The Many Formats of Documentation

Paper or Electronic?

As providers create medical records of the encounters between the doctor and the patient, the documentation format for collecting the required information can vary drastically. Practice style, patient population, and personal preference are all considerations when choosing how to gather information from the patient to meet compliance standards. Remember that compliance not only refers to Medicare and third-party payer requirements but also to your state rules and laws regarding collecting and recording information from and about your patients. Doctors must ensure that, at a minimum, they meet the standard of care. And don’t forget your patients as possible readers of what you are recording.

Many doctors struggle to implement an EHR system because they believe they must. But in fact, there are NO mandated requirements set forth by CMS stating that chiropractors must implement EHR software. The same documentation requirements exist for both paper and EHR; one option is no more (or less) compliant than the other.

The following are several sections of a full patient chart to consider as you set up your documentation systems in a paper or electronic format:

• Patient Intake
• Review of Systems and Past, Family, and Social History
• Outcome Assessment Tools
• Doctor Consultation
• Examination
• Additional diagnostic tests and results
• Initial Office Visit notes
• SOAP notes
• Therapy services

There should be an order and ease to the patient chart

When an outside reader reviews the notes, that person should be able to piece together the information by how it is written and ordered. Remember that regardless of which format you choose to utilize in your office, the doctor is responsible for the contents of the documentation. Electronic records, paper records, or any combination of the two must contain an accurate record of the patient encounter.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing 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 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.