if your assistant feels she is too busy to respond to all calls, thinking that the service has already told the caller when office hours begin and that the patient will call back. When callers receive an answering service, they have already suffered a let-down in reaching the coolness of the service when they were in need of help. It creates a warm impression when your assistant replies to the call, rather than waiting for the caller to make a second effort to reach your office.
When an electronic device is used, an assistant should play back the tape and record the messages on a standard form along with each caller's name and phone number. Return calls can then be made by the appropriate person. Be alert to the fact that many people become quickly irritated when their call is answered by a machine.
A number of methods can be employed to keep telephone costs to a minimum. There are several companies that provided long-distance rates at a lower rate than that of the telephone company if more than 25 long-distance calls are made each month. Even taking advantage of the telephone company's discount time periods will make a difference. Other economical procedures to consider are to use direct dialing whenever possible and avoid person-to-person calls.
The telephone company is not above error; thus, your monthly toll statement should be reviewed carefully prior to payment. Make sure that all credits are applied.
The Reception Area
After the telephone contact, the next typical areas of contact the office has with a patient are the exterior of your building and the reception area. These contacts help to enhance the success or failure in patient impression as they are the first tangible evidence a patient has of the service they will see.
In both physical appearance and mental attitude, be sure that your office has a reception room and not a waiting room. A waiting room is usually the result of poor appointment scheduling.
From both a clinical and a profit-producing standpoint, the reception room is a nonproductive area. Yet, it is one of the most important rooms in your office. It is here that both new patients and visitors receive their first close impression of your values in neatness, cleanliness, taste, and consideration for patient comfort. It is also here that returning patients gather their thoughts before they see you.
Receiving the Patient
Every patient entering the reception area should be cheerfully greeted and properly registered. This is the first direct human contact the new patient has with your practice. Depending upon the quality of this approach, either positive or negative impressions will be made.
Proper atmosphere and patient contact are the two major points in a good approach. Your receptionist holds the responsibility for developing a receptive patient attitude prior to meeting you. In its simplest terms, the goal is to have the patient like the people associated with the practice.
Marketing authorities rate "the approach" as high as 80% in importance in all sales. As health practice is not a business but a profession, any reference to "salesmanship" here might be in poor taste. However, it is difficult to completely differentiate sales psychology from human relations common sense. Obviously, the approach in a chiropractic office to either a new or continuing patient is important to the success of the practice. When poorly handled through a thoughtless act or tactless word, your skills and professional reputation may be sharply minimized in the mind of the patient affected.
Your assistant should greet the entering patient with a smile and cheerful welcome, as if she were the hostess in her own home, being gracious and pleasant and making the patient feel welcomed and at ease. The rules of courtesy, appearance, decorum, hospitality, and tact apply. A kindly smile, never forced, will do much to tell the patient in distress that he or she will be served with consideration. As in any human contact, the choice of words, voice tone, gestures, posture, and grooming are important parts of the approach.
Your receptionist's initial smile and friendly greeting are much more than a behavior pattern to be memorized. They set the stage for all else that follows in the office.
First words as first impressions have a lasting effect. It is good policy to always use the name of the patient in the opening statement. Assistants should be taught that phrases such as "Good morning," "Good afternoon," or "May I help you?" are warm openings. Such stern expressions as, "What can I do for you?" or "What seems to be the matter?" should be avoided. These openings may frighten the timid person. The expression, "How are you today?" may invite a problem.
Special assistance with clothing, walking, and seating should be offered to the elderly, the crippled, the painfully distressed. When new patients to the practice are greeted for the first time, they should be shown where coats can be hung.
If a patient enters the receiving area while your receptionist is on the telephone, the patient should at least be recognized with a friendly nod. If the assistant is busy at her desk, she should stop momentarily to greet the patient and exchange a few words.
After the patient is made comfortable in the reception room, your assistant should state that "The doctor will be with you directly." This is better than, "The doctor will see you soon" or "The doctor will be with you in a few minutes." These last two statements imply uncertainty. The word directly in the first statement implies a short wait, and yet it is noncommittal.
It is the rare patient who enjoys a long wait in a reception room. To most, it's very annoying. Your receptionist should always try to give the patient some idea of when you will be available. 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, your assistant should re-enter the room and graciously apologize for the delay: "We're sorry, but an unfortunate situation has arisen that has delayed our schedule a little." The patient should never remain in the reception room well past the appointment time without some type of explanation. This would be discourteous. Nothing less than good social conduct should be the guideline of the receptionist-hostess.
ENTERING PATIENT DATA
When a new patient to your practice enters the office, basic information must be obtained or verified such as the 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 your practice, health-insurance information, and how the patient wishes to pay for your services. If the patient is a woman, the number and ages of her children, if any, should be recorded. Necessary forms should be provided with a clipboard and a ballpoint pen (Fig. 3.6).
When a patient is interviewed, an interested, reasonably relaxed, politely inquiring attitude will elicit more information than a hurried, tense interrogation. Basic information is usually recorded on an index card and kept on file for administrative reference. In some offices, the doctor may also desire to have an assistant take some of the basic case history. Usually, a standard form or checklist is used.
An assistant should then prepare a folder for the entering patient, insert the data obtained plus anticipated forms to be filled out later, then prepare an office visit slip and attach it to the folder. This composite of data is called the patient's chart. The patient can then be escorted to the consultation room.
If considerable time has elapsed since a patient's last visit, your assistant should see that you are given a few moments to review case records before the patient is escorted into your presence.
Receiving Other Visitors
Every business or professional office has a steady stream of salesmen and solicitors calling, and how nonprofessional callers will be handled is a matter of office policy. Many of these callers are important to the operation of your practice. Others are unproductive or unnecessary callers.
The attitude that all callers other than patients are nuisances should be avoided. Your office may need the service or product offered. Your practice must have good equipment, supplies, and outside services to run efficiently and profitably. You must have the opportunity of keeping abreast with the latest developments in clinical technology. Salespeople are not only an excellent source of information, they are also carriers of good will or ill will. In addition, sales professionals and their families need chiropractic care too.
An assistant should first interview all salespeople unknown to you and request basic literature for your review. If this becomes of interest, an appointment can be set up with you for an in-depth interview where the salesperson can present full information of the product or service.
Many doctors and/or their assistants designate specific days and hours solely for meeting with sales representatives and solicitors. If a salesperson should call at the office without an appointment, the assistant should request a card and the purpose of the visit. She should tactfully find out if the subject is important enough to be called to your immediate attention.
If the visitor is another doctor, your receptionist should discreetly bypass all waiting patients and escort the doctor to your consultation room when it is available. You should then be notified. Such visits are usually for a specific purpose and can be handled quickly without greatly disturbing the day's schedule.
Reception Room Literature
Reading material should be placed neatly in a rack. Topics are commonly of varying interests in good taste and directed to various reading levels. An exception to this is the newly established office that wishes to educate as many people as quickly as possible to the benefits of chiropractic. In this case, literature might be restricted to that of lay-directed chiropractic publications. Professional journals and newsletters, or technical, political, or highly religious material have no place in a health-care reception area that serves the general public.
For some reason, many patients tend to associate the progressiveness of the doctor with the type and date of reception room literature. For this reason, dated publications should be removed after they become two issues old.
Chiropractic educational literature prepares the mind of the patient or prospective patient for further education. It also helps to create a desire for more information. Thus, either in the reception area or the preparation rooms, or both, a supply of modern chiropractic educational literature should be available in organized racks.
When tactfully suggested by 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 problem and is not a chiropractic patient, you or an assistant can suggest a specific tract that the patient may wish to forward.
A wide assortment of topics is available for patient and prospective patient education, directed to both adults and children. For further information, contact the Sales & Service Department of the American Chiropractic Association.
Your assistant should schedule patient visits intelligently so that too much time is not allowed between appointments. Once appointments are made, they should be serviced promptly and efficiently in an orderly fashion.
Surprisingly to some, the most frequent complaints from patients do not concern fees or health services. They concern the time wasted waiting in the reception room when the doctor is behind schedule. Waiting complaints, in fact, are heard twice as often as complaints about fees. It is only natural that some patients 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 --an example of poor management resulting in poor human relations.
Your reputation and your practice's image is best developed on an appointment system that is truly a system, one that does not deteriorate into a "catch the doctor when you can" operation. An appointment system in control takes into consideration the best interests of the patient and the practice. That is, time is just as important to your patients as it is to you. Poor appointment management, for instance, can result in businessmen missing important meetings and employees being penalized for being late. This develops animosity rather than good will.
SAMPLE TYPES OF ENTERING PATIENTS
Although there are exceptions to all generalizations, we shall briefly discuss four general types of new patients to a practice so you will be in a better position to instruct your assistants how to handle the type of appointment necessary.
One type of patient will be characterized by being referred by a satisfied patient. Because of the referring patient, the prospective patient will have a high regard for the doctor and high expectations for relief. Such a patient will usually be respectful of office policies and the doctor's professional advice, and be somewhat informed of office policies beforehand. This type patient is usually interested in a complete rehabilitation program. Appointment schedules can be established accordingly, depending upon the clinical judgment of the doctor.
Another type of patient presents a history calling for a complete rehabilitation program, but for one reason or another, such a schedule is not possible at the time. Reasons may be financial, an occupation requiring a great deal of long-distance traveling, baby-sitting problems, or some other factor that would prevent keeping necessary appointments. Such a patient may have a high regard for the doctor, realize the necessity of complete rehabilitation, but not be in a position to engage in a comprehensive program at the present time. The only alternative is to place this patient on some type of temporary program that will allow the patient a maximum amount of comfort possible within the circumstances.
This third type of patient does not have a high regard for the profession. Such a patient usually has been exposed to negative propaganda for many years, but previous care for a disorder has not been beneficial. Although skeptical, the patient has called your office upon the advice of a friend. While patients like this will often manifest clinical indications for a complete rehabilitation program, they are usually not psychologically prepared to agree to such a recommendation. They make appointments with the expectation of receiving limited service or extraordinary results, pay a fee, and come back "when they've a mind to." For you to try to alter such deeply entrenched opinions on one visit would be folly. Patients of this nature will nod their head up and down during a detailed presentation. But upon returning home and being re-exposed to negative ideas, old thinking patterns will be reinforced. They might even feel that they were the victim of some type of "high-pressure salesmanship." A definite future appointment is rarely scheduled for such a patient.
Although the patient is left to his own volition, you should plant the seeds of what should be done. This is the DC's moral and professional obligation, even if you know that your constructive suggestions may be going in one ear of the patient and out the other. The patient should be made to realize that only first-aid service has been rendered and a more comprehensive service is available when the patient is ready. By enlightening the patient of the need for a complete rehabilitation program, the chiropractic physician has fulfilled his or her obligation. The responsibility for further action is then placed squarely on the patient. He or she is free to either ignore the advice or reflect on it and take positive action. If patients choose to ignore your advice, they assume responsibility for the progression of their complaints and any complications that may arise from lack of proper care. In any event, the patients are not in a position to criticize you, your practice, or your profession. They cannot truthfully say you took advantage of them in any way. The only thing they can say is that you pointed out the folly of continuing procrastination and suggested a constructive program regarding their condition that should be undertaken at the earliest opportunity. These patients have at least been educated that chiropractic health care is not only interested in relieving pain and discomfort, it is also obliged to prevent health disorders from progressing or recurring if possible.
There is another type of patient that may erroneously appear at first to be the type just discussed. It is important that both you and your assistants make proper differentiation. These patients have become discouraged with the superficial first aid treatment received in the past, even if it was all that they would allow. They may have recently been informed of the quality services of your practice and are now prepared to have a full diagnostic work-up and a comprehensive rehabilitation plan outlined. This is their purpose for calling your office for an appointment. Thus, these patients are more akin to the first type of patient discussed than the third. To not allot enough time in the appointment schedule for proper consultation would be a gross injustice to these patients. There is but one good way to find out what patient expectations are --ask!
SAMPLE TYPES OF PROFESSIONAL SERVICES
Office policies and procedures are basically designed to support three major services:
(2) examination, and
These lead to five different forms of typical health service depending on the problem involved:
(1) emergency case,
(2) acute case,
(3) chronic case,
(4) rehabilitative care, or
(5) prophylactic care.
In addition to the consultation and history being required to assist you in determining the type of examination necessary to isolate the cause(s) of the patient's complaints, they are necessary to counsel toward healthy behavior. Once the examination profiles the patient's structural and functional status and a diagnosis is arrived at, therapies can be designed to assist the patient in returning to as near a state of health as possible.
All office policies and procedures should be designed and administered to assist your practice's services and the types of cases treated. From the time patients enter your office until they leave your office, every procedure should be planned to support the best interests of each patient. By so doing, the best interests of your practice will be served.
Records, supplies, equipment, and furnishings are but vehicles to reach this goal. They are never an end in themselves. Be alert to the fact that systems originally designed to aid the practice, in time and with habitual use, have a tendency to dictate to rather than serve their creators. The only safeguard is to constantly remember that the patient is more important than the procedure.
PATIENT CONTROL AND HUMAN RELATIONS
The business world recognizes the value of its customers, and the alert businessman can tell the doctor much about human relations. Elaborate business systems are maintained to keep constant contact with customers, enhance good will, and maintain customer and product loyalty. Providers constantly research the wants and needs of consumers. Businessmen seek answers to why people buy or stop buying. The customer is the sole purpose of all significant activity.
The successful practice is one that truly recognizes the value of each patient. The typical patient entering a doctor's office seeks help. To help the patient, the doctor must have control in the doctor-patient relationship. This control is founded upon a desire to serve the patient. If personnel of a practice do not understand the desires and needs of a patient, the patient will not be inclined to follow instructions or might be motivated to seek fulfillment elsewhere. The practice not only loses face, it loses an opportunity to serve and ultimately suffers an economic loss.
In another instance, a patient requiring frequent care may call to postpone an appointment for several days. The interrupted treatment schedule results in a relapse, and the patient becomes discouraged and discontinues treatment. Another type problem is seen with the patient who becomes free of pain but requires further care to prevent a recurrence and calls to cancel an appointment in the erroneous belief that further treatment is not necessary. Thus, control is necessary to maintain the quality effects of services and positive patient relations, and to safeguard the financial stability of your practice. An important aspect of such control is your practice's appointment system.
