Minimal Documentation is Basic, Enhanced Documentation is Necessary
While states require minimum documentation requirements for chiropractors, many states require chiropractic-specific details. While it is not recommended that you only do the minimum to scrape by, there might be times when you only need to document to the level of meeting the state requirement. Enhanced documentation is recommended for the level of care you desire to provide to your patients. Better documentation means better patient care and better patient outcomes.
Documentation of Routine Chiropractic Office Visit
In your chiropractic practice, you must attain state specific minimum documentation requirements or greater by establishing standards for documentation defining your policy requirements and your standard operating procedure (SOP). These will include an explanation of the use of your patient’s subjective data, the provider’s objective findings, the assessment, and the treatment rendered.
I want to thank you for your expertise and time spent educating and assisting our company, Harmony Healthcare, Ltd. with regards to becoming more HIPAA compliant so that we can better serve our clientele. In our current times, the safety and protection of personal information is of high importance and concern and we are blessed to have KMC be our expert guide. We appreciate you and your team!