Meticulous Detail is Required from Beginning to End
When charting compliant documentation, you and your staff should always have a complete, thorough, compliant final patient note in mind. The doctor, during the examination, follows a ‘walk through’ utilizing an expert knowledge base beginning with the initial evaluation, recommendation of chiropractic care and physical medicine procedures, and the written treatment plan.
Compliant Chiropractic Documentation Includes Modalities, Procedures, and Therapies
In every step, meticulous detail is required, establishing medical necessity for modalities, procedures, and therapies, which promise the desired functional improvement to the patient. Keep the functional deficits and functional goals in mind when you document your patient’s care.
After watching the webinar “Security Risk Management, A HIPAA Requirement”, I went to the government website and spent 4 hours trying to research what I needed to do and had to walk away as I was overwhelmed. After contacting my Account Manager, and setting a time to review the Compliance materials that are available at KMC University, I now feel this is what I was looking for…simple steps to walk from A-Z.