Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 265

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

"Documenting Patient Education"

Over the last year, "patient education" has become a HOT TOPIC. It has become a requirement for many states' workers' compensation claims and other state and federal programs. As a result, in order to stay ahead of the curve, I strongly urge you to include patient education in the documentation of EVERY evaluation and re-evaluation performed. Depending upon your clinical encounter, you need to customize the language for each patient. Here is sample language that I used for a patient: 

Patient Education: Discussed information on spinal adjusting, all ancillary care, activity and restrictions as well as adverse effects. The findings were also explained so that the diagnosis, prognosis and treatment plan and goals were understood. Questions were encouraged to stated satisfaction. 

By staying ahead of the curve and providing the information before it is requested, you will help place yourself in the "less likely" category to be audited by anticipating and meeting the future needs of the insurers and regulators.

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