Bulletproof Your Documentation
SOURCE: Chiropractic Economics
By Kathy Mills Chang
Part 1: Ensure your admitting and ongoing paperwork isn’t slipping through the cracks
Because of the many different techniques and philosophies involved in chiropractic, you can be assured different doctors utilize different admitting and ongoing paperwork.
A recent survey of 80 chiropractors revealed that 72 percent of them collected paperwork for their clinic from various sources, creating a patchwork effect. Because very few utilized an actual system of paperwork, they admitted concern that some documentation could fall through the cracks.
So, what paperwork should you have in your office?
Most state chiropractic boards that have a standard of care for patients include taking patient history. If one were to follow the evaluation and management documentation guidelines, history is a significant portion of the value.
Because the requirements entail collecting information about the chief complaint; the history of the present illness; a review of systems; and the patient’s past, family, and social history, there is a substantial amount of information that can and should come from the patient.
Having information laid out in a clear fashion on your admitting paperwork allows the patient to answer the majority of the essential initial consultation questions. Using your admitting paperwork as a template allows you to ensure the required bullet points will be answered by the patient and reviewed by the physician.
There are many more articles like this @ our: