Documentation by Dr. Gregg Friedman and The Bulletproof Chiro

In my previous article, I wrote about how important a great Assessment is in our SOAP notes and how most chiropractors don’t even come close to documenting a good assessment. Some chiropractors complain that some patients respond more slowly than others and that should be taken into consideration. I couldn’t agree more. In fact, a great idea is to document complicating factors for EACH condition you’re treating for each patient, if they exist. A great resource

There’s ONE part of our SOAP notes that I’ve been preaching about for years, but it seems as though not many doctors are paying close enough attention to it. It’s the Assessment. Here’s what I see in most records that I review in the Assessment part of the SOAP Note: “Patient is responding well to care.” “Patient is the same.” “Patient is responding slower than expected.” To begin with, according

There seems to be some confusion among chiropractors as to what objective findings we need to document on our daily visits.  I, and others, have been teaching for a number of years to follow the PART format of documentation for ALL of our patients.  This PART format is what is REQUIRED by Medicare, and, to be honest, it works quite well for ALL of our patients. So, let’s review what PART is. 

In my last article, I discussed the MUSTs and the SHOULDs of Subjective Documentation, that being Pain Intensity, Pain Frequency and the use of Outcome Questionnaires. Now we’ll tackle the Objective Findings. Even though many chiropractors don’t treat a lot of Medicare patients, please understand that Medicare creates many of the rules. I’ve seen other commercial payors using the Medicare documentation guidelines for their policies, which actually makes it easier

Let’s face it. With regards to our documentation, some doctors don’t say enough, while other doctors say too much. So which is better? Let’s narrow this down to the big three: The Must, the Should and the Could. There are some things we MUST document. They’re required components and if we miss them, we’re toast. Then there are certain things that we SHOULD document. These things aren’t exactly required, but they really enhance our documentation. And then

After being in practice for 32 years, teaching documentation and coding for about 20 years, reviewing records and performing IMEs for a lot of years, I see and hear the same things over and over again with regards to documenting subjective complaints. Let’s make this easy. Initial Visit According to the Mayo Clinic, 80% of the proper diagnosis comes from a good history. Unfortunately, many chiropractors tend to take shortcuts

I remember the “good ‘ole days” of chiropractic. The days when it seemed that everyone in America had health insurance, when the typical deductible was about 100 bucks and the patient only had to pay 20% of the charges. And their policy limited chiropractic treatment to only “UNLIMITED VISITS.” Sigh… When a new patient came in, we did the ortho/neuro exam we all learned in chiropractic school, found a few

In the old movie, Cool Hand Luke, the Captain said to Luke, “What we’ve got here is failure to communicate.” This has been a major problem with the chiropractic profession since our inception. So many people who’ve never been to a chiropractor have simply no idea what it is that we do and why we do it. In fact, the rest of what I like to refer to as the