3 spine surgeons share advice for improving clinical documentation


Three spine surgeons discuss how they stay on top of clinical documentation.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What is your best advice for young spine surgeons who are in the process of selecting a practice environment?

Please send responses to Anuja Vaidya at avaidya@beckershealthcare.com by Wednesday, Dec. 12, at 5 p.m. CST.

Question: What are your best strategies for ensuring comprehensive clinical documentation, especially in the current era of increasing regulatory burdens?

Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: I plan on taking a [professional] society-sponsored coding classes every year to stay current. They are really a self-sustaining investment. I cannot say enough about these courses and encourage doctors to take advantage.

J. Brian Gill, MD. Spine Surgeon at Nebraska Spine Hospital (Omaha): The EMRs have helped to ease this ongoing and ever-changing burden. The amount of information needed to be imputed can be overwhelming. A good EMR can help this burden. Additionally, hiring personnel to help enter the information can improve the overall patient experience as well as lead to a better quality of life for the provider.

Noam Stadlan, MD. Neurosurgeon at NorthShore University HealthSystem's Neurological Institute (Skokie / Evanston, Ill.): The most useful strategy for ensuring comprehensive clinical documentation is having a plan and implementing it. The documentation burdens imposed by regulations and insurance companies are known and publicized, and the care team needs to devise a plan designating who will be responsible for various parts of the documentation.

In that way, the documentation will be present for all patients without having to spend time documenting on an ad hoc basis. The EMR is an excellent tool, not only to collate and collect all the documentation, but also the prompts and templates available make it very straightforward to ensure that the needed information is gathered and easily accessible.

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