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.
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.
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.
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.
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.