|
|
|
The next step in the documentation process is the daily notes. If the examination starts the engine of case management, then you could say that the daily notes is like stepping on the accelerator and makes the case move. If you didn't already receive the memo, the day of the travel card is OVER. If you want to use a travel card for your own clinical information, that's fine. They should not be used, though, for documentation.
The Problem Oriented Medical Record (POMR) is the standard for documentation in health care. One example of the POMR is the P.A.R.T. system of documentation. The P.A.R.T. system is what is required of chiropractors when billing Medicare. I did not say "recommended," mind you. Medicare actually REQUIRES us to use the P.A.R.T. system. | |
