Start with Your Chiropractic Patient’s Primary Area of Focus
One of the most important elements when evaluating a patient is collecting their History of Present Illness (HPI). Even though this data is normally placed in the Subjective section of the note, it is a contributing factor in the patient’s history that drives the examination and ultimate treatment. This is because the HPI elements that a patient presents with normally have a direct clinical correlation to the type and severity of your chiropractic patient’s condition they are being treated for.
Expand Your Search for Relevant Data to Understand Your Chiropractic Patient’s Needs
A proper Evaluation and Management service (E/M) must include a review of the relevant body systems (ROS) which could affect the patient’s care outcomes or current complaint. This ROS can help identify complicating factors or contraindications for the patient’s treatment. It is for these reasons that the ROS is vital to the case management of the chiropractic patient and must be performed as part of the initial visit for each episode of care.
Past, Family, and Social History Will Round Out Your Chiropractic Patient’s Health Picture
When a patient presents for evaluation of their health concern, we have a responsibility to thoroughly collect their Past, Family and Social History (PFSH). This information relates to ordering examination, radiology, additional testing and/or possible referrals for the management of issues beyond our scope of practice.
Back to: Documenting Chiropractic Patient Intake and History
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