“When I give you the rules and then get in trouble because you didn’t follow them… why are you complaining?” Mark Studin 2017
I have been shouting at you to follow a prescribed pattern of documentation. It is simple. For every region you touch, you need a symptom, a clinical finding and a diagnosis PRIOR to treating that region on EVERY VISIT.
I am now doing an opinion letter to help prevent a doctor from being leveraged by a lawyer who is trying to not pay his lien. The lawyer is threatening a licensure complaint and using the doctor’s past history of having an infraction for a non-related issue coupled with treating for 4 visits where the patient did not complain of pain. The lawyer is alleging fraud as a result even though the lawyer used the doctor’s notes to get a sizable settlement.
The bottom line is that this “scumbag” lawyer (and others who simply want your money) will do anything to leverage you, inclusive of going after your license. Don’t give them an opening. Although it is compliant to treat without pain provided you have a clinical basis to do so, it is much easier to follow the hard rule above.
It is an academic standard to elicit pain, then document the hypertonic muscle in the elicited region. After 37 years of treating a patient, I have never (yes, an absolute) had a patient that needed to be adjusted and didn’t have taught and tender fibers in the region.
Follow the rule above and get paid, while protecting your license!
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
Adjunct Assistant Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences
Academy of Chiropractic
US Chiropractic Directory