“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!!!!!
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
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