Patient signs in on master sign-in sheet.
1. Patient fills in "PATIENT'S COMPLAINT IN OWN WORDS" at the front desk before any treatment. Writes time in. Patient carries chart with him/her. ("S" of a SOAP.)
2. Patient takes chart to therapy room and is placed on predetermined physiotherapy. (Usually IST)
3. After P.T., patient takes chart and goes into adjustment room and gets adjustment.
4. Dr places an "X" at appropriate service(s) provided. (part of the "P" of a SOAP) A mark to the right at a vertebral level indicates a subluxation at that level is PR. A mark to the left is PL. A mark to one side with a down arrow (like the ENTER key on a computer keyboard) means PRI or PLI. An AS or PI on an ilium is self explanatory. Head, shoulder and/or pelvic tilt may be indicated. These constitute both the O & A of a SOAP. Dr. notes technique used at different levels, signs chart, makes any other notes. (part of the "P" of a SOAP)
IST & massage are considered full spine modalities. All other modalities are regional in application. In order to prevent a question in an adjustor's mind as to whether a modality was applied to the body area they are liable for and not to another area they are not liable for, I circle the area the modality was applied to and run a line to the "X" I made to indicate I am billing for that modality. Yes the chart can look sloppy, but who cares as long as the info is clear and complete. This helps to prevent payment delays, too.
5. Dr initials for TX or signs for exams (Calif Board requirement). The statement above the doctorís signature is a Calif work comp necessity. Other exam forms used as desired to document exam.
6. Patient takes chart to front counter and fills in "TODAY AFTER TREATMENT I FEEL" writes time out and signs. Places chart in basket. (prevents a later doubt as to whether there was/was not improvement)
All of the other parts are used only as needed. When I do the initial diagnosis I circle "DIAGNOSIS" and write the codes. For ADD I circle it and add codes. For DELETE I circle it and write the code(s) I want deleted. When I circle CHANGE all new codes are written in and all old codes are deleted. (Done when needed only)
FLARE-UP/AGGRAVATION/ACCIDENT (Calif specific terminology as defined by law) circle the appropriate and enter the date. (Done when needed only)
APPORTIONMENT YES/NO Circle appropriate (Y/N) and give ratio.(Done when needed only)
DISABILITY [circle appropriate type (e.g., TTD, TPD) give dates and RTW date. (Done when needed only)
RESTRICTIONS list as appropriate. (Done when needed only)
The Tx Plan is done only on reeval dates.
I no longer circle the type of case printed at the bottom. Some day I'll delete it.
This method of daily record keeping uses one side of a piece of paper per treatment, but you are done before the patient leaves the room. It has also stood up extremely well both in PI cases and in comp cases that have gone to court. I have had compliments from judges on the clarity of my records.
This chart was done in a graphics program in pieces, printed, cut and pasted together. The figure was the best copy I had. I used only the codes I most commonly use. I'm sure you can make a neater looking job of it. I just haven't bothered to do so. I have been using this chart for over 4 years and attorneys love it as it leaves nothing in doubt as to whether that was really the patient's complaint or whether they got better. (it's in their own handwriting). My Clinic name, address, phone # are at the top (deleted on this example). If I get a really good copy of the anatomical figure I will re-do the form and resubmit it.
For my re-evals I use the charts on http://.www.FreeChart.com/ . If necessary I use more than 1 exam chart but without duplicating anything already marked on another chart. VERY good for following the HCFA guidelines for E&M documentation & very fast. You have to set your internet browser security setting to LOW to access the charts. They are working on a chart specifically for chiropractors.
My method may use more paper than other methods, but I never get behind in treating or have to spend any other time just catching up on the record keeping. I know other Dcís who spend an hour after closing each day and several hours each weekend catching up on record keeping. Not my idea of a way to spend my time.
Any constructive comments for improvement will be considered. email@example.com