Academy of Chiropractic’s Doctors PI Program
Build Your Infrastructure #148
From the Desk of :
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
“Verifying Patient Intake Forms Were Reviewed”
You now must read the Quickie Consults... They are equally important... Call me if you need any help...
A Significant Compliance Issue
When a patient starts care, they ALWAYS have paperwork to complete. In most offices, they have forms to fill in “old school” format with a pen and paper. In some “paperless” offices they are given a tablet to check off information or type in answers. Both paradigms have challenges from a compliance perspective.
Upon performing compliance reviews in offices nationally, this is the #1 pitfall doctors have; verifying that you have reviewed the review of systems, history, etc. Although these items MUST be done by you in your evaluations and documented accordingly, having reviewed the patient’s own words, whether handwritten or typed into a system, gives you a level of insulation that you collected and saw the data.
The solution is rather simple and I am shocked that I have not seen it previously (which verifies I am heading in the direction of senile and stupid!).
The opening paragraph should read:
“Mrs. Jones was seen today for a history and evaluation (if applicable add the following, if not, stop here) from injuries sustained in an automobile accident on March 14, 2017. Prior to the examination all the forms she brought with her and/or completed in the office were reviewed by me.”
These 2 simple sentences will protect you in many ways that you could not have predicted. Simple solutions to very large potential problems that just disappeared!