The importance of allowing the correct amount of time for each patient and their needs cannot be overemphasized. Allowance must also be given to the examination or treatment that takes a little longer than necessary, the emergency situation, special visitors, and other unexpected but necessary interruptions. A free period of several minutes scheduled in midmorning and midafternoon would allow for catch up as well as time to enter an unexpected emergency case.
Accurate foresight takes experience on the part of your scheduling assistant --knowledge of your work habits and knowledge of the patients. Proper calculation of the time necessary for a patient's appointment greatly reduces reception room waiting time, prevents clinical care from being rushed, and con-tributes to positive human relations. The appointment book is your diary of professional activities and determines how you will schedule your professional time. It will be no better or worse than the accuracy and intelligence related.
A good appointment book is a prerequisite of a good appointment system. It is the place of battle against time. There are numerous systems on the market designed to fit a variety of needs. They come either bound or loose-leaf, and the choice is a matter of personal preference. Some doctors with special needs have sheets custom printed and bound to their specifications. Regardless of the type used, it should be informative and concise.
Many commercially available logs offer a line every 15 minutes, with 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, 3 days to a page (Fig. 3.7). Most scheduling assistants prefer a large appointment book that reveals the weekly schedule at a glance.
While the 15-minute line appointment book has been common in the past, many offices today find this division highly impractical and prefer 5-minute or 10-minute intervals or space for additions. As appointments should be scheduled according to the services rendered, this offers better accommodation for the various types of consultations, examinations, therapies, or quick tests necessary that might require 50-minute, 35-minute, or 10-minute scheduling. It is also more practical for the practice that serves more than four patients an hour on follow-up visits.
Entries should be made in pencil rather than pen so that cross-outs and erasures can be made neatly. Patient cancellations, changes, and "no shows" should have a line drawn through them and not erased, and these acts should be recorded in the patient's permanent records. This is to protect the doctor against a later charge of negligence. The assistant in charge of scheduling should try to put as much pertinent information as possible in the small space provided in the appointment book or on a companion form.
To simplify the recording of specific time allotments, the estimated amount of time anticipated for each visit can be blocked out in the appointment book by drawing a vertical line through the necessary amount. In differentiation, single diagonal lines (ie, / /) can be used to indicate time reserved for nonpatient tasks or emergencies and large crossed lines (ie, X) can be used to indicate when the doctor will be out of the office.
The efficiency of almost your entire practice can be greatly aided through a well-planned appointment schedule. Good appointment planning maintains an even patient flow through the office and avoids nonproductive time. As time means money, such planning directly influences practice economy.
Logical Scheduling. It is rarely possible in a busy office to give a patient an appointment for the exact time desired unless the appointment is made far in advance. Your assistant, however, should always let the patient calling know that you are available and will see him or her as soon as possible. If distressed callers are put off for several days, they will undoubtedly turn to another doctor who is more accommodating. You also put yourself in a position of possibly being charged with abandonment or negligence if the delay of an established patient would be considered unreasonable under the circumstances. A continuing patient not in distress or a new patient with a chronic condition will not usually mind if an appointment cannot be arranged for a few days. Even in these situations, a 3 or 4 day wait is about maximum to suggest.
Control. Although appointment schedules should be arranged as far as possible to suit a patient's convenience, the patient should never be allowed to determine the interval between appointments. You must determine this, according to the patient's progress. When the patient makes such a decision, you are no longer in authority in the case. You must have the authority to direct quantity and quality of practice services if you are to be responsible for case management.
Advanced Planning. If the health service agreed to requires several visits that can be fairly accurately predetermined, your assistant can schedule a series of appointments for specific times during specific days in advance. This indicates consideration about appointments in the near future, and serves to act as a commitment between office and patient. Whenever possible, patients on long-term appointment schedules should be given the same day and time to help establish a habit pattern. On the other hand, if a patient who is accustomed to a definite appointment time and day cannot be allotted that time, your assistant should inform the patient immediately of the change in routine.
Regularity. Most doctors desire appointments to be scheduled at regular intervals whenever possible. If it is necessary for a patient to be seen three times a week for a few weeks, the patient can be scheduled on Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday. Patients to be seen twice a week can be scheduled on Monday and Thursday, Tuesday and Friday, or Wednesday and Saturday. Patients to be seen once a week or less can frequently be scheduled most any day that's open.
Data Gathering. Full name, phone numbers at home and work (with extension number if necessary), reason for the visit, and dates and times of appointments are the important elements that should be recorded in a record book after they have been verified as correct. It should also be determined if the appointment is for a new patient or an established patient of the practice and if there is any urgency to the appointment request. Depending upon the disorder involved and its seriousness, the age of the patient is sometimes quite important to record. How long has the condition existed? Has the patient sought help elsewhere for this particular disorder? Is the patient under care of another doctor for another reason? This information will help the office to prepare for the patient prior to arrival. Any doubts about the type of an appointment or the length of an appointment necessary should be resolved. This will avoid a possibly serious error.
Third-Party Appointments. Patients will often make appointments for other people such as relatives, friends, or employers. Both the name of the patient and the person making the appointment should be recorded.
Coding. If your scheduling assistant is to control smooth patient flow, she must be able to see at a glance why the patient is scheduled. If a patient is scheduled for an extensive examination, for example, noting this allows for proper time estimation as well as alerting the staff to necessary preparations. Most offices will code all standard procedures; eg,:
physical examination → P
roentgenography → X
blood profile → B
urinalysis → U
spinal adjustment → S
extremity manipulation → E
acupuncture → A
diathermy → D
traction → T
ultrasound → US
and so forth. With experience, the length of each procedure can be accurately anticipated and the estimated time can be allotted.
Time Planning. Different procedures and situations require different time requirements. Naturally, a patient requiring several procedures will require more time than a patient receiving one or two procedures. A patient suffering a painfully acute disorder will probably require more time than a patient with a subacute disorder. A senior citizen or an infant will often require more time than a young adult suffering the same complaint. As most office staffs function best earlier in the day, patients requiring unusual attention are best scheduled earlier in the day. The effects of fatigue become most apparent as the end of a busy day's schedule approaches.
Time Allotment. While your assistant should be specific for the patient's appointment day and time, she should never indicate to the patient the exact length of time reserved; eg, "We've scheduled you for a 15-minute reservation next Friday." When the time for the appointment arrives, different conditions and situations may develop that may require a longer or shorter visit than originally anticipated.
Appointment Grouping. Some scheduling assistants handle the unpredictability of exact service time by scheduling two patients a few minutes apart 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 (Fig. 3.8).
Scheduling Preferences. Some doctors like to schedule all acute cases at one time during the day and chronic cases during another time. Some like to schedule all extensive new-patient examinations during one part of the day or on particular days, and some like to have them interspersed between follow-up appointments. The choice is a matter of policy determined by your preferences.
Specialized Appointments and Time Demands. You may be an examiner for or a consultant to one or more insurance companies. If you are an examiner, an insurance company will refer applicants for life insurance to your practice for examination prior to approving the policy requested. When this happens, your scheduling assistant should be sure to obtain the name of the insurance company since it will be they who pay the bill. If the company requires any special laboratory tests, this should be noted in the appointment book or elsewhere. If you are a consultant to an insurance company, one of your roles will be that of reviewing claims. If the volume of such work is extensive, some hours each week should be allotted for this effort in advance.
Office Closings. When setting up advanced appointments, it is important that your scheduling assistant mark out all holidays observed by the office. She must also mark out all those days when it is known that you will not be in the office for such reasons as seminars, vacations, and other predictable absences. This will prevent numerous errors that would require many telephone calls and apologies to change scheduled appointments.
Efficient time management requires that definite plans be based on your objectives and standards. Staff activities should be arranged so that task responsibilities, and enough authority to carry them out, are delegated to specific individuals. These principles are no more importantly applied than in appointment scheduling.
An efficient assistant can keep your appointments moving steadily if the assignment of rooms, based on the treatment necessary, is orderly. When patients arrive, she should try to get them into the appropriate room as quickly as possible. There need be little conversation relating to preparation for treatment of an established patient.
People are human, and humans make mistakes. When a patient enters, the appointment book should be checked to assure that the patient is not too early, too late, or coming at the wrong hour or day. A record should be kept of all cancelled appointments or "no shows" and their follow-up.
RESPONSIBILITY AND AUTHORITY
The management of the appointment book should be the responsibility of one assistant. With some exceptions, you schedule appointments by day; but it is your scheduling assistant who must arrive at an agreeable time of day for the patient. Because your assistant has this responsibility, she must have the related authority to control the scheduling in harmony with your established policies. 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 good communications and staff relations. Second, appointment problems are multiplied several fold if two or more doctors and several assistants are tempted to make appointments. This can quickly result in chaos.
If an assistant is delegated the responsibility for appointment scheduling and control, the appointment book must be considered personal domain. Most all doctors respect this, realizing that control and authority go hand in hand. The specified assistant alone should make and change all appointments according to the doctor's policies. It is also the assistant's responsibility to write clearly and accurately so that others can readily read her entries and notations.
Except with acute cases that require close surveillance, your assistant should have the authority to change the day you suggest either a day ahead or behind to meet scheduling demands. This is especially true if the appointment is being made more than 10 days in advance.
On the surface, it may appear that anyone can look at the appointment book, see an opening, and fill in a name for the time reservation. This belief does not consider the problems involved. For example, your assistant in charge of scheduling may have just talked to Mrs. Anderson and told her that next Monday at 3 pm would be open for her daughter. Mrs. Anderson says that's fine, but that she will have to check with the school to see if her daughter can be excused early that day. She tells your assistant that she will call back in about 20 minutes to confirm the time reservation. Meanwhile, when the assistant leaves her desk for a few minutes, the phone rings. You answer it, glance at the appointment book, and schedule a patient in the apparently open 3 pm spot of next Monday. A few minutes later, Mrs. Anderson calls to confirm her daughter's appointment time. You now have a problem if your assistant hands the phone to you. Such confusion can be avoided if the caller who telephoned while the scheduling assistant was away from her desk was informed that the assistant in charge of scheduling would return her call in a few minutes.
PATIENT ORIENTATION TO APPOINTMENT POLICIES
A practice in control operates efficiently without unnecessary open appointments, rush periods, or seasonal trends. This takes patient education toward the value of health services, preventive measures, and health maintenance. However, before anyone can be educated, there must be a desire to learn. Such desire is based upon recognized need, admiration, and respect --human relations factors.
Every patient should be informed of the practice's appointment policies when they complete their first visit. This is usually at the dismissal desk. A good explanation here will do the most to minimize the possibility of changed or cancelled appointments in the future. In addition, your assistant is in a prime position to reinforce your concern for case management and the value of regularly scheduled check-ups in preventing relapses. After treatment and before any patient leaves, an assistant should make the next appointment and arrange for payment or collect the fee.
Continuous education and controls should be taken at the first instance of disrespect for the case plan. Your 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.
Psychology. Your scheduling assistant should be aware that it's usually good procedure 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, a choice of more than two may contribute to a patient's confusion, delay arriving at a firm decision, and waste time at the appointment desk.
Confidentiality. The appointment book should be considered strictly confidential property and its schedule confidential information. A patient should never be allowed to openly view your appointment schedule. The volume of patients scheduled for any one day or the openings present are solely the business of your appointment assistant, you, and other pertinent staff.
When a new patient is at the dismissal desk for the first time, an assistant should learn the most convenient days of the week and times of the day for each patient, and then try to accommodate the patient's desires as closely as possible when making future appointments. It is often helpful to record such preferences in the patient's records for reference. Some patients have definite preferences, while others have none.
Only in slipshod helterskelter offices will appointments be considered just names in the appointment book. Your scheduling assistant should never enter an appointment unless there is reasonable assurance that the appointment will be kept. Each patient must be educated on the importance and seriousness of time reservations with you. When your assistant appreciates the seriousness of efficient appointment planning and respects the responsibility and authority delegated by you, patients will reflect this attitude. On the other hand, if your assistant assumes a lackadaisical attitude in appointment planning and is unimpressed with the importance of efficient scheduling, patients will reflect this attitude. This can only be detrimental to a good doctor-patient relationship.
Appointments made by telephone are rarely forgotten by the patient when the patient has taken the initiative. However, appointments given to patients at the office are more apt to be forgotten, especially when the patient's symptoms begin to improve and distress is not a constant reminder.
Appointment Cards. Many practices utilize a printed appointment slip or card plus some form of added reminder (eg, telephone call, postcard). The type of appointment cards typically used is a printed card with areas to indicate the patient's name and the date and time reserved (Fig. 3.9). Although a series of appointments may have been scheduled and booked, only the next appointment should be listed on the appointment card presented to the patient.
Telephone Reminders. If an appointment interval is for a period longer than 10 days, a brief telephone call a day or two before the appointment is often 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 feel that an appointment should never be confirmed by telephone. Their reasoning is that calling patients to verify time reservations often acts as an invitation to cancel or change appointments. A patient may respond, "Glad you called. I was just going to call you. It's not convenient for me to come in tomorrow. I'll let you know when I can make another appointment." Thus, your office has invited the opportunity for an appointment cancellation. As health processes may be involved that are unknown to either the patient or the assistant, nothing should be done to encourage development of a tentative health care plan. Thus, it can be appreciated that there are strong points for and against telephone reminders. Policy must be determined by your preferences and past experiences.
Mailed Reminders. In contrast to telephone reminders, most doctors do prefer the use of mailed reminders (Fig. 3.10). This is especially true if the appointment is greater than 2 or 3 weeks in the future. Most offices plan that the notification is received by the patient about 3-4 days prior to the appointment. If the appointment is made when the patient is in the office, the reservation is recorded in the appointment book, an appointment card is presented to the patient, and/or a note is made in a small tickler file to mail a reminder about 5-7 days prior to the appointment (Fig. 3.11).
There are two phases in the initial consultative process. During the initial consultation, the doctor explains the need for suggested examination procedures after discussing the patient's full history. This is to achieve consent for the examination. In the following evaluation consultation, the doctor discusses the findings of the examination and his prognosis under a specified treatment program. This is to achieve consent for therapy. This medicolegal procedure is called obtaining informed consent, whether conducted at one or more sessions. You must inform the patient of all anticipated practices and procedures and receive the patient's consent prior to any necessary examination or therapy. The patient must be informed of all potential consequences involved so that the patient's consent is given with full knowledge of the inherent dangers, if any, to which the patient is exposed.
