SAN DIEGO Organization in both record keeping and patient scheduling is essential to a successful Mohs surgery practice, Dr. Edward H. Yob said at a meeting sponsored by the American Society for Mohs Surgery.
Patient care records may include handwritten notes, dictation/transcription, and electronic medical records, although electronic records are becoming the documentation method of choice, noted Dr. Yob, a specialist in Mohs surgery and dermatologic surgery in Tulsa, Okla.
The best electronic medical records system for your office is one that is accurate, simple, and cost effective and saves you time. Ease in training is also important; a high school-educated medical assistant should be able to learn the program with minimal training, said Dr. Yob, who owns stock in Ratio Medical Software, the company that markets the Razor electronic medical records system.
Clinical records for Mohs surgery patients include the preoperative evaluation, operative consent form, operative notes, Mohs map, anesthesia record (if any), and postoperative notes.
"Not everyone has this entire set of items for each patient, but you need enough information to substantiate the indications for Mohs," Dr. Yob said.
The preoperative record establishes the patient's candidacy for Mohs, including the general state of health, any medications, or past surgical or anesthesia difficulties, he noted.
The Mohs map is an integral part of the record. "Every bit of information you could want should be on that Mohs map," Dr. Yob said. "Accuracy is the key, and the map should tell the story exactly as it is."
Document postoperative visits, even if the patient simply comes in for care and cleaning of the wound by a medical assistant. In addition, keep the referring physician in the loop. Dr. Yob always sends a simple cover letter, along with a copy of the operative notes and photos of the defect and final repair, to the referring physician.
"I want to educate the physician and let him or her know that they made the right choice in referring the patient for Mohs surgery," he said.
Clinical logs are descriptions of your practice, compared with clinical reports, which are descriptions of individual patients. Photography is a crucial time saver when it comes to keeping a clinical log. "Digital photos are accurate and easy, and there is no better way to document treatment than photography," he said.
In Dr. Yob's office, a nurse first photographs the patient's name from the chart; the succeeding photos are of that patient until the next photo of a patient's name in a chart is taken.
When staff members archive the photos, they label the computerized file with the patient's name. In some offices, the technicians set up a file for each day and download the day's files into one directory, then erase the digital card in preparation for the next day. A staff member can later sort the photos by patient.
Data storage is another important element of record keeping in a Mohs practice. "You are going to have glass slides to store, and you need an archival system," Dr. Yob said. Store all operative reports and Mohs maps and keep track of expenses.
"You are going to generate an enormous [number] of documents, photographs, and slides, and if you take some time to think it through before you start practicing Mohs surgery, you can develop a system that will be organized and not take you an enormous amount of time to process," Dr. Yob said.
He also shared tips for patient selection and scheduling.
There are two types of scheduling: integrated and exclusive, and there are advantages to both. Integrated scheduling is more efficient and more economical, but it is extremely distracting. "You could be ready to do a Mohs repair, and then you get a complicated consultation on a lupus patient," Dr. Yob said. This type of scheduling is not practical for a high-volume Mohs practice.
Exclusive scheduling means treating Mohs patients from start to finish without interruption for other types of patients. This type of scheduling is more predictable and allows more time with the patient. "I like to see patients preoperatively so I can talk to them and evaluate them. I want them to feel comfortable, and I want to take their blood pressure," Dr. Yob said. "I don't want to waste a surgical slot if the patient's blood pressure is high."
Dr. Yob's office ranks patients by three levels of complexity: quick, average, and complex. He recommends that surgeons determine how the total number of patients with varying degrees of complexity fits with what they consider their workload. "A complicated patient may be the only Mohs surgery you do in one morning," Dr. Yob said.