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Documenting The Exams

Exams vs. Daily Notes - and the winner is...

The most common question I'm asked by doctors is "which is more important - documentation of the exams or the daily notes?" 

The answer is...BOTH.  The exam AND the daily notes are equally important, but in different ways.

Think of it this way.  If you think of chiropractic case management as a finely tuned race car, the examination is the engine.  If you don't start the engine, the car will never move.  We need the exam in order to determine if it is appropriate for us to begin chiropractic care for our patients.  The more objective and quantifiable the examination is, the BIGGER and STRONGER the engine.

The examination is the first part of the documentation process.  This includes a thorough history that follows the format of the Problem Oriented Medical Record.  Our treatment of the patient depends on what we find in our examination.  Without determining the need to begin care (medical necessity), we have no justification to treat the patient.  The examination must be thorough.  Even when documenting subjective symptoms, the more quantifiable it is, the better the documentation.


The History

If you graduated from chiropractic school after 1982, you probably learned how to take a history using the OPQRST format.  If you graduated before 1982, you may not have learned it this way.  In case you forgot, OPQRST stands for Onset, Provocative/Palliative, Quality, Radiation, Site and Temporal.  We need to get the answers to EACH PART for all conditions for which we will be treating the patient.  You can either ask the questions to the patient verbally or in a written format.  I created an intake form that asks the patient all of the appropriate questions, including the OPQRST questions.  When it's time for me to see the new patient, I simply review all of the information with the patient, which is about a MILLION TIMES FASTER than asking the questions and writing down the answers.

We also need to get certain pieces of information from the patient in order to satisfy the Problem Oriented Medical Record and the Review of Systems.  I use a Review of Systems format that I found in a medical office I work with that I like because of how specifically it's laid out.  This is part of my new patient intake form.  Click below to see a sample.

review of systems sample.pdf
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The Evaluation/Management (E/M) Exam

The next step in the evaluation of the new patient is the Evaluation/Management Exam.  According to HCFA/CMS, the basic requirements of the E/M exam include a visual assessment of range of motion noting pain, manual muscle tests, deep tendon reflexes, dermatomal sensation, orthopedic tests and palpation findings.  If the exam form is designed properly, it is easier for the examiner to cover the basic exam findings in a short amount of time, all while thoroughly documenting your findings.  Click on the sample exam form below to see what I use.

Sample_Exam_Form.pdf
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