required to write (in California, check your state’s rules) on the days you perform treatments in
between the monthly re-exams.
The secret is genuine and thorough progress exams. You will note that with my forms, the
patient fills out the Symptoms form and the top two-thirds of every extremity exam form. The
patient with a brain concussion also fills out the Acute Concussion Evaluation, the Epworth
Sleepiness Scale and the Rivermead Post-Concussion Symptoms Questionnaire. Using my
forms means the patient is doing a lot of your work and you are billing your hourly rate for all
the time you spend reviewing those forms with the patient and checking off all the boxes on the
Diagnosis and Treatment Plan forms.
These forms communicate exactly what is wrong with the patient in plain English so that
attorneys and claim adjusters. Your records are bullet-proof. If anyone ever asks, “What were
Mary’s symptoms on May 3?” You reply, “The note I made May 3
rd
refer back to and
incorporate my most recent consultation and Symptoms form with this patient. The most recent
Symptoms form on the patient was filled out April 14
th
. Mary’s symptoms waxed and waned
from day to day but I was still treating Mary on May 3
rd
for the same symptoms she had on April
14
th
. So Mary’s symptoms on May 3
rd
were (list off all the symptoms checked on the April 14
th
Symptoms form in your patient chart.)
What if you are pressed with a question like, “How do you know that is accurate?” You simply
reply, “My standard practice with note keeping is to incorporate by reference forms that are
already in my patient file and to only write an exception when I deviate from what is already on
file. For example, look at the note I made March 28
th
. See how I wrote, See most recent
symptoms form on file. In addition, patient also has the new symptom of left index finger pain.
Since I did not write any deviation or exception on May 3
rd
, I am quite certain that the symptoms
for which I treated Mary on May 3
rd
are accurately reflected in the April 14
th
Symptoms form to
which I referred on May 3
rd
.”
Show Your Work To Get Paid For Doing Progress Exams
I also suggest that the treating chiropractor using my forms follow the advice of their sixth grade
teachers. Show your work. Remember that the teacher would give partial credit on math
problems if you showed your work (even if you did not get the answer correctly.) Claim
adjusters at the medical payments department get claims all the time printed on simple claim
forms and they think, “This is a lot of money. I wonder how much work this chiropractor
actually did?” In a situation involving Medical Payments insurance, faxing the Symptoms,
Exam, Diagnosis and Treatment Plan forms to the medical payments adjuster along with the bill
allows them to see all the work you did. The claim adjuster will see your excellent work, know
that you did all the work you have billed for and will pay the claim (and be far less likely to try
to reduce the bill.) Show your work and get paid like a doctor again.
In the case of group health insurance, there is often no mechanism of showing your work when
you submit a bill (especially electronically.) However, you still have all this thorough and
accurate written documentation in your file in case they ask to see your file or ask you to “send
your SOAP notes.)
In case the State Board receives a complaint about you from any patient, you have a thorough,
accurate, detailed patient chart that describes on paper exactly what is wrong with your patient
and your reasoning for treating the patient in the way you did. Ethical, accurate patient notes
will help you very much in case of a State Board complaint or a malpractice lawsuit.