I do not have a “one size fits all” approach. My mantra is "Understand, Analyze, Identify, Execute". My mission is to help you to institute or fine tune your clinical documentation plan to meet community standards while supporting the way you work.
My promise is that I’ll be there, as questions or issues arise, every step of the way.
Who I Work With
- Clinicians starting their practice and looking to setup their documentation to meet rigorous insurance and CMS requirements
- Established practices looking to restructure their current documentation approach
- Supports development and operation of clinical group Quality Assurance programs
- Clinicians/Practices going through an insurance audit or facing a corrective action
- Facilities/agencies facing audit or corrective action
Some of the Services Available to You
- Global Documentation Assessment -- I review every element of your documentation: from the initial assessments, through treatment planning, to progress note documentation. We'll look at what's working, and what's not working, and where you have gaps and risks in your current process.
- Documentation Plan Development -- Based on where your documentation standards are, and where you want to head, we'll work together to develop a plan the fits the EHR platform you have, the clinical work you do, and how you want to implement any improvements you want (or need) to make.
- Quality Assurance Program Development -- Clinical groups can benefit from establishing a fully formed Quality Assurance program. From the ongoing auditing of treatment records, surveying discharging clients, and evaluating outcomes, establishing quality functions can make a big difference in how your organization successfully operates, providing valuable information for its clinical leadership. These processes can be built in stages to meet your group's specific needs over time.
- Group Documentation Training -- A virtual live training focused on your organization's needs. Everything from specific topics, like treatment planning or approaching progress note documentation, to a front to back conversation about clinical documentation. This training can be geared specifically to your group's particular needs.
- Ongoing Record Auditing -- Regular (quarterly or semi-annually) monitoring of a small selection of records (3 to 4 full records) with a coaching/consulting meeting with you and your supervisors to discuss finding; exploring improvements made and opportunities to strengthen documentation approach.
- Review of Assessment Tools -- the utilization of standardized assessment tools and questionnaires can make a huge difference in your total documentation plan. The review will help focus this use in context of your practice.
- Organizational and Professional Coaching -- The documentation plan might be only a part of a larger goal for your organization. If you need support here, let's make it part of the overall conversation.
- Audit Support and Guidance -- A strategic approach to preparing for submissions and communications when you're in the middle of an insurance audit and need someone on your side.
Ready to look at how effectively you are documenting today?
Your next step in the process can be to schedule an appointment. I offerings start at a half hour appointment option. It will give you the opportunity to discuss what you need for your practice and how I can help. Or, if you're ready to dive in there are additional time options.
Copyright Steven D Welton