What’s the Purpose of Chiropractic Documentation?
Doctors often become frustrated with the many required components of documenting patient care. It is no longer acceptable to simply treat the patient as you see fit, noting the date that the patient was seen in the office along with minimal clinical information and the patient’s listings. And it shouldn’t be! There are many valid reasons to document the encounter between you and your patient. It is essential to the practice for accurate record-keeping; it is valuable to the patient to have their medical history recorded for any future need, and it is required by the payer to indicate that the services that were billed were performed and coded correctly.
Documenting The Initial Visit
The documentation of a patient’s first visit goes something like this – the patient reports information, and the doctor obtains clinical findings. Doctors assess what is happening with the patient by recording their thoughts about the data gathered and identifying the patient’s diagnosis. This process enables the doctor to create a plan to treat the patient. All these pieces are necessary and should be recorded at the initial visit encounter. What follows is tracking the patient’s progress through the recommended plan by documenting the daily office visits and re-evaluations.
As providers, we have regulations that require us to document what happens between the doctor and the patient any time there is an interaction in the office. Remember, the patient’s medical record is a legal document and should be able to withstand any scrutiny. Its purpose and intent are to provide a detailed and accurate account of the patient’s care.
Preloaded Macros and Quality Documentation
With the introduction of electronic health care records came preloaded macros. And while macros are great for speeding up the creation of patient notes, they can also negate support for what is being coded. Often in the day-to-day care of patients, providers click through these macros thinking they are adequately documenting the patient encounter. Instead, when reviewed, the documentation looks canned, as each separate date of service looks like the next. Using the macros for efficiency where appropriate is fantastic but there will always be instances when you must type in additional information to capture the individual details specific to each patient.
Be aware of your potential audience and the following considerations when writing patient notes!
- Other Healthcare Providers
- Standards of Care
- State Licensing Boards
- Malpractice Coverage
- Risk Management
- Third-Party Payers
The bottom line from any guideline or regulation is that you must document support for the care being performed. As we have all heard, what is written is what happened and what is not written, essentially did not happen! Regularly reviewing and continuing to strive towards improving your documentation is essential to protect your practice and serve your patients.
Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and practiced for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016. In November 2020, Dr. Auchenbach joined the excellent team at KMC University as a Specialist and, as part of this dedicated team, is determined to bring you accurate, current, reliable information. You may reach her by email at info@kmcuniversity or by calling (855) 832-6562.
Check out our HelpDesk Hot topic video:
“If It Isn’t Written, It Didn’t Happen”
We have all heard the term “location, location, location”. In the medical record, the term we must learn to do properly is documentation, documentation, documentation. When relative to the patient encounter, location and documentation go hand in hand. Did you know about the KMC University Proactive Chart Review? Let us take a look before they do. We are here to help you before they are there to recoup.
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