There is no shortage of opinions about what compliant treatment records should look like. So let me give you my opinion. This opinion is based off of more than two decades of defending chiropractors in front of boards, with the FBI, with the Office of the Inspector General.
Pretty much anything you can think of I’ve done. I’ve been there trying to defend records; some of them written records, some of them travel cards, some of them electronic health records. There are a few misconceptions I can clear up, and guidance I can give you based on my experience.
Just to be clear, I am not the perfect guy to be telling you this. There are a lot of other people that could be giving you really good information too. But I can offer up my perspective.
ALWAYS TELL THE TRUTH! It’s pretty simple when you think about it. In your treatment records, just tell the truth. That’s all you have to do. Personally, I really detest narrative treatment records. In my opinion the best treatment records are in bullet points because that helps you to tell more of the truth.
If you have long narrative forms that just keep duplicating one after another, it creates an issue that I call “sameness.” This is something that you’ll want to avoid.
When a third party payer looks at your treatment records and they see the same thing over and over and over again, they think, “Ah, it doesn’t look medically necessary. Let’s send them to an adverse examiner; have them cut off. Let’s stop paying on the care.”
So you really want to avoid “sameness”. You always want to tell the truth. Another thing to remember, along with more is not better, is to make sure you understand the data elements that need to be in your treatment records based on your state laws and on the federal laws if you’re dealing with a Medicare patient.
If laws require the subjective, then note the subjective. If something is objective you’ve got to note that. If they say you’ve got to put the plan or what you did, then note that. But don’t go into great detail. Think of it in bullet points. You either took an action or you didn’t. You either found something worth noting or you didn’t.
Remember, when you go from one adjustment or one treatment visit for a chiropractic adjustment to another, usually there is not much that changes from visit to visit. But often times the areas adjusted, the subluxations found, do change. So just note those things and then move on.
Whatever system you decide to use needs to be able to create the treatment note and the claim in under ten seconds. And you can’t get there unless you’re using an electronic health records system. So, explore different options for electronic health records systems.
Find one that’s going to work really well for you and hold them to that ten second standard to make sure it works really well in your clinic and that it exceeds all other parameters you would have with the other hand-written health records.
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