Chiropractic documentation gap analysis

Recognize what’s missing to master your reimbursement and collections!

This Documentation Gap Analysis allows us to evaluate the significant components of your current Documentation program. It should take less than 5 minutes to complete.

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The Best of Both Worlds

The doctor-patient relationship has changed over the past several years, mostly because of the third wheel in the room, the device used to document. Doctors are conscious of the level of documentation that is required to prove the medical necessity of services to meet payer requirements. They have resigned themselves to the fact that they are always at least slightly distracted as they make more eye contact with their computer or tablet screen than the patient. In an effort to have the best of both worlds, some offices are finding that using hybrid documentation allows their practice to stay compliant and efficient without sacrificing patient care.

Oig phase 3

EHR | Electronic Health Records

Electronic Health Records (EHR) are undeniably here to stay. The many benefits include rapid data entry, secure storage of records, and the ability to easily share patient data with multiple staff members for functions ranging from billing to patient treatment. With many of the daily healthcare operations automated, it could be assumed that this would contribute to more positive doctor-patient interactions, yet that isn’t always the case. It is the quality of that time together that determines positive interactions between patients and healthcare providers.

Personalized Patient Care

With hybrid documentation, the doctor can use paper notes or paper template forms for patient interactions that are more communication driven such as new patient visits and re-examinations. While the doctor still needs to document the details of all patient visits, using a pen and paper instead of a keyboard and mouse allows the doctor more freedom to ask the patient personalized questions based on their findings rather than computer prompts. Both parties are more engaged when the conversation is customized for the patient’s needs.

Detailed, easy to read, hand-written notes can be scanned into the computer and uploaded to the patient’s account for future reference. If the note contains a lot of abbreviations, is hard to read, or is very vague, the doctor can schedule time to re-write the patient’s note in a more narrative format to fully explain the patient’s condition and the doctor’s decision-making process. The original handwritten notes should also be uploaded to ensure there are no discrepancies between the two versions.

Paper and Electronic Systems Working Together

The paper forms used during the patient interaction could also be formatted to align with your EHR system. Once the encounter is complete, the doctor can enter the information into the EHR system to ensure a compliant note for the patient record. Be aware, travel cards and handwritten notes are not always compliant and could put the practice at risk for insurance recoupment should an auditor deny services due to not being able to decipher what the patient record says.

If the EHR process is getting in the way of creating meaningful relationships with patients, consider implementing a documentation system that works for patient care as well as third party payer requirements. Hybrid documentation may be the win-win situation your office needs. EHR is not mandatory, but compliant documentation and good patient care are.

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 at or by calling (855) 832-6562.

Posted by Team KMCU on May 2, 2024

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