Chiropractic documentation gap analysis

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Good communication is vital in the doctor/patient relationship and first impressions set the tone for all future interactions.

A patient’s first visit can be hectic and nerve-wracking. Imagine walking into a strange new place, in pain, and being asked to fill out a stack of forms. Probably not the highlight of anyone’s day. What both patients and clinical staff need to understand, however, is that patient intake forms are not just a way to waste time or paper- they are a way to begin the conversation of how the practice will be able to help the patient.

Expectations of an initial visit

Chiropractic Assistant Duties

While a doctor may see hundreds of patients a week, a patient may have waited weeks to see a doctor. There are a lot of pressure and expectations to be met on an initial visit. And that’s exactly why intake paperwork should be completed at home before patients ever set foot in the office. It gives them the time and the clarity to think about their past medical history, their current symptoms, their insurance information, etc. The patient can share who they are and what they feel, in their own words, so that nothing is forgotten or overlooked. Make your intake paperwork available on your website or offer to send it to patients by mail or email so they can have it ready when they come in for their first appointment. Or perhaps your software company allows for an online form to be filled out. Let your patients know that if they wait to do it until their appointment, it will add 15-30 minutes to the time they will spend in the office.

The intake paperwork is only valuable if:

  1. It asks the right questions: It doesn’t matter if your intake paperwork is two pages or 10, just make sure it’s not all “fluff” and no “stuff.” It should help complement and guide the history, exam, and treatment goals. It may help to determine if there are contraindications to care for or if the patient has other doctors in their healthcare team that you can reach out to for additional information. Only ask the essential questions on the initial paperwork and save the rest for small talk during future visits.
  2. If you have followed #1 above, then every question has meaning and is important to a patient’s treatment. A question with no answer next to it is the same as a question that was never asked. Ensuring that the paperwork is completed is a team effort. A team member should always review the documents before they are given to the doctor and any questions that are unanswered or illegible should be returned to the patient for clarification. Quality patient care is dependent on this. Keep in mind that this paperwork may also be sent to the patient’s insurance if the medical necessity of care is questioned or to an attorney if malpractice is alleged. Don’t accept anything less than 100% complete.

What about incomplete intake forms?

If patients often return incomplete intake forms, consider some of the reasons. If it seems that the patient is just not taking it seriously or is impatient with how long it takes to complete, remind the patient that knowing their medical history is essential so “…the doctor can provide the best care possible.”  Visual impairments, language barriers, and reading comprehension issues may also play a role in poor paperwork compliance. If one of these issues seems apparent, have a team member assist the patient with completing the paperwork and make note of what was done by the patient and what was answered with assistance. Keep a mental note of what questions are often skipped by patients and re-evaluate your intake forms on a routine basis so that they are always improving and patient-friendly.

Your paperwork reflects both you and your practice

It can convey a sense of professionalism, thoroughness, and competency that are so important in developing a trusting relationship with patients. It should not be seen as a burden but rather a helpful tool that can guide the history and exam process and ensure that the patient is receiving the most appropriate care for the presenting condition. Developing training and procedures for all staff members to follow regarding new patient paperwork will ensure that your staff is comfortable and confident with its use. This will allow the doctor to devote more one-on-one time with the patient and focus on their health and wellness.

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.

Posted by Team KMCU on Feb 1, 2024

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