Documentation Made Easy
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Hi, I’m Dr. Mark student. Welcome to the academy of chiropractic doctors, PI program consultations. I am very excited that you took the time to do this and make the commitment to your career, to your family, to yourself, just to be the best of the best of your clinical excellence. Sit back and enjoy the consultations.
Hi, I’m Dr. Mark student and welcome to today’s topic. Documentation made easy listen documentation for any practitioner was always been the bane of our existence. Oh my goodness. It’s just so challenging and being in the pits for 41 years and, and, and, and, and, and going through this, it’s not easy. You know, the last time I went to my primary care provider, I recall sitting and talking to him and all I saw was the top of his head. He was sitting in the computer and typing the entire time and he just wasn’t present. So it it’s a problem. So the other side to the coin is you do very little and you use those old fashioned travel cards when you’re done three checks on a piece of paper and you, and, and you’re, you know, you finished, the problem is both of those extremes are dangerous.
They’re dangerous because your documentation has, is about two things. It’s about compliance and it’s about reputation. And it it’s just an issue. And the most overwhelming perspective is compliance. Because if you’re not compliant, it can cause you your money, your license, or your freedom. If your reputation is off, it’ll cause you your referrals from, from lawyers, MDs and your patients. So you’ve gotta be very careful to ensure that you’ve got a healthy balance with documenting everything you need. Now, here’s, chiropractic’s dirty little secret, 95% of every chiropractor based upon my market research. And my market research is doing an depth compliance review on every word on every page of every document a person does in an initial counter is fraudulent. 95% of every chiropractic, initial documentation is fraudulent. Let’s follow it up. 95% of every chiropractic. Sona is fraudulent. And when I say fraudulent, it has elements of fraud.
It’s missing require things that you do when you’re billing. And there was a significant change in coding requirements, January 1st, 2021, and everyone should be up on that. And that’s real important. So when you look at documentation, what’s the best way to approach it? I don’t care if you’re on paper. Well, I do care. You should never, ever, ever end up with a paper document, a handwritten document. I mean, that’s very 1974, and it’s gonna destroy your reputation and you’re gonna end up missing things, but you should really work with a a template of elements that need to be in every single report. You need to have past medical history, social history, family history, review of systems, all the things you learned when you were in school. Listen at various, I teach in three chiropractic colleges and two medical schools at various levels, and these are consistent.
And what you learned in school really should carry you through today. So what about personal injury? Do I need special documentation for personal injury or for MDs or what’s the least I could do for cash? That state is the slippery slope to the short end of an S I U investigation, special investigative unit within the carrier or a licensure probe, because there is no special documentation for personal injury, other than looking at cause a issues instead of being a slip and fall, or I sneezed, or I woke up and it hurt. I was rear-ended while I was stopped. Therein lies. The only difference your documentation should be the same, no matter the financial class of your patient, if you don’t, you are leaving your license exposed to being pulled away. You’re leaving yourself to be, to be considered complicit with a, with a plaintiff’s attorney in a PI case.
So you’ve gotta be very careful to have one standard of documentation and it’s nonnegotiable. I don’t care if you are working in, in one of these three minute clinics where you, where you’re treating patients, you gotta have the same standard of documentation as everyone else. And there’s a minimum standard, which you must meet for not just to carriers, but your license and license. Your boards are making example of people all over the country. And they’re challenging. So listen, I could really talk about this for quite some time. And as a consultant in the academy of chiropractic that’s, this is something we spend a tremendous amount of time about making documentation, so, so easy and compliant and holding up your reputation. And I look forward to doing that with you whenever you want. So gimme a jingle. However, if you like an outline of what a good evaluation looks like, just send me your request to my email address at Dr. Market academy, chiropractic.com. Listen, thank you so much for sharing this time with me and we’ll catch you on the next one.
I hope you enjoyed the podcast you just heard, and it’s been my pleasure to bring this to you. Please understand that this is a very small piece of the puzzle, and it is my goal to bring you many, many pieces of the puzzle so that the picture can become clearer. Your practice can throw I chiropractic and thrive, and I at least can be a small part of that by my pleasure. So again, if you want to chat, gimme a general 6 3 1 7 8 6 4 2 5 3 that’s 6 3 1 7 8 6 4 2 5 3. Or go to our website at teach T E a C H chiros, C H I R os.com. Thank you so much. And I look forward to seeing you or chatting with you on our next podcast. Have a great day.