If you had to do a critical assessment of your daily chart notes, how would you rate them? Do you record all the necessary components that would aid someone in understanding your patient’s case? Would you be proud to share your notes with another professional such as a physician, lawyer, or associate? If the answer to the above questions is “NO” you are not alone.
Since 2000, the CERT and more recently the OIG report have revealed what we already know about chiropractic documentation; it is abysmal. We were especially weak in recording evaluations, treatment plans, treatment goals, and supporting the necessity for care. Read the rest of this post »
Read the rest of this post »