Intake Fundamentals
Start with Your Chiropractic Patient’s Primary Area of Focus
One of the most important elements when evaluating intake fundamentals is collecting patient 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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I am writing in regards to the KMC Compliance program my office signed up for. At first, I thought it would just be a program to look at our office and make sure we were doing things correctly, but as the meetings went on I realized the KMC program provided a ton of information at my fingertips. I have worked in chiropractic offices for 12 years (and currently work in two), and this is the first time I finally felt like I was receiving the answers to 'grey area' questions I've had for quite some time. I absolutely love the training videos, and the one on one meetings with you were greatly appreciated. We got knowledgeable and personalized answers based on our practices needs. I highly recommend this program to any practice considering it, having doctors and staff trained in this is an absolute necessity if that practice is accepting insurances. Thank you for all your help with making sure our office is compliant and has the knowledge to continue dealing with all the rules and regulations of very confusing insurance policies.