Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 831
Infrastructure 197 I

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: many of these issues are small, yet each issue is just that… an issue. If you take care of the small issues, then the larger issues often take care of themselves and you can focus on the larger issues… a larger, more profitable practice and more family time.

“1st Adjusment SOAP”

“You did what…without what!” Mark Studin 2017

Treatment does not belong on E&M reports. That is a hard rule and non-negotiable. In an E&M report, you need to have treatment orders in the “Plan” section. Should you document care rendered on the same report, you did care WITHOUT a treatment order and that can be argued as fraud. Even if you win, you will have had to defend it and in the process even if you win, you have already lost because of the time, legal expenses and loss of sleep!

Therefore… you need a separate SOAP note for the treatment on the first day in addition to the E&M report. It IS permissible and usual and customary to treat on the first day WITH treatment orders. Most of our patients come to us initially because they are in pain and it is your ethical responsibility to help alleviate as much pain as possible as soon as clinically appropriate. 

REMEMBER… for everything you do… no orders… NO TREATMENT!!!!!



Adjunct Associate 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
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