Patients can become quickly discouraged if they feel their appointments are routine or will be without end. Thus, it is important that you give each patient a quick review of the progress made to date and the progress needed during each visit. This only takes a few moments, but it reinforces why the patient must return as scheduled.
"You're coming along quite well Mrs. Jones. Now that the swelling has reduced and the pain has eased, we can start strengthening the tissues to help prevent recurrence. Because of your progress, it looks like it won't be necessary to see you again until next Wednesday, but call me immediately if your discomfort increases." A statement like this tells the patient that she is getting better, she needs more care, the length between visits will be increased as she improves, and you care about her welfare.
Many practitioners feel strongly that no patient of the practice should leave the office without a specific appointment unless the case has been formally dismissed. Such an appointment may be for the next day (eg, an acute case) or several months in advance (eg, periodic examination). A patient that leaves the office without an appointment is often considered lost to the practice for all practical purposes. In some cases, a patient may feel that he has been discharged if his symptoms have abated and he is without a return appointment. In other situations, a patient may be told to return in 3 weeks, for example, and when the call is made for an appointment, there is no time available. Thus, it is advisable that most all patients be given a specific day and time for the next appointment, even if the appointment is far in the future.
MANAGING INCOMPLETE APPOINTMENT SCHEDULES
There is no room for overlooked appointments or misunderstandings in a well- run office. Open spots in the appointment book are costly nonproductive periods. Crowded periods are sources of patient dissatisfaction and may jeopardize clinical quality. A tactful assistant can effectively manage your appointment schedule by manipulating appointment times to suit practice needs without disrupting the cordial doctor-patient relationship so necessary in health care. Patients who admire the doctor and respect the services respond affirmatively to tactful requests.
After your practice has been in operation for several years, it is possible to have your appointment schedule filled in advance 95% of the time. This can be accomplished by rescheduling patients on the periodic examination list and patients on a once-a-month program. If, for example, today is Thursday or Friday and your scheduling assistant notes openings for next Monday morning, the appointment book can be examined for patients scheduled to come in later in the week for a periodic check-up. These patients can be called and asked if they would mind coming Monday rather than the previously scheduled Tuesday or Wednesday, for example. Most patients who have not been in the office for several weeks or months usually do not mind such a suggestion. If this procedure is not fully adequate, monthly patients scheduled for later in the week might possibly be moved to Monday. The specific days given in this example are not as important as grasping the logic of the procedure involved. The objective is to see that each practice day represents a minimum of unproductive time. Emphasis is placed on Monday morning because an opening on Monday afternoon will often be filled by a call received Monday morning. Many patients have a tendency to overexert themselves on weekends, and the office telephone is usually busier on Monday morning than any other morning of the week.
Another method to maintain full production capabilities is called "the Recall System." In this procedure, the doctor reviews his files and selects about eight patients that do not have scheduled appointments, are considered worthy patients, and have not been in the office for several months. Such patients have not been properly educated by the doctor on the importance of preventive or maintenance care. Statistics show that for every eight patients telephoned, five of the eight will accept an appointment. No attempt to "pressure" a patient into a return visit should ever be made. More patients are contacted each day until the appointment schedule is filled to a desirable degree, allowing for urgent new patient calls and emergencies.
When using such a system to complete incomplete schedules, a patient's cooperativeness should be noted in the records. Requesting the same patient to change his or her appointment reservation on two consecutive occasions should be avoided. In addition, asking patients to change their time when previously they appeared quite irritated with the request would be an error. Thus, the necessity of detailed records.
It is more difficult in newly established practices, if not impossible, to maintain a completely full schedule for the simple reason that patient volume has not been developed to that point yet. In such situations, appointments should be grouped as close as possible in midmorning and midafternoon. It's more practical to have a full hour open at the beginning or end of a morning or afternoon, rather than four 15-minute or six 10-minute openings scattered about.
NEW PATIENT REFERRAL FOLLOW-UP
In addition to obtaining the patient's correctly spelled name, address, telephone number, and the reason for the visit, it is important when a new patient calls for an appointment that your scheduling assistant ask the caller who referred him to the doctor.
Professional Referrals. If it was another doctor who suggested the call, it is customary that a report of findings and recommendations be sent immediately to the referring doctor. Such cases usually warrant that the condition for which the patient is being referred is recorded when the appointment is made along with the length and type of treatment previously received. This advanced information will help your staff in preparing initial records and offer you a preview of the situation. When the referred patient must travel a considerable distance, your scheduling assistant might ask if the patient would appreciate help in obtaining lodging arrangements at a nearby motel.
Patient Referrals. When it is found that a new patient was referred by an established patient of your practice, it is good policy to send the referring patient a note or letter of thanks. If the referral was instigated by someone other than a patient such as a relative of a satisfied patient or a friend aware of your good reputation, the same procedure should be followed.
Human Relations. As referrals are the life-blood of the practice, the human relations factors must be considered. The foundation for most all new patients ill be referrals from present patients. One survey indicates that less than 6% of new patients will be referred by sources other than present patients. No practice can survive if it depends solely upon referrals from location, the yellow pages, or other influences. When it is realized that 94% of all new patients are the result of direct patient suggestions, the importance of recognizing and thanking patients sincerely for each referral is underscored.
Mechanics. Some offices use a printed fill-in card. However, most doctors feel that a printed card is too impersonal and prefer that an individually typed letter be forwarded. Most offices will have on file several form letters of this nature that can be personalized. Records are maintained to assure that the same patient will not receive the same letter twice.
Public Relations Referrals. If the new patient was not referred by another individual but solely by location of the practice, an advertisement or publicity release of some sort, etc, this should be recorded so later evaluation of your practice's public relations program can be evaluated.
THE APPOINTMENT CONTROL RECORD
To maintain office efficiency and its economics, a minimum of lost production time caused by broken appointments, changed appointments, and tardy patients must be controlled.
An "Appointment Control Record" is helpful in analyzing problem areas. It is a sheet on which each patient scheduled for that day is listed followed by several columns indicating the patient's next appointment. Other data concern a broken, cancelled, or changed appointment, the source of a new patient's referral, and other information of interest.
From both a human relations and an economic standpoint, it is important to have recorded and periodically evaluate the number of cancellations and the reason for the cancellations. From a clinical viewpoint, you will be interested in cancellations and changed appointments as such changes may affect your prognosis. They are also an indication that some patients are assuming responsibility for case management by directing their appointment schedule. When patients do this, there is a breakdown in the doctor-patient relationship reflecting that the patient questions your authority, competence, or sincerity. A control sheet offers a means to analyze the quantity of such occurrences. When the number of new referrals does not exceed the number of patients lost to the practice, your practice is diminishing quantitatively.
Human relations and patient control can be evaluated by noting such factors 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 "troubleshooting" information.
Miscellaneous Problem Resolution
Good appointment planning requires adapting to reality --to face situations as they are and not as we wish them to be. Office policies and procedures are not laws; common sense and good judgment are needed by every scheduling assistant to know when it is logical to bend the rules and when it is not. This talent requires constant nourishing and just compensation for its value to the practice.
You can examine a patient to determine the cause of a health disorder. You can recommend to the patient a plan that you feel would be the best method to correct the disorder in the shortest possible time if it is possible to correct. If the patient accepts the program suggested, he or she can expect that you will do everything possible to see that the plan is carried out. Likewise, you must expect the patient to cooperate by following your recommendations. You cannot accomplish this goal alone. Bringing a sick or disabled patient back 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 your patient and your practice.
In essence, the effectiveness of any appointment control system (or any office system) depends primarily on the doctor himself. If the practitioner is lackadaisical, deficient in professional deportment and authority, does not take the time to adequately train his assistants or supervise their performance, he or she will find that patients will reflect this behavior in their attitudes toward the recommended appointment schedule. If either the doctor or an assistant hesitates to tactfully discuss appointment irregularities with lax or uncooperative patients, they cannot expect to maintain control of the appointment schedule. The consequences are inevitable.
Every well-run practice must have administrative mechanics, but people are not machines that can be operated with simple pushbutton controls. Your scheduling assistant will frequently have to respond to some unusual requests that will test her efficiency and tact. By helping patients without disturbing good management standards, everybody benefits.
Living in reality, the wise assistant will anticipate some appointment changes, tardy patients, broken appointments, last-minute cancellations, times when you will be late, as well as overly sensitive, irritable, and demanding patients. Such situations, however, should be rare for any one patient. A patient who habitually enters your office without an appointment and requests immediate attention or the patient who habitually calls at the last minute for a specific time reservation must be discreetly educated to the necessity of adhering to office policy. Good policy is in the best interests of all patients.
Balance is the key in handling problem situations. First, it should be remembered that a health practice is a service operation. Its primary goal is to serve people in need. Second, office policies must be adhered to whenever possible. If there are too many exceptions, satisfying the needs of a few may be detrimental to the needs of the majority. By balancing the needs of the individual with the needs of the practice as a whole, logical decisions can be arrived at.
FUTURE APPOINTMENT REFUSALS
The doctor must assume the responsibility for proper case management, but he cannot do this if the patient does not grant him the authority to direct and schedule proper care and progress evaluations. This should be thoroughly explained to the patient during the consultation or review of examination findings prior to initiating a comprehensive therapy program. In fairness to both the doctor and the patient, a cooperative spirit must be maintained at all times.
A patient who refuses to accept a future appointment must be educated to understand that you cannot be responsible for the consequences. The patient must assume full responsibility for failure to follow professional advice. If a patient still refuses to accept a tactfully suggested appointment, your assistant should make a notation on the patient's chart of your recommendation and the patient's refusal. This record helps to relieve you from any responsibility for the patient's condition if at a later date the patient suffers a relapse.
Whenever you have recommended a future appointment but the patient fails to make arrangements, the reason should be noted in the patients' records. A "will call" should be considered the same as a cancellation and treated with appropriate follow through and medicolegal safeguards.
Requests for a definite time of an appointment can be a problem area. If the time is available, it should be granted. If the time has been previously filled, your assistant should offer two alternatives as near the requested period as possible and say something to the effect: "What is your second choice of appointment, Mr. Brown? I can probably be more helpful at another time, and then if there is any change in the doctor's schedule, I'll call you immediately." Most patients will appreciate this response rather than receiving a curt, "Sorry, that spot is filled." If no change in the schedule occurs so that the assistant can satisfy the patient's original request, she can telephone the patient and say, "Sorry Mr. Brown, but there has been no change in the doctor's schedule, so I'm verifying your second choice at 1 pm on Wednesday. If a change does occur, I'll call you immediately." This again reassures the patient of personalized interest and enhances office good will --the essence of practice security.
THE UNSCHEDULED WALK-IN
A continuing patient or new patient to your practice who enters the office without an appointment and requests immediate service also requires tact. If it's not an emergency, your assistant should schedule an appointment for the next day. If an opening is available, your assistant can explain office policy yet comply with the request if the patient can be worked into your schedule without causing confusion. The assistant might say, "Because of a recent change in the doctor's schedule, the doctor will be able to see you directly."
Some walk-in patients feel that while you may prefer appointments, they are not absolutely necessary --at least, not for them. An attitude like this soon grows to a lack of respect because your assistant was not in control of the situation on its first occurrence. In due respect for the assistant that does not have the doctor's full support, some patients will bully a timid assistant.
Telephone requests for an immediate appointment can be handled in the same way as requests for a definite time. We are not referring here to the emergency case, but 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, the appointment should be made if an opening is available. Your assistant might say, "You're very fortunate, Mrs. Kingsley. It just so happens that we just had a schedule change." It is never wise to say that the office just had a "cancellation."
Your assistant's good judgment is necessary to determine whether a patient's request for an immediate appointment is a true emergency or not. In fact, you may be liable for actions your assistant may or may not take. If your assistant is in doubt, you must make the decision. Frequently, however, answers to polite questions will offer your assistant the information necessary to arrive at a competent judgment whether the patient should be "squeezed in" a full schedule or scheduled the next day.
When asking questions about a patient's symptoms, your assistant should be taught to never minimize the patient's problems. Patients' complaints are very real to them or they would not be calling. An opportunity should be encouraged for patients to air how they feel and what is happening. Most patients will be more receptive to suggestions after they have fully expressed themselves.
When patients persist in demanding an immediate appointment and your schedule is full, they can be informed that the appointment schedule is full and you are running behind. If a patient feels he or she cannot wait until tomorrow, your assistant should respond that you would be able to take a quick look at the condition today, but it might be preferable to have an appointment the next day when you will have more time to thoroughly evaluate the condition. As few patients want a hurried visit or enjoy waiting a long period only to be rushed in and out, most patients will ask what time the doctor can see them the next day.
Emergencies do happen, and they cannot always be avoided. Life-threatening emergencies are not common happenings in the typical chiropractic office, but your entire staff must know exactly what to do. Basically, there are two types of emergencies: those that happen when you are in the office and those that happen when you are not.
When you are in the office, any emergency situation should be brought to your attention immediately. If a telephone call reports an emergency, it is important that your scheduling assistant be trained to keep calm and in control. Necessary data of who, what, when, and where must be accurately and clearly recorded. These notes, along with the patient's clinical chart, should be brought to you immediately. When you are out of the office such as at your residence, at a meeting, or out socially, the office staff should know how to reach you by your personal calendar. A list of backup professional help should also be at hand.
If office systems are well-planned, emergency treatment can be administered to unscheduled patients without greatly disrupting the schedule. This takes a great deal of staff diplomacy because both the emergency patient and patients with standing appointments feel that their problems are of priority importance. Assistants should be taught that patients in severe pain should always take precedence over scheduled patients. Time is often borrowed from other patients such as prophylactic cases or unworthy patients. Even if the patient has a scheduled appointment, he or she should not be left sitting in the reception room "waiting a turn." Patients not in severe pain do not resent a patient in distress being taken ahead of them, for they realize that everyone can be in the same situation some time and should receive immediate attention.
After a severe accident, a patient may be rushed to your office without time for someone to alert your office that the patient is coming. This must be anticipated and adapted to as best as possible. An assistant should immediately place the patient in a private room and discreetly inform you of the situation. Experience of many practitioners has shown that the emergency patient should only receive services of an emergency nature. Extensive examination and therapy should be scheduled at a later time.
If you will be out of town or unavailable for emergency needs, you should make arrangements with another doctor to attend to patient needs and alert your staff who this doctor is and where he can be located. If your assistant must communicate with a substitute doctor by telephone, some confidential data from the patient's file may have to be reported.
