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DOCUMENTATION

This step-by-step guide provides a thorough framework for documenting initial patient forms and conducting consultations in a chiropractic setting. It outlines essential information to collect, including personal details, medical history, and consent forms, along with structured examination procedures. You'll learn how to perform chiropractic assessments, orthopedic and neurologic evaluations, interpret findings, choose appropriate diagnoses, and optimize billing codes. Proper documentation practices such as SOAP notes and re-exam protocols ensure excellent patient care and compliance with healthcare standards.

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DOCUMENTATION

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  1. DOCUMENTATION STEP BY STEP PROCEDURE TO GOOD RECORDS

  2. INITIAL PATIENT FORMS • Name, age, sex, address, SS#, Married • Consent forms • Family history • Medical history: surgery, medications • Past traumas • Visual Analog scale • Oswestry forms

  3. CONSULTATION • Go over forms and ask questions • Confirm reason for visit • Past DC care - what kind, did it help?

  4. EXAMINATION • Chiropractic A) palpation B) inspection

  5. ORTHOPEDIC EXAM • Range of motion • Regional orthopedic tests

  6. NEUROLOGIC EXAM • Sensory • Motor • DTR • Cerebellar • Cortical

  7. RADIOGRAPHIC • When and why? • Who? • What views? • Repeat studies

  8. DIAGNOSIS • How to choose? • How many to use? • When to change?

  9. HOW TO CHOOSE • The diagnosis should be based primarily on the examination information. • Secondary information should be the nature of the incident. • Generally, the diagnosis should not be based on the radiographic findings.

  10. HOW MANY • HCFA forms only have space for 4 codes. • Optimize that space • List the primary diagnosis first • List neurologic diagnosis next • List complicating diagnosis last

  11. EXAMPLE 1 • Primary - 847.0 • Secondary - 723.4 • Complicating - Arthritis

  12. EXAMPLE 2 • Primary - 847.2 • Secondary - 724.3 • Complicating - Scoliosis

  13. EXAMPLE 3 • Primary - 722.10 • Secondary - 728.85 • Complicating - previous surgery

  14. WHEN TO CHANGE • When the soft tissue injury has reached MMI. • When your care is subluxation based. • When the patient is in active rehab. • When the condition has worsened. • When there is a new injury.

  15. CERVICAL SPRAIN/STRAIN • Subjective neck pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma/insult to region

  16. THORACIC SPRAIN/STRAIN • Subjective mid-back pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma/insult to region

  17. LUMBAR SPRAIN/STRAIN847.2 • Subjective low back pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma or insult to region

  18. LUMBOSACRAL SPRAIN/STRAIN=846.0 • Subjective low back/sacral pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma or insult to region

  19. CERVICAL DISC722.0 • Subjective neck pain • Affected joint movement painful • Reduced neck motion • Spasm or hypertonicity in cervical spine • History of trauma • Positive cervical compression tests • Radicular symptoms

  20. LUMBAR DISC722.10 • Low back, buttock, and/or posterior leg symptoms with at least one of the following positive tests: A) SLR (+) at 30-70 degrees B) Bechterew’s test C) Lasegue’s test D) Kemp’s test E) Antalgic posture

  21. BRACHIAL PLEXUS LESION353.0 • Cervical rib • Costoclavicular • Scalenus anticus syndrome • Thoracic outlet syndrome

  22. BRACHIAL PLEXUS LESION353.0 • Tenderness at the supra-clavicular and/or lateral aspect of the lower cervical spine • At least one of the following test (+) A) Adson’s test B) Wright’s test C) Costoclavicular test D) Hyperabduction test

  23. ACUTE ACQUIRED TORTICOLLIS = 333.83 • Acute neck pain - no trauma • Spasms usually involving the trapezius or stenocleidomastoideus • Head tilt present

  24. MYOFASCITIS729.1 • A condition of chronicity • Circumscribed palpable nodule (trigger point) • Causes referred pain

  25. HEADACHES784.0 • Tension • Muscular • Vertebrogenic • Tenderness by palpation in the suboccipital and upper cervical region

  26. MIGRAINE, CLASSICAL346.0 • Aura consisting of at least one of the following: A) Visual disturbances B) Numbness or weakness on one side of the body C) Transient aphasia D) Vertigo

  27. MIGRAINE, CLASSICAL346.0 • Unilateral head pain • Nausea and/or vomiting

  28. COMMON MIGRAINE346.1 • Unilateral or bilateral head pain • Pain in the eye (stabbing) • Often aggravated by light or noise

  29. WHAT TO BILL? • Examination • X-rays • Manipulation codes • Modalities

  30. DAILY DOCUMENTATION • SOAP NOTES a) Inappropriate examples b) Good examples c) Computerized notes

  31. PROPER DAILY NOTES • SOAP FORMAT

  32. RE-EXAM DOCUMENTATION • What to do? • How often? • What to bill? • Now what? a) treatment plan change b) release from care c) referral

  33. RE-EXAM SHOULD INCLUDE • Brief consultation about current condition • Repeat (+) tests & significant (-) tests • Visual analog scale • Oswestry repeated • Have patient sign exam form

  34. RE-EXAMINE HOW OFTEN? • Every 10-12 visits • Every 4 weeks • Whenever there is a worsening of the condition • Whenever there is a new area of complaint • Upon release from care or MMI

  35. WHAT TO BILL? • Simple re-exam - 99211/99212 • New injury possibly - 99213 • Significant new injury - 99214 A) Major auto accident with multiple injuries requiring detailed history and detailed examination

  36. NOW WHAT? • Treatment plan needs to change • If patient is improving the following needs to happen: A) fewer weekly visits B) fewer modalities C) move towards active vs passive care

  37. NOW WHAT? • If the patient has not made significant improvement the following needs to happen: A) A change in the treatment B) Referral for second opinion to DC, MD, or DO C) Additional advanced testing - CT, MRI, EMG

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