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The Importance of Documentation in a COVID-19 World

Posted On: September 22, 2020

The Importance of Documentation in a COVID-19 World

The COVID-19 pandemic has drastically changed the way we do business—likely forever. We’re now in an environment where services are rendered both in person and remotely. Products are being dropped at the doorstep with instructions given over the phone, and some services are being provided in a fully virtual environment. But one thing hasn’t changed—proper documentation is still one of the key ways to protect your business.

Check out our #RiskyBusiness video for tips on continuing to protect your business with proper documentation.


Here are some best practices to protect your business through documentation:

  • Implement an online document-signing program
    One of the biggest differences in our “new normal” is the need to collect signatures without standing in front of (or too close to) our customer. You still need to ensure you have the patient’s signature on the documents that you need. There are many great third-party software options available to help, or this could be as simple as emailing the document to the patient, then having them sign and return so you can keep it on file.

  • Create a system that allows you to log notes with dates, times, and details of what transpired
    Since your staff may not have direct contact with a customer when they deliver supplies or equipment, and the customer may not sign immediately, it’s critical to document the necessary details to add to the customer’s file. It can be as simple as: walker delivered, fully assembled, instructions given, no questions from customer. Add your name and the date, and you have your documentation. Consider having your team take pictures of deliveries and setups to add to this documentation.

  • Document compliance (or non-compliance) with safety protocols
    Some aspects of the care you provide simply has to be done in person. To keep everyone safe, many businesses have instituted policies that require individuals to wear a mask, social distance, or sanitize their hands before entering. Businesses should have clear documentation in place regarding these policies, and these should be shared with patients in advance. Unfortunately, it’s possible some patients will try to refuse. Staff should be trained on how to handle non-compliance safely, and details of a patient’s compliance (or non-compliance) with these policies should be noted in their file.

  • When in doubt, document
    This is perhaps the most important tip of all. If you aren’t sure if you should document something…you should! This includes non-billable events and detail —phone calls, text messages - log any and all communication with a patient or customer. It’s always best to have the notes in the file than to try to remember what happened after the fact. The smallest, seemingly irrelevant detail can be crucial during a claim investigation.

  • Bonus tip: Write legibly
    You may not be documenting as much by hand these days, but if you do, make sure it can be read. It’s a simple and effective way to improve documentation. Remember, if the note is illegible, it might as well not be documented.



For more information and guidance, contact your VGM Insurance Services Account Manager or contact us today at or 800-362-3363.


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