ADVERSE TRAVELING CONDITIONS
Patients living many miles from the office may be subjected to poor driving conditions, inclement weather, undependable transportation systems, and other unpredictable situations that may place a severe handicap in maintaining appointment regularity or promptness. Here, too, attempts must be made to find a logical solution.
PROBLEMS WITH TRANSIENTS
Offering services to tourists is often a perplexing problem. On one hand, you are faced with a person in need and it is your professional obligation to help. On the other hand, because you have no experience with the specific patient, a thorough history and examination are necessary to provide competent care. Few tourists are willing to go to such an expense when they know they will be leaving town soon. You 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 which course of action is preferred. First aid should always be extended upon request, however.
TRAVELING SALESMEN AND SERVICEMEN
Some types of sales or service positions require extensive or emergency traveling to meet customer needs. This may involve a multicounty route or unpredictable service calls to remote areas from community headquarters. It is important that anticipated irregularities to your recommended appointment schedule be explained to the patient and a means sought to assure regularity.
PATIENTS WHO COMMUTE SEASONALLY
A patient may live in Arizona during the winter, for example, reside in Minnesota during the summer, and vacation on the coast. An attending doctor who has recommended a comprehensive health plan must adapt the ideal to anticipate periodic scheduling interruptions. Either the less than ideal must be adapted to or you must restrict service to only prophylactic care until the patient can be convinced it will be necessary to reside in your community for a longer period than originally desired by the patient. While several doctors in different areas who practice closely alike may cooperate on a case of a commuting patient, it is most difficult to do so. In any event, it is important to determine how long the patient expects to be in the area when scheduling appointments.
Employees working in factories whose employment requires a rotating shift pose a problem in maintaining a regular appointment schedule. Entertainers presenting both matinee and evening performances will also present a scheduling difficulty. Policemen, firemen, and nurses on rotating shifts present similar problems.
Before accepting a patient under these conditions, you should educate the patient on the importance of following the case plan. You and the patient must agree on ways to correct irregularities to the recommended schedule. It would be foolhardy to embark on a comprehensive rehabilitation program for a serious condition if it is felt that adherence to the schedule could not be made. If you and the patient cannot agree upon a logical method to establish an effective appointment routine, it would be better to postpone recommended services until such time as a satisfactory schedule could be maintained.
Patients late for appointments cause another type of problem. Because people meet unexpected problems, occasional tardiness must be accepted as a part of reality. On the first offense, the late patient only needs to be reminded that he is late and that the doctor will see him as soon as possible. If necessary, a late patient can be tactfully told that his time with the doctor may be shortened as other appointments have been scheduled. Whether or not the patient will receive the total service scheduled will depend on the type of service specified and how tight the appointment schedule is.
The habitually late patient is a much 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 will not allow the patient to be worked in. A very late patient should be asked to reschedule the appointment or wait until there is time in the schedule for proper care. Such explanations require a great deal of diplomacy on the part of the assistant. They should never sound sharp or paternal.
Patients with undependable appointment habits must be frequently re-educated to the importance of their time reservations. This is only logical if the doctor and staff are punctual. It is most difficult and hypocritical to criticize patients for being late for their appointments if the doctor is consistently behind schedule. A punctuality policy cannot be enforced one way only.
Sometimes it is difficult for a doctor to dismiss a talkative patient. If your assistant suspects such a situation, you may wish to tell her that it would not be inappropriate for her to inform you that the next patient has been prepared and is waiting.
If you are late in arriving at your office and patients are waiting, an assistant should inform the patients that you have been delayed. When you will be extremely late or delayed for several hours, new appointments should be scheduled for those patients who do not wish to wait. A patient who requires immediate attention should be referred to an appropriate doctor on the office's referral list.
Difficult situations can arise when you must cancel one or more appointments. An emergency housecall, bad weather, a special professional meeting, and other unforeseen situations may necessitate several appointments or even the entire day's appointment be changed. When this happens, patients should be notified immediately by telephone or mail, whichever is more appropriate.
Whenever a scheduled time reservation is cancelled, a new appointment should be offered at the same time. Your assistant should give a reasonable explanation as to why the appointment must be changed. Abruptness should be avoided such as, "Mr. Brown, this is Dr. Carey's office. We must cancel your appointment for next Wednesday. Could you come in Thursday?" Such a cold approach would be received by most patients as an indication of little concern for patients' best interests. A better approach would be, "Mr. Brown, this is Dr. Carey's office. Dr. Carey must attend a special meeting in Capitol City at your appointment time on next Wednesday. He asked me to call, extend his apologies, and see if we can arrange another time for you on Tuesday or Thursday. Which day would you refer?" In this example, the assistant has used tact, appreciated the inconvenience to the patient, and offered the patient a choice in selecting the date of the next appointment without greatly disrupting the care plan.
If patient contact cannot be made, the only thing left to do is for the assistant to apologize to patients when they arrive for their appointment. This is an unpleasant task, but it is much better than for patients to arrive and find the office door locked.
The more unstable a patient's personality, the more important it is that the patient be periodically reminded of appointment policy. Severely neurotic and otherwise unstable patients need constant guidance and reinforcement. If such patients fail to profit by the advice, you may be forced to postpone further service until full cooperation can be extended following psychiatric help. If the recommended case program cannot be followed, the patient is wasting money and you are wasting time that could be better applied to cooperative patients.
OFFICE HOURS VS APPOINTMENT SYSTEM
A practice operating on office hours rather than on an appointment basis requires a different approach for the receptionist. In the office-hours system, patients are seen in the order they arrive during office hours. It is important that the receptionist register each patient in the order of arrival for several reasons. It avoids any question who sees the doctor next, provides a record of the patients the doctor sees each day, and allows the assistant to gather patient files in proper sequence. The major disadvantage of this system is that most patients tend to come about the same time. This means that the clinical staff may be idle at some hours and then be forced to handle a large volume of patients at other hours. This situation can be avoided, however, if half the active patients are told to come in the first half of the day and the other half are told to come in the last half of the day.
HOUSE CALL APPOINTMENTS
For whatever nonemergency reason you must make a housecall, your assistant should schedule them to your convenience and in the most efficient manner (eg, grouped by geographic area). 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 of your planned arrival.
When scheduling an appointment for a housecall, your assistant should ask what major streets or landmarks are near the residence and note this for you. Your instrument bag should contain an area map.
The Routing List. If you make prescheduled rounds of house visits, your assistant should prepare a daily routing list so that you need not crisscross the town after each visit. The list should be prepared with consideration for 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 you must be contacted, office staff will have an approximate idea of where you will be at any one time.
Housecall Records. A record of out-of-office visits can be handled by a number of ways:
When you return, your assistant can note on her copy of the routing list the services rendered, the fee involved, whether the fee was paid or charged, and other points necessary to record. These points can then be transferred to the patient's permanent records.
You can carry a pad of printed housecall slips that are filled out at each residence visited. When you return to the office, give them to an assistant for processing.
You can 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 rendered, patient's condition, charges made or payments received are entered on the right-hand page directly across from the patient's name. Such a ledger is usually kept at the appointment desk when you are not on calls so that your assistant can schedule efficiently. Pick up the ledger as you leave for calls and return it to your assistant when you complete the calls of the day. Data from this ledger are then transferred to the patient's permanent records.
You can record all pertinent data on a small portable tape recorder after each housecall. The information is later transcribed by an assistant, edited by you, and then entered into the patient's permanent records.
Changed or Cancelled Appointments
A patient who habitually misses, cancels, or changes appointments might be considered an unworthy patient of your practice. Unworthy patients are considered by many doctors for elimination from the practice. Unworthiness indicates a profound lack of appreciation of the doctor and his services.
It is not logical for any doctor to spend 95% of his time worrying about 5% of his patients who are uncooperative. Lalla puts it this way: "If you encounter patients who want to be the doctor, then they should be freed to go to a doctor who doesn't want to be the doctor --and it's just that simple." The human has yet to be born that can satisfy 100% of the people 100% of the time.
If the case plan is being affected, you should take time to have a heart-to-heart talk with the patient on the importance of appointment regularity. If this fails, steps should be considered for postponing further service until cooperation can be achieved. This may be difficult in the newly established practice where every patient is important to the practice's economic stability. However, such a patient is likely to be a detriment to the practice's reputation. 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 own health needs.
As with other irregularities, patients who change appointments without adequate notice or justification must be tactfully reminded of office policy else the practice would be contributing to the patient's delinquency and help to establish a negative habit pattern. The patient should be made to feel, in a polite manner, that you and patients have been greatly inconvenienced. The assistant might say, "Mr. Jones, you realize that a time reservation has been personally set aside for you. When so many people want to see the doctor, it isn't really fair. I know you will do your best to see that it won't happen again."
Several methods in handling cancellations are utilized. One of the most common methods used when a patient calls to cancel an appointment is to have your scheduling assistant immediately suggest another time. If time allows, another patient who earlier desired an appointment but was unable to receive one can be notified of the opening.
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 would indicate a lack of interest on your part. The reason may be a simple oversight, or it could mean a breakdown in communications. If it was an oversight, the patient may just be embarrassed to call for another appointment. Obviously, if the practice does not show interest and concern for the patient's welfare, the patient will lose interest and concern for your services. If a patient becomes discouraged or has a complaint, you must know this to analyze it and keep similar situations from recurring. For your sake and the patient's welfare, you are obliged to determine the reasons behind cancellations and failures to meet a scheduled appointment.
Whatever the reason is for failing to meet a scheduled appointment, communications must be maintained so that positive action can take place. A cancellation may be the result of a death in the family. If so, you will have the opportunity to forward an appropriate sympathy card. Communication of sympathy, congratulations, and the like cannot be expressed if the facts are not known. This takes follow-up. Intelligent patients appreciate such consideration.
Naturally, all legitimate reasons for cancellation are excusable. Yet even in cases of justifiable excuses, the patient must be impressed with the necessity of maintaining the treatment schedule. If appointment changes are not justifiable, the case plan must be reaffirmed to the patient through education and motivation. The results of such conversations should be noted in the patient's records. Your concern over cancellations and changed appointments reaffirms in the patient's mind the importance of office policy and the staff's interest and concern for the welfare of the patient. When the patient is thoroughly
impressed with the seriousness and importance of the appointment, there is greater desire on the part of the patient to see that there are few appointment irregularities.
Patients who fail to show up for their appointments can be handled in the same manner as that used for patients who habitually cancel appointments without due notice or justification. Habitually tardy patients or "no shows" should be scheduled at the end of morning, afternoon, or evening hours, when they are less likely to cause delays for prompt patients or cause a lull in an otherwise busy schedule.
There are four common reasons for the absent patient:
(1) lack of respect for the doctor,
(2) the patient forgot the appointment,
(3) the patient feels so good that he believes future appointments are not necessary, or
(4) the patient feels worse and is discouraged in continuing treatment.
Lack of Respect. Lack of respect may be the result of the patient's personality, negative environmental factors, or negative conditioning. The cause also may well be within your practice itself. Were telephone contacts handled effectively? Were first impressions positive? Was the patient greeted with a warm and professional approach? Were the case history, examination, and case plan presented in a professional manner? Does the entire staff maintain the highest professional standards, and do their constant attitudes reflect sincere concern for patients' welfare? Was the patient adequately educated of office policies, and were appointment policies emphasized? An objective analysis of the important phases of patient contact will often spotlight weaknesses in the office system.
The Patient Forgot. If the patient simply forgot the appointment, there is usually no difficulty in quickly arranging another.
The Patient Feels Good. If the patient reports that he feels so good that he doesn't believe another appointment is necessary at this time, the assistant might respond, "That's wonderful that you're feeling so much better, Mr. Smith. Dr. Anderson will be glad to hear that because that is what he's been working toward. Let's arrange an appointment for Thursday or Friday so that you can discuss this with Dr. Anderson and avoid any recurrence of this problem. Which would be better, Thursday at 10 am or Friday at 3 pm?" If the patient still refuses the suggestion for an appointment, your assistant should let him know that she will give you the message and that you may want to call him. Depending upon the circumstances of the case and your assistant's report of the conversation, you may wish to call the patient and explain the difference between relief of symptoms and making as much of a permanent correction as possible.
The Patient Feels Worse. If the patient reports that he feels worse, is discouraged, and doesn't wish to continue treatment at present, your assistant might comment, "Mr. Smith, it's only human to get discouraged when response is not coming rapidly. However, the fact that you haven't responded indicates that further treatment is necessary to get you well. Dr. Anderson would not have asked me to call you if he were not thoroughly convinced that further therapy is necessary. Let me arrange an appointment for you on Thursday at 10 am or Friday at 3 pm. Which would be better for you?" If the patient still refuses an appointment, your assistant should let him know that she will pass on the message to you and that you may want to call him. Again, depending upon the circumstances, you may wish to call the patient to attempt to re-establish faith.
If a patient cancels at the last minute or fails to notify the office that he's not coming in, some doctors feel that the time reserved should be charged for. This, of course, is strictly up to your policy. Those doctors who do charge usually do not like to charge a patient for the first offense. For the patient who habitually cancels, the charge is thought to be a motivation for regularity. While a charge for a broken appointment is legal in most states, most doctors feel that the procedure is psychologically unsound except in rare cases. The basic problem that must be corrected is to educate the patient to the need for appointment regularity.
A volume of cancelled appointments can severely effect office economics, as most doctors base their fees on anticipated patient volume and office expenses. To the practice with a tight schedule, cancellations and "no shows" represent a drastic influence on practice stability. If your office is open 200 days a year and you charge $35 for a typical office visit, two broken appointments a day that are not filled represent a $14,000-a-year loss.
In the situation of the absent patient, your assistant should initiate a follow-up call. With the patient's file folder on her desk for reference, she might 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 tomorrow afternoon ...or would Friday morning be better?" Calls to "No-Shows" should be made approximately an hour or less after the patient was due. The goal is to arrange another appointment as soon as possible so that the patient's schedule will not be too upset. 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.
