Academy of Chiropractic’s Lawyers PI Program

Narratives 48

From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP

"Documenting the not-so-obvious Treatment"













Chiropractic care, surgery and physical therapy are obvious treatment modalities that we never miss. However, there are numerous treatment modalities in the medical – legal – insurance world that have great value when considering the totality of the case. Please understand that although I am highly prejudiced towards my conviction of the power of the chiropractic adjustment there are times that other forms of treatment will help the patient. Please...I hope I don't go to hell for that!!!!!

HOME EXERCISE PROGRAMS

It is important to document a period of time during which the patient is performing home exercises. This is one of the most under-reported activities and is central to the active care of the patient (remember, active care is what the patient does outside of the Doctor's office). Home exercises can be anything from weightlifting to walking to stretching or anything the patient chooses to do to help the feel better and/or get better. It is not unusual for patients to do home exercises during the entire course of the passive care (doctors care) that they're under and for that it is not unusual for home exercise programs to continue weeks or months after the end of doctors care. This all must be documented.

The following is a partial list of other treatments that also need to be documented. You get to add everything your patient does:

  1. Medication, either prescribed or over-the-counter
  2. Home traction units
  3. Tens units
  4. Immobilization: this includes devices such as supporting collars
  5. Confinement to bed
  6. Hospitalization

Each of the above must be documented as to duration, specifically what was done and if receipts are available inform the patient that they should share this with their lawyer.