Home Page
Seminars
Seminar Testimonials
Documenting SOAP Notes
Contact Us
About Gregg Friedman
Documenting The Exams
Documenting Daily Visits
Get Free Information

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

Both.  Or neither.  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 prove the need to begin 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 E/M Exam

This is the first part of the physical examination process. According to HCFA/CMS, the basic requirements of the Evaluation and Management (E/M) Examination of the Musculoskeletal System should include a visual assessment of range of motion noting pain, subjective manual muscle tests, deep tendon reflexes, dermatomal exam 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. To see a sample of the exam form I designed and use, click here.  The exam forms come in packages of 50 and cost $15 (including shipping). Click here for an order form. Just print it, fill it out and fax it (fax number is on the order form).

It is important to understand, though, that the E/M evaluation does NOT prove medical necessity or justify the need for care.

So How DO We Prove Medical Necessity?

Once the E/M exam has been performed, it is important to quantify as many findings as possible.  The more objective the findings are, the better the documentation is.  This helps the doctor PROVE if the patient needs to begin and/or continue chiropractic care.  It is also critical that we perform re-evaluations at regular intervals in order to help determine when the patient has reached maximum medical improvement.  If the functional tests plateau at some point in the patient's care, either a change in treatment or an outside referral might be indicated.  When all tests are normal and they stay normal without further treatment, the condition may be considered to be static and stationary.  

Remember, it's the examination which helps us determine if treatment is necessary or not and if the patient is improving with our care. 

Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Sign up for our Email Newsletter
For Email Marketing you can trust
Copyright 2005 Dr. Gregg Friedman. All rights reserved.