The Departing Patient
After the patient has seen the doctor, the assistant at the dismissal desk should receive the visit slip (Fig. 3.12) from the patient and total the charges for the services and supplies received. She should then tell the patient the total charges and open the receipt book in front of the patient. This invites prompt payment. If the patient pays immediately, a receipt can be offered with a friendly "Thank you!" If the patient requests to be billed and this is agreeable with office policy, the patient is presented a copy of the totaled visit slip as a bill. The assistant then presents any literature or supplements recommended by the doctor, arranges another appointment for the patient according to the doctor's instructions, and sets up an appointment verification date according to office policy.
When asked the secret of his success, a famous chef once admitted that few people remember more than the first and last course of an excellent dinner, thus he gave these courses extraordinary attention. This supports the idea that both first and last impressions prevail. In bidding good-bye to the patient, your assistant should remember that it is the last chance for personal contact with the patient that day and the last opportunity to enhance good will by making a favorable impression. If the patient needs a taxi, a cab should be called. The elderly or disabled should be assisted with their coat and boots if necessary, reminded of personal packages, and offered an appropriate farewell as the patient leaves: "We'll be looking forward to seeing you on Monday, Mrs. Wilson." If a patient is departing when your assistant is on the telephone, the assistant should always spare a moment to recognize the patient, smile, and say good-bye. A courteous farewell is good manners, professional conduct, and excellent human relations.
Even in solo practice, a communications gap can exist between doctor and assistant. A good memory may fail at the most unpopular moment. The best prevention is if it's worth remembering, it's worth a written notation. Soukhanov states that "Information is the basis of all decision making and planning. No organization can grow and prosper without adequate records."
A record eliminates guesswork and avoids the chance of forgetting instructions or patient's comments. In times of personal sickness or a vacation, records carry on in your absence. Many attorneys who specialize in malpractice cases feel that accurate, comprehensive, and neatly prepared records are the doctor's best defense. These points are true for both your clinical records and your assistant's administrative records.
Record Function and Management
Chiropractic physicians are both legally and ethically responsible for providing quality care. This responsibility includes adequate documentation, although statutes are quite vague on exactly what is required. Nevertheless, documentation offers the best record of what was done, when it was done, and its effects. Thus, proper surveillance of comprehensive data flow is imperative.
Record management can be defined as the systematic control over the development, maintenance, storage, and protection, of records. It is critical in health care because the data are highly confidential and the absence of accurate facts may jeopardize appropriate patient care.
Quality records protect the interests of both the doctor and the patient, save preparation time, and reflect a well-organized office system. Accurate information helps the doctor provide quality services, aids the continuity of patient care, and serves as a clinical and legal history of the doctor-patient relationship.
Anyone 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 requirements. Regardless of who does the recording, accuracy and completeness must be above criticism. The test of good records is a presentation that a knowledgeable third party (eg, consultant) can easily obtain all pertinent facts about a patient's condition, treatment, and progress.
Case records are as important to the patient as they are to the practice. Courts will frequently recognize written records and not accept solely the verbal testimony of a professional witness. 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 in practice development.
Studies have shown time and again that the doctor who keeps accurate and detailed records of all important phases of his practice, and evaluates them carefully, is bound to be more successful than one who doesn't. The number of new patients, the number of broken appointments, the number of x-ray and physical examinations in a given period, and other such accountings, are the only means you have of objectively analyzing and controlling your practice. This is impossible without good assistance, adequate records, and efficient management systems.
Every office requires an array of records and communications, but the specific types of records and reports necessary depend upon the nature of the practice.
Types. There are two basic classifications of records: administrative records and clinical records.
Administrative records concern the business side of practice. They help in scheduling, financial control, analyzing practice growth, and recording information for business and tax purposes. These records should be kept separate from clinical records because auditors legally accessing accounting records have no right to confidential clinical information.
Clinical records concern the health-care aspects of the practice. The patient's history, examination findings (initial and progressive), your diagnosis, the therapy recommended and extended, the patient's progress record, summaries of findings and treatments rendered by outside consultants or facilities, and consents for examination, treatment, and data release constitute the patient's basic case record. Without these records, few doctors would be able to remember from one visit to another what was previously learned or accomplished. Such records must be referred to often during initial treatment and whenever the patient needs subsequent care.
Below is a list of records found in a typical chiropractic office:
Address file or book
Laboratory request slips
Lending library records
Appointment book sheets
Medicare receipt slips
Patient recall cards or letters
Cash disbursement reminders
Patient scheduling sheets
Collection letters, cards, or memos
Permanent ledger sheets
Personnel time cards
Daily financial control sheets
Petty cash slips and vouchers
Daily work sheets
Recall file cards
Entering patient data forms
Referral cards or slips
Equipment inventory sheets
Reminder memos, letters, or cards
Excuse slips (Fig. 3.13)
Roentgenography record forms
Expense book or forms
Statements and envelopes
Financial account records
Supply inventory control sheets
Financial arrangement form
Telephone number file
Furnishings inventory sheets
Health insurance claim forms
Worker's Compensation forms
House call slips or notebook
X-ray ID cards.
Related supplies might include the following:
Assistant's professional cards
Health education literature
Corrective exercise forms
Letterheads and envelopes
Doctor's professional cards
Referral thank you cards and letters
Standard case instruction sheets
Stock announcement cards (Fig. 3.14)
Thank you notes.
Quantity. How many records to have is determined by actual need, and this is often a problem. Too few records result in poor patient and administrative control, and too many records increase office "red tape" in case management. The ideal number would be an inventory of records and forms that would offer the least number of items in stock which would allow the simplest and most efficient method of practice management.
During the initial telephone contact, the assistant usually puts some information on a form when the appointment is scheduled. This information is held in a "future appointment," to be reconfirmed by the assistant on the patient's arrival when more detailed data are recorded.
Old and new records should be made ready by an assistant prior to the arrival of the first patient of the day. You will undoubtedly wish to review each patient's file before the patient is seen professionally. During the visit, it is customary that you enter notations as to case actions and progress and not on the visit slip the services rendered. After you dismiss the patient, the patient presents the visit slip at the dismissal desk. The assistant totals the slip, determines how fees will be paid, and enters the completed visit slip into the patient's records. The patient's next appointment is then scheduled.
If laboratory work is necessary, the assistant makes necessary arrangements and offers the patient appropriate instructions. If vitamins or minerals have been dispensed or if rehabilitative equipment has been loaned, rented, or sold, entries should be made within the records. When it is known that the patient is scheduled for roentgenography on the next visit, this should be noted in the patient's record so that the identification marker may be prepared in advance. If the office has a lending library, all books leaving the office should be noted. When appropriate, entries are made for recall, thank you letters, etc, and entered either in the case record or another file.
Record flow is determined by your office policy. The above routine offers a general system that must be amended to meet individual needs of a specific practice.
Entering Patient Data
Every office requires certain basic data on every new patient to initiate the patient's file. The basic information gathered from a patient new to the practice is often called statistical data or identifying information.
When patients new to the practice enter the office, they are typically greeted by an assistant, seated comfortably, handed a clipboard to which has been attached a form, and requested to fill out the information desired. The information usually requested concerns the patient's name, address, mailing address if different from the patient's residence, telephone numbers (ie, residential and business), date of birth, chief complaint, marital status, number and ages of children, occupation, employer, referral source, and health and accident insurance company data.
Each of these facts has a specific purpose. The date of birth is a more courteous request than age, and it gives information that can be transferred to a birthday-record book if the office mails cards in recognition of patients' birthdays. For legal and insurance requirements, it is always good to have the patient's chief and minor complaint in the patient's handwriting. Marital status and number and ages of children offer the doctor an initial overview of the patient's family environment. If the office sends out anniversary cards, a space should also be provided to record the date of the marriage. Occupational and employer data are necessary if the case is an industrial accident or if the patient's occupation has an influence upon the complaint that must be controlled.
Referral source gives the office an opportunity to thank the person who referred the patient to the practice. Insurance data (eg, company name and account number) are necessary for billing and/or reporting purposes. If the patient is a minor or incompetent, space should be provided to record the name of the patient's parents or guardians. This is necessary to obtain legal consent for services to be provided and for billing purposes.
This form usually concludes with a printed statement of standard office policy concerning payment for services rendered such as "Payment is expected at the time of the visit unless other arrangements have been made in advance." Whatever the office policy is, patients should be informed as soon as possible. After the patient completes the form, an assistant should review it to be sure that all appropriate blanks have been filled and that the writing is legible.
Case History Procedures and Records
The case history offers a permanent record of the patient's disorder and its evolution and background. In many respects, it is an elaboration of the patient's chief and minor complaints along with other facts necessary for accurate case evaluation.
Confidentiality. Absolute privacy must be granted the patient whenever case history data are being recorded. This confidential information is not for the ears of strangers, friends of the patient, or even relatives of the patient unless the patient is a minor or legally incompetent.
Questionnaires. To save patient and office time, many doctors utilize a type of personal history form that requires only a simple "Yes" or "No" answer which can be checked or encircled by the patient. These forms are usually designed so that a group of questions refers to a pertinent system of the body. The major advantage is that the listing offers a reminder of important factors. The major disadvantage is that no form of this nature can list all the points that should be discussed in a particular condition.
Assistant-Gathered Data. In many offices, an assistant is delegated the responsibility of recording some of the case history data. Assistant-gathered information is usually restricted to the patient's chief and minor complaints, when present symptoms first appeared, how long the disorder(s) has existed, what the patient has done about the condition, the patient's medical and surgical histories, the patient's accident and obstetrical histories, dietary and recreational habits, and the patient's family and social histories. These points will offer you specific facts that can be explored in detail. If a patient appears to feel embarrassed to tell an assistant necessary information, the assistant should not press the point but she should inform you of the patient's hesitancy.
Doctor-Gathered Data. During consultation, you should deeply investigate the information previously gathered, conduct a thorough systems review, and arrive at a judgment of what type examination procedures would be best suited for the particular complaints involved. Several authorities state that a good patient history will offer 85% of the information necessary to arrive at an accurate diagnosis.
At the completion of the consultation, you should propose the type of examination felt necessary and explain any possible hazards involved if appropriate. Upon receiving the patient's "informed consent," the examination proceeds or another appointment is scheduled for the examination.
Case History Records. Case history forms come in a large variety of sizes, shapes, and styles (Fig. 3.15). There are cards, double cards, sheets, and multiple-page forms. Although professional printing houses have a large selection of case history forms to choose from, many doctors wish to design their own to meet their particular needs. There are two reasons for this:
(1) many doctors do not like to be restricted to a standardized format, preferring to develop case histories in their own way as the situation demands;
(2) if all areas on a printed form are not filled in, the doctor may be subject to negligence.
Thus, some doctors dictate case histories according to an established general format and have the information typed later on plain bond.
Subjective patient data obtained in the case history must always be supported by objective diagnostic data. Both positive and negative findings should be recorded. After the patient is examined, you will record or dictate the results of your physical examination, orthopedic and neurologic findings, spinal analysis, x-ray and laboratory findings, and other data necessary to profile the patient's condition. In an uncomplicated condition, case history and examination procedures may sometimes be completed in a matter of minutes. In a severe or chronic condition of an obscure nature, this process may take several visits before a working diagnosis can be arrived at.
Regardless of the nature of the patient's complaint, you should meet with the patient after the history and examination findings have been evaluated to discuss professional opinions and recommendations for treatment or referral to another practitioner. The liabilities involved in not obtaining proper consent for examination and treatment will be discussed in greater detail in Chapter 10.
While the case history indicates the patient's health status at the time of the initial visit, progress records indicate the patient's state of health at subsequent points in time. Progress notations constitute a permanent narrative record of what was done and offer a chronological record of patient status.
Each time a patient returns to your office on subsequent visits or a housecall is made, the patient's condition should be recorded together with changes in treatment or to previous instructions. Dated entries should also be made for any telephone report made or advice given. Instructions or literature given, unusual occurrences and reactions, failure to follow professional advice, reasons for referral, and refused recommendations are also important points to note.
Progress records should indicate the patient's name, the date and place of the visit, the examination procedures conducted, the therapy administered (type, strength, distance, pressure, duration, special instructions, etc), how the patient responded, the type of service the patient is to receive on the next visit contingent upon examination findings and patient progress, necessary dietary instructions, exercises, home therapies, occupational and recreational restrictions, and changes to previous instructions. These facts allow continuity of patient care, record the type and quality of care administered, justify payment for the services delivered, portray the facts upon which clinical decisions were made, offer evidence against claims of negligence, and serve as a basis for submitting reports to appropriate agencies.
All entries made on a patient's record should be initialed by the person making the entry regardless if it be the doctor or an assistant. This is especially important when several staff members may be making entries on a patient's record. If an assistant or associate is new to the office, it differentiates these entries from those of predecessors.
Chart Routing Slips
In large practices that require several assistants and possibly more than one doctor, a routing slip is helpful when several people are involved during a patient's office appointment. A routing slip enables each staff member to initial each service conducted as it is completed. This can avoid an oversight.
Day sheets itemize professional activities conducted on a specific day, offering a summary of the doctor's professional and financial affairs (Fig. 3.16). Their primary purpose is for activity and growth analyses, but they also serve as a cross-check against posting, billing, filing, and third-party reporting deficiencies. Thus, day sheets are one of the most important control sheets in the office.
How the activities are broken down is a matter of personal preference. Many doctors total daily office visits, initial examinations, housecalls, consultations, and laboratory tests. Financial data are also summarized such as total charges and collections for the day.
The typical doctor of chiropractic belongs to several professional, social, and fraternal groups that assist in broadening his or her professional skills and social standing. It is thus helpful to have an office record of your memberships, headquarters address and telephone number, month when membership fees are due, regular meeting dates, related publications, and a summary of special duties or positions. Each sheet or card should have an area to list dues payments: date mailed, check number, amount, and expiration date.
An annual meeting calendar for the current year is helpful in advanced scheduling (Fig. 3.17).
Postgraduate Education Log
Most states have established specific requirements for re-licensure. As the number of hours required and the courses and seminars approved vary from state to state, contact should be made with the State Board of Chiropractic Examiners for specific information. Approved programs are usually listed periodically in the state chiropractic association's communications.
It is helpful to develop a continuing education log (Fig. 3.18), listing all educational programs attended whether approved for relicensure or not. Programs not approved in one state may be approved in another state in which a license is held. It is important to file and safeguard all certifications of attendance so that proper credit can be given.
Credit cards are a convenience to many doctors. They minimize the amount of cash that must be carried and offer a record of purchases. However, if they become lost or stolen, severe difficulties may result. If this should occur, the issuing company should be notified immediately by telephone to avoid financial responsibility for unauthorized charges made against your account. Thus, a log of your credit cards is an important record (Fig. 3.19).
