Documentation provides clear evidence of continuity of care to communicate with other providers. It can act as a legal record of the care given. And it should support the billing for the services rendered. Have third parties tried to claim that your documentation is insufficient? Is it a weakness they seek to exploit so that they can avoid payment? Or, do you see your records as a protection and shield from liability and audits?
The ChiroCode DeskBook contains all you need to create heavily fortified documentation that won't take excessive time to complete. Here are some targets and the solutions:
|There are too many visits||Use Evidence-based Guidelines as you outline your care plan. See Chapter 4.5 in the 2016 ChiroCode DeskBook|
|There were too many services at a single visit||Understand the codes and when to use them. See Chapter 5.2 in the 2016 ChiroCode DeskBook|
|Billing does not match the documentation||Just read the whole DeskBook. Please. It's all in there.|
Good documentation will prove that the visits were medically necessary, the services were needed to help the patient get better, and the billing is an accurate reflection of the record. All of the following are key weaknesses that auditors look for. Make sure you are not guilty of any of these errors and your records may be able to protect you.
- Illegible records
- Missing dates
- Missing signature
- Missing informed consent
- Missing re-assessment
- Missing patient identifiers
- Missing metrics/objective
- Blanks used to indicate “WNL”
- Missing legend for abbreviations
- Missing care plan
- Cloned records
In 2012 the American Chiropractic Association released the third edition of their Clinical Documentation Manual. This book was carefully reviewed by many committees and top experts in chiropractic to help you find everything you need to know to solidify your record keeping. There is currently a fire sale on this book. It is only $45! Order your copy now, while supplies last.