CYA Documentation for Technicians
By Steve Hill, CO

Documentation is becoming increasingly important in O&P, and it’s not just for practitioners. Technicians need to make sure they cover all the bases too. These days, generating accurate paperwork isn’t just a good idea, it’s essential if you want to get paid by Medicare, Medicaid and private insurers. The documentation writer’s cramp started with doctors, filtered down to O&P practitioners and has inevitably made its way to us, the bench technicians.

There are four broad categories that require proper documentation in O&P: quality control, legal coverage, CMS accreditation and HIPAA. I’ll touch on each one from a technician’s perspective.  

Documentation is a formal word for simply writing down what you did, when you did it and why. Every time a doctor writes a prescription, a practitioner fills out a work order, fits the patient and makes adjustments or an insurance company makes a payment, that’s documentation. All of that information goes into the patient’s file. It’s equally important that technicians archive information applicable to the work they do.

Quality control
In my opinion, the foremost reason to keep accurate and complete records is to achieve quality patient care. No matter who lays their hands on that device—now or five years hence—they should know exactly what parts and materials were used, all measurements that apply to fabrication and corrections, the dates all work was done and by whom it was done. Knowing what was done in the past will guide us in what to do in the future.

It sounds like a pain in the butt, but it really isn’t that hard. For example, you don’t have to write down all the part numbers and sizes you used—you can simply cut the tag off the product and staple it to the work order. Or, you could photocopy all the tags on one piece of paper and attach it.

In Europe, manufacturing regulations have become very restrictive, and Otto Bock has responded by supplying peel-off labels on the product packages. If more manufacturers did likewise, it could really simplify our lives now that the U.S. is beginning to follow a similar road.

Keep all the packing slips in the patient file as well. You never know when this data will become useful. With this information, we will be able to replace a worn part with an exact duplicate. If a patient’s device shows routine breakage, we can demonstrate how we increased part size to accommodate increased activity levels.

With the exact information on the part’s label, we also know in what lot number the component was made, in the event of a product recall. Also, be sure to write down all information on corrections and adjustments you made to each device and the dates they were performed.  

In the end, you’ll be able to give your patient the best care possible. If you can look into his or her chart and see that you ordered a specific part number from a specific company instead of just “brown shoes,” you can avoid a lot of unpleasantness and unnecessary repeated research and work for both the patient and yourself.

Legal coverage
Sometimes we have to defend our decisions in a court of law if a patient sues or there is a Medicare fraud issue. If we ever find ourselves in that position, we’ll be asked to prove that we manufactured a device to accepted industry standards. Since there are currently no standards for the fabrication of orthotic and prosthetic devices (see sidebar below), all we can do is document what we did do. We should supply part numbers, keep a log of manufacturers’ fabrication specifications and indicate that we have followed those specifications on the work order.

This may seem like overkill, but lawyers will pick apart every detail. If you didn’t document something, then it didn’t happen. If you can show on paper that you aligned the hinges to the same axis, tightened the screws to manufacturer’s specifications and then applied a suitable thread locking compound to a device, then there is very little for the lawyer to argue with. Saying that you don’t remember what you did on that particular device out of the many you have made, but that you’re sure it was correct, just won’t cut it in court.

HIPAA compliance
In 1996, HHS (the Department of Health and Human Services) introduced HIPAA, the Health Insurance Portability and Accountability Act, which is intended to protect certain patient health information. If your practitioner hasn’t trained you on it, he should. The basic idea of HIPAA is that some patient information, specifically patient name and diagnosis, must be protected from anyone who doesn’t need that information to treat the patient. Treat that private information as if it were your own.

Where do you keep your patient’s work orders? Do they follow the cast or device around the lab? Are they maintained in a stack on a desk? Are they only available on computer? Are they locked up at night? Who has access to them during the day? If there are people coming and going through your facility at all hours, then you may have a compliance problem. Ensure that your patients’ personal information is kept private, or you’ll have HHS breathing down your neck.

CMS accreditation    
You may have CMS (the Centers for Medicare and Medicaid Services) breathing down your neck as well. CMS has stated that any facility that expects to get paid by Medicare or Medicaid must be accredited by September 2009.

If you fabricate your own devices, then you must keep accurate and complete records of all work done. Is there a place on your work order designated for fabrication specs and a checklist to show that it’s been done? Is there room for technician notes or extra practitioner instructions? Are you writing down the dates (and perhaps times) of each step of the fabrication process?

If you send your work out to a central fabrication facility, the same rules apply. You must establish a formal business agreement in writing, indicating the quality control standards which you expect the central fabrication facility to implement. Keeping the patient information secure is one of those things, but it should include several other key aspects as well, such as the signature of an inspector who personally handled the device and verified the fabrication specs. This means that your central fabrication facility should have an ISO 9001-style quality assurance program (or similar).

No way around it
In short, there are many reasons to document all that technicians do. It may involve a lot more writing than we are used to doing, and there is no way to sugarcoat that fact. We will spend time and energy with paperwork that appears to gain us nothing. Your practitioner will tell you, “Welcome to my world.” Like it or not, it’s here to stay.

But in the end, documentation will help your patients, as well as ensure that you are covered. And that means fewer worries for everyone.

Steve Hill, CO, is secretary of OPTA and CEO of Delphi Ortho, located in Asheville, N.C. and on the Web at www.delphiortho.com.