Emergency Telephone Numbers
Although dire emergencies are rare in a chiropractic office, they do happen and your entire staff must be prepared to act calmly and decisively. This requires established policies, procedures, and training. A log of important telephone numbers will save time and eliminate confusion (Fig. 3.20).
Each doctor develops a list of particular specialists to whom he or she refers patients for specialized attention (Fig. 3.21).
Your professional history, periodically updated, should be on file at the office so that your employees will know your background to the extent that questions from patients can be answered appropriately. Typical data to include are your full name, date and place of birth, family background, speciality (if any), states in which licensed, educational background, professional association affiliations, official positions held, awards and special recognitions, major publications, and professional certifications and fellowships.
Another helpful log is that for personnel (Fig. 3.22). This should include each staff member's name, title, address, and telephone number in the event offduty personnel must be contacted. Data of your attorney, accountant, banker, insurance agent, and travel agent can also be placed on this list for ready reference.
Office policy will determine the extent of your assistant's responsibilities for handling office mail and correspondence. In any event, communication processing should be frequent, smooth, and alert to priority situations. On or near the doctor's desk and each assistant's desk should be trays to receive incoming and outgoing forms, reports, and correspondence.
Management of Incoming Mail
Every office receives a large quantity of mail each day. In comparison, incoming mail far exceeds outgoing mail except when office statements are mailed. Some mail will be urgent or important, some will be of casual interest, and some you may classify as "junk" mail. Training is necessary so that your assistant is alert to what you consider "junk" mail (not to be forwarded), what incoming mail you want to see first, what priorities should be given to certain types of mail, and how the mail should be organized. An assistant properly trained in screening the mail and processing routine requests will save you a considerable amount of valuable time. However, incoming mail marked "personal" or "confidential" should not be opened by a third party.
To save your time, you may wish an assistant to directly process payments received, appointment requests and changes, routine insurance forms, and customary bills to be paid. If a controlled purchasing system is not in effect, it is good policy to initial all statements or invoices prior to payment.
SORTING AND PROCESSING
In most offices, it is the responsibility of an assistant to sort the mail, slit the envelopes, remove and open the contents flat, attach the contents with a paperclip, stamp letters with a dater, and stack the mail in an orderly fashion. There is usually no reason to retain the envelope unless the letter does not contain a return address or if the addresses do not match. If it is absent or does not match, the envelope's corner imprint can be cut from the envelope and taped to the letter.
Mail Sorting. Most doctors do not like their mail screened, but they do like it sorted. Following is a common priority order for mail sorting:
2. Registered letters
3. Special delivery letters
4. Express mailings
5. First-class professional mail
6. First-class business mail
8. Third-class circulars
Some doctors also desire that their incoming first-class mail be subdivided. One common procedure is for an assistant to sort the mail into three piles:
(1) those letters that require the attention of someone outside the office staff;
(2) those that require the doctor's personal attention; and
(3) those that require an assistant's attention.
Distribution. Mail should be immediately distributed after sorting to the most interested party. For example, personal mail goes to the person to whom it is addressed. Checks and overdraft notices should be attached to the patient's ledger card and given to the person responsible for posting payments, and invoices and statements should be given to the person in charge of accounts payable. Upon receipt, supplies should be checked against the requisition order and listed on the inventory sheet, the packing slip should be attached to the purchase-order copy and filed under accounts payable, then the supplies can be placed in their proper storage area.
Priority. When a great quantity of mail is received, it is helpful to have it sorted according to priority. In most offices, laboratory and pathology reports are given top priority, followed by incoming checks, bank credit and debit memos, requests concerning patients, other requests, and bills, respectively.
Attachments. If the letter is a reply, it is helpful that the office copy of the original letter be attached. If the letter refers to a patient's account, it is efficient if the patient's financial ledger card is attached. Letters from patients or about patients' health status and laboratory and pathology reports of patients should be attached to the patient's clinical file.
Requests Requiring Multiple Action. If one staff member attends to part of a letter before it is sent to someone else for further action, a paragraph that has had attention should be noted, dated, and initialed (eg, Did 6/17 JM).
Document Routing Slips. If several people should see correspondence, a report, document, or publication, routing slips can be used effectively (Fig. 3.23). The originator need only fill in the numbered sequence of the routing. Each person then initials and dates his review before forwarding.
Enclosures. When the mail is opened, care should be taken to assure that all contents have been removed from the envelope. Patients will frequently insert small notes when paying bills. These can easily be overlooked and discarded if the envelopes are not carefully inspected. When your assistant opens the mail and notices that a letter refers to an enclosure that is not enclosed, she should make a notation to that effect on the letter before you receive it.
X-Ray Films. Films from another facility should be left within their mailing tube or envelope. This will assure that the proper size tube or envelope is at hand when the films are returned.
Mail Processing in the Doctor's Absence. If you are scheduled to be out of the office for several days because of a meeting or a vacation, your assistant should be informed of what mail she is authorized to respond to and what mail she should hold for your return. Any type of mail the assistant is normally authorized to process should be processed in your absence. However, there may be some other correspondence that you wish your assistant to acknowledge receipt with a note that you will reply as soon as possible on your return. Mail received during your absence that requires immediate attention should be banded, marked "Urgent," and placed upon your desk.
The Holding File. Copies of correspondence requesting reports, insurance statements, etc, that cannot be replied to immediately should be placed in a readily accessible holding file. This important file should contain a copy of the request until the request can be fulfilled. A holding file is also a constant reminder of things to be done. It should be reviewed daily to determine the status of its contents.
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 (Fig. 3.24).
Correspondence containing checks requires special attention. Your assistant should examine each check to assure that it has been signed and properly dated.
Each check should be reviewed to assure that the written amount and the figures match. Improperly prepared checks returned from your bank can cause confusion in your bookkeeping system. Patients can make both unintentional and intentional errors. When noted, your assistant should tactfully call this to their attention so that a correction can be made.
If a check is received that is marked "in full settlement of account" or "final payment on account" and the amount is below the account's balance, your assistant should immediately call this to your attention. Depositing such a check may make it impossible to collect the full balance due.
When a check is properly made out, the proper data should be entered within the daily record and patient's ledger. Care must be taken that an error is not made as the information is transferred.
As some patients write checks with a minimum of funds in the bank, all checks received should be processed and deposited daily. Banks operate on a "first come, first served" basis.
Management of Outgoing Mail
Office policies differ widely in replying to or developing correspondence. Some doctors prefer to prepare a handwritten draft from which an assistant types. If your assistant takes shorthand, you may wish to dictate letters. If dictation equipment is available, you may prefer to use it in developing correspondence. In routine situations, with a well-trained assistant, you may wish to make only a few notes from which the assistant can prepare a complete and more formal letter or report.
Timing and scheduling are also important aspects of good mail handling. Some doctors prefer to set aside a special time each day to review incoming mail and developing replies. As a chiropractic office should maintain an image of efficiency and promptness, mail requiring an answer should be responded to within a day or two of receipt if possible.
MECHANICS AND STYLE
As your office will be judged by some by the appearance of its letters, the composition should be well spaced and composed accurately, neatly, and in accordance with an acceptable professional style. This will reflect thought, care, and concern. A letter's appearance, content, tone, and grammar will often determine a favorable or unfavorable response.
Ziegler points out that every letter that goes out of a doctor's office contributes to the image of the practice, regardless of whose signature it carries. However, the proper form to use in developing professional correspondence varies with what authority is used and your personal preference. An excellent reference source is the ACA's Basic Chiropractic Paraprofessional Manual.
What letters an assistant will write above her signature and what letters she will prepare for your signature is a matter of your office policy. Some doctors prefer to sign all letters. Other doctors sign only those letters dictated and authorize an assistant to sign his or her name to certain types of correspondence.
If a writer might be offended when his letter is answered by an assistant, it would be poor procedure to create a negative impression. However, if the writer only desires specific information regardless of source, the assistant is usually allowed to compose the letter over her or the doctor's signature.
Letters With an Assistant's Signature. Typical letters written over an assistant's signature are those that acknowledge routine correspondence received in the doctor's absence, follow-up letters, replies to meeting notices, requests for refunds, hotel and automobile reservations, letters arranging appointments, collection letters, letters calling attention to account errors, service complaints, and letters of a routine business nature.
Some doctors expect an assistant to handle nearly all correspondence except those of a strictly clinical nature. However, except for form letters, it is good policy to at least quickly review all office letters that are mailed regardless of whose signature they contain. Generally, the assistant's responsibility will be limited by her ability to parallel your desires, tone, and style.
Letters With the Doctor's Signature. The major category of letters that will normally be prepared for your signature are those concerning a case, contractural arrangements, the legal aspect of the practice, and personal letters. With experience, an assistant may be able to develop a first draft of such letters without detailed instructions; eg, after a few words or guidance or from brief marginal notes on the incoming letter. Whether you dictated the letter or prepared the initial draft, you should review the final letter after it has been attached to its envelope and possible enclosures before it is signed and mailed.
In the event of your prolonged absence, you may wish to authorize an assistant to sign your name in routine correspondence, with the assistant's initials placed beside your signature. Some offices do not require such initialing.
As a legal safeguard and management control, a copy of any correspondence leaving the office should be filed. For example, letters should be carbon-copied, duplicated, or filed on a word-processing disc. Memos given to patients are often best made in duplicate so that a dated copy can be placed in the patient's file.
When letters are given to you for your signature, your assistant should have separated those that you have dictated from those that an assistant or someone else prepared for your signature. As contrasted with executives, most doctors prefer that letters requiring their signature not be accompanied with the carbon copy or envelope.
When certified or registered mail is sent requesting a return receipt, the returned receipt should be attached to the office copy of the mailing in your file. This documents proof that the mailing was received by someone at the residence in case of certified mail or was personally received by the addressee in case of registered mail.
Enclosures should be clipped to a letter requiring your signature unless they are quite bulky. Regardless, mention of the enclosure should be made as a postscript notation in the letter itself.
When enclosures are approximately the same size as the letter, the common procedure is for your assistant to fold the enclosures, then fold the letter and slip the enclosures inside the last fold of the letter so that when the letter is removed from the envelope, the enclosures will come out with it. If the enclosures are smaller than the letter, they are often clipped to the letter in the upper left-hand corner on top of the sheet. If two or more enclosures are to be sent, the smaller one should be placed on top. If the enclosures are larger than the letter, your assistant can either put the unfolded letter and enclosure in a large envelope, or an alternative is to affix the letter envelope with first-class postage to the face of a arge evelope with either first- or third-class postage.
PERSONALIZED FORM LETTERS
Your office will find it helpful to keep a file of form letters and model paragraphs that may be referred to in similar situations, thus saving time and thought whenever a letter need not be slanted toward a particular reader. They are efficient as they are usually based on a great deal of creative thought as opposed to a letter developed "off the top of your head." However, any form letter or paragraph will need periodic review to see if it is still current with today's needs or require minor changes to suit a particular reader.
THE DAILY RECORD
It is good policy to have a simple daily record kept of all important mail sent out of the office each day that requires action by another person. This is especially important for insurance records, reports, and legal documents. A daily record serves as a check on the receipt and disposition of mail that may get misplaced (Fig. 3.25). The typical format of a daily record for outgoing correspondence is a three-ring binder to hold letter-size forms.
Stamps. If the vast majority of your office's outgoing mail consists of first-class mailings, all you will probably need is a coil of stamps. Coils are better than sheets as they take up less space and are easier to tear apart at the perforations. As first-class postage rates are determined by the ounce, so second-ounce stamps (which are about half the cost of first-class stamps) should be kept on hand.
Meters. If your office is required to send considerable third-class mailings or parcel-post packages, a small or medium-size postage meter would be of benefit. However, certain precautions must be taken when a postage meter is used. Instruct your assistant to change the date of the meter the first thing each morning. Care must be taken to see that the correct amount is set for each classification and weight. Daily entries must be made within the meter record book showing ascending and descending totals. If these totals do not balance, the machine requires immediate repair. When the meter is refilled at the post office, the record book must accompany the machine. An adequate amount of postage should be purchased to keep trips to the post office limited to a monthly basis. If mistakes have occurred while metering, the meter stamps not used will be refunded or credited at the post office.
No practice or business can be operated successfully without its key people being able to retrieve information quickly. 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 other information that is needed from time to time. Thus, prompt and proper filing is of great importance.
All correspondence and their answers should be filed promptly, with the most current letters filed at the front of the file folder. Office policy differs widely whether clinical correspondence should be filed with the patient's records or if the correspondence should be filed in a separate folder under the name of the individual, institution, or company, in alphabetical order. Filing with the clinical records is the common practice in solo practices.
Aside from patient record files, additional card files that remind you and your assistants of important dates and matters to be taken up at a later date reduce burdening memories with sundry details.
The prime requisite of any good record system is accuracy, completeness, and immediate accessibility, along with simplicity in recording, filing, and retrieving information. No system is any better than the manner in which it is used. An efficient filing system should provide for at least three general types of records:
(1) patients' clinical records;
(2) patients' financial records; and
(3) general correspondence, reports, reprints, legal documents, inventory sheets, etc.
All systems require alert attention. No system will run itself. Filing by an assistant may be delegated to a certain part of each day, with a carry-over from one day to the next avoided. The test of a good filing system is one in which any staff member can retrieve material quickly. Simplicity, organization, and convenience are the keys to smooth function and efficiency.
SECURITY AND PRESERVATION CONSIDERATIONS
Your entire staff should be cautious in keeping records out of sight of patients. They should never be left lying open on a desk when unattended. People are curious and can easily be frightened by what they read and misunderstand. All records developed at your office are records that belong solely to you. If a patient's record cannot be found, have an assistant first look through the entire letter of the file alphabet to see if it has been previously misfiled.
Next, she should check the desks of other staff members where files are commonly placed when in transit. To avoid misplaced documents whenever anything is removed from a file, an "out card" should be inserted in its place, noting at least what was removed, who removed it, and the date it was removed. Such a record (Fig. 3.26) will save much frustration in locating missing documents.
SPACE AND STORAGE CONSIDERATIONS
Few offices contain excess filing and storage space. Thus, prudence must be maintained. Several methods can be utilized to save file space:
(1) Loose papers take less space than those which have bulky fasteners, clips, or staples. Of the three, staples are the best unless the papers must be separated.
(2) It helps to transfer papers and records that should not be destroyed, yet are rarely referred to, to inactive storage facilities. If such material is stored in boxes, each box should have an outside label indicating its contents.
As current patient files have the greatest use, their cabinet or shelf should be placed next to the assistant's desk. As your practice matures, cabinets or storage boxes holding inactive and closed files can be placed in a distant storage room so that valuable active office space is not burdened.
SAFES AND VAULTS
Valuable papers, personal and professional, should be stored in one or more safety deposit vaults. Documents deserving special care include contracts, deeds, leases, mortgages, title abstracts, surveys, birth certificates, diplomas, marriage and divorce records, wills, passports, investment records, insurance policies, stock certificates and bonds, copies of current licenses, and inventory lists. Originals are usually stored in a safety deposit vault of a bank with copies in your office's safe for quick reference.
Federal and state statutes of limitations and your preference determine what should be destroyed and what should be stored in active and inactive files. Most doctors wish to keep all case, legal, financial, and tax records regardless of the statutes of limitations. A patient may return after many years or a patient's children may be benefited from knowledge within a parent's record. However, grossly outdated correspondence, literature, records, and catalogs that are not longer pertinent should be periodically destroyed to save active filing and storage space. When inactive, former, and closed files become a storage problem, microfilming is one solution.
When destroying material (eg, shredding) that was once considered of value, each item should be listed on a sheet and someone should be with you to witness the destruction. This offers documented proof of disposal in case the action is later questioned.
Types of Filing Systems
There are two general filing systems popular in chiropractic offices: alphabetical indexing and numerical indexing. Of the two, alphabetical indexing is the most popular in small and medium-size practices.
Most offices file strictly alphabetically by the patient's last name or subject of the topic to be filed. In large volume practices where several patients may have the same name, patient's records are filed by case number and the patient's number is cross-indexed to an alphabetical list that incorporates the patient's address. It is not unusual in large practices to have several patients with the name Mary E. Smith or John J. Jones. Regardless of the system used, guides should be used to divide the drawers into appropriate sections (Fig. 3.27), and patient folders or pockets should be used to hold all records of a patient or topic.
The Three-Unit System. There is little difficulty in assigning the correct alphabetical position in the file to each patient's record when indexing is done by the unit method. 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 initial. For example:Unit 1 Unit 2 Unit 3 Jones John J Jones John L Jones Mary P Jones Mary W
Two difficulties sometimes arise within the three unit system. First, family chart errors are difficult to avoid. Second, confusion results when patients have the same first, middle, and last name.
The Five-Unit System. A more sophisticated form 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 person's nickname or name by which the patient prefers to be called, enclosed by parentheses. For example:Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 JONES Mr John J (Johnny) JONES Dr John J (Jack) JONES Mrs John J (Mary) JONES Miss Mary J (Mary)
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 by offering in parentheses the patient's preferred first name. This system greatly reduces the risk of having two files labeled identically.
Miscellaneous Folders. In alphabetical indexing, it is good procedure to have a miscellaneous folder for each letter of the alphabet that is placed behind the last folder within a particular alphabetical section. Material may be filed here for which there is no separate name folder. Filing within this folder should be made alphabetically rather than by date. Papers relating to a particular subject should be clipped together; and when they reach a logical number, a separate folder may be made.
Presorting. It is often best that your assistant presort all charts to be filed before they are actually inserted into the filing cabinet. This organization saves time and effort by allowing proper sequencing at the assistant's desk so the actual filing can be completed without going back and forth from drawer to drawer.
Numerical indexing is sometimes used in large practices conducted by several doctors and assistants. In a numerical indexing system, identifying numbers are used on the file folders that are arranged numerically. The advantages of this system are those of fast and more accurate refiling, the opportunity for indefinite expansion, and confidentiality.
While numbers may offer an illusion of modernity and conciseness, the system has several drawbacks. After each patient is assigned a case number, the patient's folder is labeled by the number and this is followed by the three-unit alphabetical system (eg, 1476 - Jones, John L). A small cross-index card must also be prepared that contains the same information in reverse (eg, Jones, John L - 1476). 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 that the same number will not be assigned to different patients. The extra steps involved in this system offer few advantages over the more simpler alphabetical system. It is more appropriate for businesses that have thousands of active accounts.
Some offices use different files for different categories of patients. Some use the same file, but folders are color coded to indicate the appropriate category. Folders can be color coded, forms and papers can be color coded, and stickers can be color coded to signify subdivisions. Color coding also speeds retrieval and reduces misfilings. For example, colored folders can be used to subdivide letters of the alphabet:
ABCD Red EFGH Yellow IJKL Blue MNOP Orange QRST Green UVWXYZ Purple
A growing number of offices use elaborate color-coding systems to indicate subdivisions within a particular major category to differentiate cases (eg, Medicare, Medicaid, worker's compensation, Health Insurance, etc). Color codes can also be used to indicate any number of signals such as patients who are excellent sources of referrals, the numbers of years the patient has been an active patient, etc.
Filing equipment comes in a large variety of styles and sizes. Current case records, inactive case records, subject files, correspondence files, tickler files, public relations files, and financial records, for example, may be filed in separate cabinets or within the same cabinet as space permits. Most all offices, however, use separate cabinets for active and inactive case records.
The 15-inch X 28-inch four-drawer letter-size filing cabinet is the conventional style. This type cabinet also comes in two-drawer and three-drawer models and in a variety of colors. They take up considerable room depth, but not too much wall space. If room depth is a problem but wall space is not, cabinets can also be obtained in which folders can be stored sideways.
Typical File Organization
Case records should be filed separately from all other materials; eg, subject and nonpatient correspondence files. Preferably, this should be within another cabinet or at least another drawer. Case records should also be separated into at least active and inactive files, based upon activity. For example, if a patient has not visited the office in 2--5 years, the patient's records are placed in an inactive file. The cut-off point is a matter of personal judgment and the storage space available.
If the case history form is not a self-contained folder, a manila folder should be made for each patient and labeled according to either an alphabetical or numerical system. The case record folder normally contains all pertinent clinical data, releases, and correspondence about the patient. The usual custom in organizing patients' file folders is to place the newest material, that with the latest date, at the front of the folder with records running from back to front in chronological order.
THE ACTIVE/INACTIVE/FORMER-PATIENT SYSTEM
You can divide patient 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, do not owe the office money, but are likely to return;
(3) former patients who are not under care, do not owe the office money, but are unlikely to return. This latter category is usually used for patients who have not been heard from in 2--3 or more years, were transients, have moved from the community, or are deceased.
Active, inactive, and former patient files are usually placed in an alphabetical file where the folders are placed behind alphabetical tab dividers. When such files become crowded, they may be subdivided according to second letters (eg, Aa--Al, Am--Az). When any section contains more than 20--30 folders, it should be subdivided. A wide variety and styles of guides can be obtained from a business supply store. Subdividing enhances organization and rapid retrieval.
THE CURRENT/ACTIVE/INACTIVE-PATIENT SYSTEM
As a popular alternative, you can separate patient records into current, active, and inactive categories. In this system, current patients are those presently under care or who have an established future appointment; active patients are those not under care and without an established appointment; and inactive patients are those who are unlikely to return for whatever reason.
The file is first divided by month. Next, the current month is organized according to the days of the week, beginning with the present day and 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 folder in the appropriate divider for easy access. Patients scheduled ahead for a longer interval than a month have their folders placed in the appropriate monthly division. They remain there until the specific date becomes current. For example, if today is January 9, and the patient is scheduled for the 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 prior to the March appointment, the folder will be placed under the appropriate day tab. In essence, this system is a "tickler file" (Fig. 3.28). When the assistant is ready to arrange the next day's case records with this system, the folders are already gathered and only need sequencing according to the time of appointment.
To avoid overcrowding your files, records should be moved immediately when patients change their status from "current" to "active" or when "active" patients can be designated as "inactive patients" or "former patients." Some offices place files of deceased patients and of patients who have moved from the area within a "closed case" file.
THE SUBJECT FILE
If the subject is more important than the writer, the information is better filed by subject in an alphabetically indexed file. For instance, if you wish that a paper on "diathermy" to be filed, it would be better placed in a subject file than filed under the name of the author. A brief sampling of subject file titles is:
Form Letters Taxes
Organization. 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;
(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. If desired, a five-division system can be used.
Subdivisions. Invoices for office expenses, for example, should 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 made in payment should be noted on the invoice. "Equipment" subjects would include purchase orders, related correspondence, descriptive brochures, and price lists. Equipment files can be subdivided into office equipment, diagnostic equipment, and therapeutic equipment if desired. Similar information may be filed under a "Supplies" tab, which may be subdivided into "Office Supplies" and "Clinical Supplies" sections. A file should also be established for each association and organization to which you belong. And, if you are a member of a certain committee or commission, this file may be subdivided accordingly. Under the "Taxes" file, all necessary receipts for deductible expenses can be stored. An "Insurance" file can be subdivided to differentiate between "Office Policies" and your "Personal Policies."
Index Cards. In this system, a card is made 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 as it is more readily kept up to date. It also allows for cards that cross-reference subjects headings, subheadings, and synonymous titles.
THE CORRESPONDENCE FILE
Correspondence concerning specific patients and copies of letters and reports relative to cases should be filed within the respective patient's case record folder. The separate correspondence file involves correspondence that does not specifically relate to a patient. It should be reviewed annually by an assistant, and all letters 2--3 years old should be either destroyed or placed in storage according to your judgment.
In contrast to the subject file, nonpatient correspondence should be filed alphabetically by the name of the company, institution, organization, agency or author. Some offices divide the correspondence file into two sections: incoming correspondence and copies of outgoing correspondence. Most doctors, however, prefer to have the incoming letter and its answer stapled together and filed under the name of the incoming letter's author or company.
THE FINANCIAL RECORD FILE
An alphabetically arranged credit file contains ledger 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, and this information is used in preparing monthly statements. Tabs of different colors can be used to distinguish delinquent account cards, with different colors identifying the stage of delinquency.
THE PATIENT RELATIONS FILE
Although not in wide use, some offices keep a separate file on patient relations. In this type of file, patients who refer others to the practice are recorded so that appropriate thanks can be extended. A record can also be kept of office mailings if a separate advertising/public relations file is not maintained. On the negative side, cancelled appointments, broken appointments, and other data relative to poor cooperation can be noted.
X-ray films are probably the only clinical records that are not typically filed with case records, and this is essentially because of their large size. Films are filed separately, even the smaller sizes, in specially designed envelopes and cabinets. The envelopes are generally filed alphabetically by the patient's name and cross-referenced by the x-ray film number. Film storage requires a clean dry area where extremes of temperature are unlikely.
Each film should contain an identifying name or number, the patient's age and sex, the date of exposure, an indicator showing the direction of exposure, and something to designate the patient's right or left. The film envelope should indicate the patient's name and case number (if any). The exposure factors and other basic data involved are usually kept in a separate log (Fig. 3.29).
All radiographs and their concurrent diagnostic findings should remain with the doctor as part of the case records for a minimum of 7 years. The information garnered from each film (ie, the report) is legally regarded as the patient's property and as such may be given to the patient or to whomever is designated on a release authorization.
While the storing of films is space occupying, their usefulness for comparison with newer films offers a pictorial progression of a patient's condition. Most offices attempt to keep films as long as space permits, after which they can be sold to have the silver reclaimed.
Microfilm or microfiche is often the answer when storage becomes a problem and your office obtains a projector. Local companies as well as Remington Rand and Xerox outlets perform processing services. Sources available will be listed in the yellow pages of the telephone directory. Aside from clinical records, microfilm is also helpful in storing books and professional papers. An 869-page book, for example, may be reduced to ten 4-inch x 6-inch cards, occupying only 1/8-inch file space. In addition, many technical books and publications no longer in print are available on microfilm.
A cross-reference filing system is necessary in addition to the types mentioned for a numerical indexing system and a subject file. Each can contribute to an efficient filing system.
Clinical Files. A letter received concerning two or more patients can be handled two common ways. Either the letter can be copied and a copy placed in each pertinent file or the letter can be filed with the records of the first patient mentioned and a cross-reference sheet (Fig. 3.30) can be placed in the records of other patients discussed, noting where the original letter is and what it is about.
Correspondence Files. Whenever a document, letter, report, or form may be looked up under two or more names or subject titles, a cross-reference sheet or one or more copies of the original should be used. Preprinted cross-reference sheets are available at most office supply stores. When they are printed on a bright-color paper, they are quickly noticed and speed retrieval.
Subject Files. An example of a need for a cross-reference sheet in a subject file would be for a paper on "The Use of Ultrasound in Osteoarthritis of the Shoulder." It could be filed under "Ultrasound" and cross-referenced under "Osteoarthritis" and "Shoulder Disorders."
If there is one main file that is set up by name and occasionally there is material that should be filed by subject or if you have a subject file and have material that should be filed by name, such occasional literature can be combined within one main file. This is accomplished by either:
(1) putting a cross-reference sheet under the name in the miscellaneous folder for the letter of the alphabet with which the name begins or
(2) establishing a subject file, including a folder labeled with a person's name (last name first), which would be a subject.
When your assistant pulls records for patients with appointments, they should be placed on the desk in the sequence that the patients are to be seen. Usually the best time to do this is 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, data will have to be gained after the patient arrives; thus the file cannot be given to you until just before the patient is introduced.
The need for an orderly reminder system is necessary as every member of your staff has the responsibility of seeing that certain things are done at specific times.
A well-organized tickler file is helpful in keeping special notations and memoranda in order. This type of file is usually a small container holding a card for each day of the year. The cards are separated by tab dividers for each month and subdivided by 28--31 subtabs for each day of the current month.
Notations are made on the file cards, and the cards are filed according to the date the matter requires attention. If an item is recurring (eg, meetings, installment payments), the card is moved from week to week, month to month, or as necessary. Each morning, the card for that particular day is removed and reviewed.
The type of information usually listed consists of appointment reminders, approaching due dates for insurance premiums or taxes, subscription expirations, and other reminders of what should be done that day. You might like to be reminded of personal anniversaries, approaching birthdays of family members, pledged charitable contributions, and other important dates or approaching events. Patients' birthdays and anniversaries may also be noted in such a file.
Reminder calendars, available in various sizes, serve the same function as a tickler file. The two most common designs are those for a desk and those for a wall. Both types afford a box by each day in which scheduled events can be recorded (Fig. 3.31).
It is usually efficient if every member of your staff has a calendar of some type or a yearbook where entries can be made for important appointments, special dates, things to remember personally, and things to remind others about. A small pocket notebook is also helpful to jot down things that arise outside of the office that can be transferred to a reminder calendar. While reminder calendars and memo books are helpful, they limit the number of possible entries as compared to a tickler file.
A follow-up file is a large type of tickler system that contains letter-size folders. It offers an excellent method to follow-up correspondence requests waiting a reply, matters that are referred to others for action, orders for periodic purchases, and promises made for future action. The follow-up system itself can be handled in either of two ways. Either the pertinent material is placed in the tickler file or a cross-reference sheet is placed in the tickler and the material is left in its normal file.
In situations where information is conveyed verbally to another person, in person or by telephone, it is often helpful to have a written reminder for reinforcement and substantiation. These memos should be brief but include the necessary facts of who, what, when, where, and why.
The two most common types of case reports within a chiropractic office are personal reports and narrative reports.
A personal report is that type in which you give a patient an evaluation of your examination findings and prognosis. This is usually a verbal report; however, in some instances it may be given in writing for the benefit of an absent party. Even in situations of a verbal report, it is good procedure to speak from an outline so that important facts will not be inadvertently omitted.
A personal report should be designed to first calm unnecessary fears of the patient, inform the patient of what is and is not involved in the disorder present according to your best judgment, and explain the significance of the patient's symptoms. Your working diagnosis and treatment plan should then be discussed. During the course of the report, you should inform the patient of all anticipated practices, procedures, and consequences so that you can receive the patient's informed consent prior to any therapy.
The relationship between a patient's condition and the treatment procedures to be used is called the medical necessity. Third-party contracts usually call for a distinct relationship between the covered services and medical necessity. It also underscores why you should document substantiation for the need of the services rendered.
In addition to gaining informed consent and substantiating the medical necessity, you should explain to the patient and differentiate between therapeutic, rehabilitative, and maintenance care necessary in your judgment. This is especially important in third-party situations where the patient's health insurance may not cover all types of care that you feel are necessary. At the end of a personal report, it is customary that the patient be given an opportunity to ask any questions that remain unanswered to his or her satisfaction.
A narrative report is a written summation of findings and conclusions prepared for a referring physician or directed at the request of the patient to an insurance company, attorney, or some other third party. It is much more structured and formal as compared to a personal report and covers in detail the history, examination data, and recommendations of the examining physician.
Custom dictates the form in which a narrative report is developed, although there is some variation in framework depending upon the doctor's preference and specialty (if any). Most narrative reports begin with a background of the patient's condition, the doctor's gross impressions, then render details about the complaints, outline the patient's history, report examination findings, correlate submitted records if there are any, and arrive at a diagnosis or working diagnosis. The report usually concludes with a statement of the doctor's clinical judgment of the case, recommendations for therapy, and prognosis based upon the recommendations.
In any professional office, the purchasing process must consider both quality and quantity if the practice is to avoid an unnecessary hardship. Efficient purchasing, comparative shopping, good storage procedures, and alert inventory control offer distinct savings to any office.
Quantity Decisions. When buying supplies that are used quite frequently, check for quantity discounts. If three or four units are used each month, determine the price break on a dozen units. A good rule of thumb is to order a 4-month supply if it is profitable. Less than a 3-month supply is usually poor economy. However, ordering in excess of a 6-month supply to save a few dollars is not usually wise. If you buy too far ahead, you may be burdening your capital and find stock aging on your shelves. In addition, you may find that an item needed today won't be needed in the future because of changing policies and procedures. Nor do you want a large stock of an item on hand when a new and better product is introduced to the market. Most sterile materials have a shelf life of only 3--4 months.
Quality Decisions. Most successful professionals are quality conscious. They prefer quality bond stationery and supplies. Very cheap carbon paper, file folders, and typewriter ribbons have an extremely short life and are a poor long-term investment.
Shipment Errors. Your assistant should be trained to check all ordered items upon delivery prior to acceptance. If something is delivered in an unsatisfactory condition or a mistake has been made, delivery should not be accepted. If damaged goods are not discovered until after delivery, the supplier should be called immediately and asked 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. In addition, defective or contaminated clinical supplies may cause harm to a patient and impose a legal liability.
Storage Considerations. A central storage facility reduces both inventory time and duplication of paperwork. All items should be stored neatly in a well-organized manner so that you can tell at a glance the quantity of each item available. Protecting stocked materials from dust, moisture, and temperature extremes will greatly reduce damage. Nutritional supplements are best stored in a refrigerator.
Purchasing and Inventory Controls
Purchasing and inventory controls are separate elements that are closely related. Both of these functions must be taken seriously as a large investmentis often involved. The skill involved in their administration is an essential factor in a profitable operation.
Sound purchasing requires knowing when to place an order, knowing when to order delivery, knowing the correct quantity and quality of items to order, knowing what price to order at (comparative costs), knowing who to order from, keeping internal ordering costs at a minimum, and inspecting and approving incoming shipments.
Assistants are usually delegated the responsibility of administering purchase controls, conducting inventory counts, and preparing necessary requisitions and purchase orders. However, to maintain control, you should review all requisitions and initial your OK if the requisition is acceptable. Some assistants get lax or carried away when they are spending another person's money.
A supplies purchasing control sheet is helpful in quickly reviewing the purchase history of an item and offering basic reorder information. A sample format sheet is shown in Figure 3.32.
Once purchasing functions are carried out, inventory control begins. Inventory control means keeping a good balance between excessive stock and insufficient stock. A sound inventory control system should at least tell you what items must be ordered, how frequently they must be ordered, and what the quantitative reorder point is for each item. Much of this, initially, must be on a trial-and-error basis coupled with a sense of practical realism. A running inventory of supplies is the best procedure to assure that enough materials are available at all times.
Excessive stock means an unnecessarily high inventory investment. Insufficient stock may interfere with proper patient services. To avoid these extremes, supply and demand must be kept as parallel as possible. This also mandates that needs are anticipated prior to special mailings that may suddenly increase patient volume.
Supplies in most offices will be found in two general areas. One is the central storage area and the other is in the various work areas where the supplies are used. Many offices have a rule of thumb that the quantity of supplies in the central storage area after reordering should be about twice that located in the various work areas. That is, on a quarterly purchasing basis, a month's supply is retained in the work area and a 2 month's supply is kept in the central storage area to replenish the needs of the work areas.
Whenever supplies are removed from the central storage area, they should be subtracted from the master inventory list. At the end of each month, the quantities on hand can be counted. If you are getting low on any one item, reorder. Such a record will prevent running out of supplies and give you a guide to consider quantity purchases.
A simple supplies inventory record can be developed by an assistant by listing every expendable item in a particular room of the office. The date and quantity of the last order for each item should be recorded. Each item should have a quantitative reorder point, and this will have to be readjusted periodically according to need. A special notation should be made for items that require considerable time between order and receipt.
During inventory counts, special attention should be paid to items that have a short shelf life such as nutritional supplements and sterile materials. Such materials should be dated upon arrival.
Some offices tape an inventory list on the inside of each storage cabinet door (Fig. 3.33) and transfer its information each month to a master list kept in the business office or the central storage area. The master list is usually kept in a 3-ring binder with subdivisions differentiating such items as:
Items for Consumption
Business office supplies
Patient educational literature
Clinical supplies other than supplements
Cleaning and janitorial supplies.
Items for Resale
Formal purchase orders facilitate both record keeping and inventory control (Fig. 3.34). The office copy of a purchase order will automatically file information as to the name of the supplier, what was ordered, the quantity, the cost, and the delivery date. Standard forms can be obtained at local office supply stores or from a number of mail-order catalogs. You name and address can be imprinted on the purchase orders or rubber stamped at the office. If desired, they can be obtained pre-numbered.
Placing a value on inventoried items is a major factor in measuring taxable income, thus a sound valuation policy is important. Any valuation policy must be supported by sound accounting practices and physical inventories taken at reasonable intervals.
The typical basis used in chiropractic offices is the item's cost rather than the market value, which is used in some businesses. The cost value is the invoice price plus any delivery or shipping changes and less any discount(s) given. If discounts (eg, for cash) are not deducted from an item's value, they must be listed as income.
In addition to supplies, it is important for tax and insurance records that all furniture, accessories, equipment, instruments, and books be inventoried when purchased and placed on a proper depreciation schedule.
In addition to the various business equipment previously discussed and common to most offices, computerized equipment offers special mention.
The Office Computer
When finances permit, a small computer is helpful in maintaining payroll and tax records, accounts receivable, accounts payable, and progressive inventory records. However, sophisticated computer equipment should not be considered until a manual system has proved its value over a minimum period of 6 to 12 months.
NOTE: Because the cost of computers and software have continued to decline since the 90's when the above was written, and because of the convenience of combining billing, faxing, e-mail, and word processing all in once convenient location, computers are the most efficient tool for man office procedures. Back-up of data daily is crucial.
The variety of equipment and compatible software available is vast. However, some of what is available is overrated, limited in function, and difficult to use unless its operator is well trained. There is danger in purchasing equipment that will soon be outdated for your needs or purchasing equipment with functions that you will rarely utilize. Prior to making such an investment, it is highly recommended that you read two or three good books on the subject so that you have a thorough overview of the subject.
Computerized word-processing equipment is quite efficient when developing, editing, and printing out such functions as mailing lists, statements, office lists, personalized form letters, requisitions, purchase orders, and professional papers.
Technology in this area, for both hardware (equipment) and software (programs), is advancing rapidly. Programs are becoming available that assist in diagnosis after inputting clinical data. Programs with appropriate printers are also available that can check spelling, total columns, and chart graphic financial and practice growth analyses in multiple colors.
There are two common facility inspections that should be made periodically: that of your office's overall appearance and that of its safety to patients, visitors, and staff.
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 you desire if your 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.
Care must be taken 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 your entire office is the best insurance you can have. A format for periodic safety checks is shown on Figure 3.35. Your entire staff should know your emergency fire plan, and at least one good fire extinguisher should be centrally located.
In most practices, an administrative assistant takes full responsibility for housekeeping. It is important that a schedule or checklist should be established for daily, weekly, monthly, and less frequent responsibilities for each assistant and cleaning help.
Because of constant patient flow in the busy office, constant attention must be given to scattered magazines, cluttered counters, disarranged files, and overflowing wastebaskets. Any wastebasket that may receive food particles, moisture, liquids, discarded adhesive tape, chemicals, etc, should be lined with a plastic bag.
Throughout the day, ventilation, temperature, and air conditioning should be checked in all rooms of the office. Air freshener should be discreetly sprayed around when necessary. Daily dusting, polishing, sweeping, and spot removing are usually necessary, and special attention should be given to the tidiness, cleanliness, and supplies of the toilet rooms. Dust and fingerprints should be wiped from counters, mirrors, and glassware. Window and lamp shades should be adjusted and draperies straightened as are necessary. Examining and therapy tables, sinks, and toilets require frequent disinfecting.
All clinical equipment must be kept especially clean. Sterile items should be protected while in storage, and appropriate instruments and supplies such as speculae, acupuncture needles, and specimen containers must be sterilized and kept aseptic prior to use.
Weekly, wood furniture should be dusted and polished, leather and plastic should be cleaned with a damp cloth and saddle soap, and upholstered furniture should be brushed and fluffed. Dust from plant leaves should be wiped clean, followed by use of a leaf spray. Dead leaves from plants should be removed, and the plants should be rotated for sunlight.
Periodically, pictures and their frames require polishing, lamps and lighting fixtures require occasional dusting and bulb replacement, and refrigerators require cleaning and defrosting. Trays, shelves, filing cabinets, and inside drawers also require periodic cleaning. Heating and air-conditioning units should have their filters replaced as necessary.
Heavy or specialized cleaning such as carpet cleaning, floor maintenance, window cleaning, furniture waxing, and wall and woodwork scrubbing are usually best performed by a commercial cleaning service. When necessary, an outside service should dryclean or shampoo upholstered furniture.
Equipment Servicing and Repair
All major equipment should have a maintenance checklist attached to assure that the manufacturers' recommendations have been followed. Periodic dusting, cleaning, and oiling (if necessary) will add to the service life of all clinical and business office equipment.
Policy and Procedural Changes
You are in the best position to appreciate your practice's overall objectives; however, rational flexibility is a must because you are not directly involved in the detailed implementation of every item within your office's procedural manual. As your assistants must work with and integrate specific policies and procedures each day, they are often in a position to offer constructive suggestions. A format for a recommended change in procedure is shown in Figure 3.36.
A procedure is a plan, and a plan is not a permanent order because conditions change with time, personnel changes, and growth of your 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 change within the practice.
Office policies and procedures are the result of a series of development and modification over the entire life of the practice. If your practice is growing, it is not the same today as it was last year nor 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.
Small Business Regulations
There are specific laws and regulations governing health practice certification and licensure in all states. In addition, there are usually state and local regulations governing the entry of a firm into the business arena, the use of nonpersonal names, the vending of resale items, contractural arrangements, credit arrangements, discriminative pricing, unfair or untruthful advertising tactics, and acts of unfair competition or those that might be considered a restraint of trade.
A "Seller's Permit" will most likely be required if you have items for resale, and most states require that all roentgenographic facilities be certified to meet established standards. On the federal level, an Employer Identification Number is required when submitting federal income tax and social security taxes, opening retirement programs, etc.
Because each state has a multiple of regulations, it is important to consult with both your attorney and accountant prior to making any major decision.
Basic Tax Planning
Taxes are the dues we pay for the opportunity of living in this great country. We should all pay our just dues --no more, no less.
Just as any good attorney will tell you that the best defense against a malpractice claim is good clinical records, any good accountant will tell you that the first requisite against paying unnecessary taxes is good administrative and management records. To recognize this is important in avoiding an unnecessary or unfavorable audit by the Internal Revenue Service or your state's Tax Commission.
The variety of records and bookkeeping systems available are vast. In conultation with your accountant, select a system that is simple to administer, offers all the data and controls you might need, provides proper documentation of all income and expenses, and will easily adjust as your practice grows. The more you can do efficiently within your office, the less expensive will be your outside accounting costs.