Have you ever had a medical professional not document your visit thoroughly? If so, it can be very frustrating for a variety of reasons. You may have to recount what you already told him or her, which can be irritating. The medical professional may forget what he or she determined was the medial plan you were to follow. If you have not experienced a situation like this, then you do not want to. Not providing proper medical documentation can have a negative impact on you, whether it is physically, mentally, or work related.
Just like any other health professionals, chiropractors need to provide detailed documentation with every interaction they have with their patients. If can protect not only themselves but also their patients. There is more information a chiropractor needs to collect from you during your initial visit than there is during subsequent visits.
Initial Visit Requirements
- Important information regarding the history of your condition with a detailed
- description of your current condition
- Evaluation of your musculoskeletal/nervous system through a physical exam
- Diagnosis
- Treatment plan
- Recommendation of duration and how often you should visit
- Specific treatment goals
- Functional limitations-Activities of Daily Living (ADL)
- Date of your first treatment
Subsequent Visit Requirements
- History
- Review of your main complaint
- Improvement or worsening since your last visit-patient specific comments
- Follow-up of ADL’s
- System review, if relevant
- Physical exam
Making sure all of this information is documented is important because it promotes your safety and the quality of care you are receiving. Thorough and accurate medical recordkeeping will help make sure you get the right care at the right time.
Recording proper documentation during each visit is also important because it helps with communication between healthcare providers. It looks at your patient care from admission to discharge, including topics such as diagnoses, treatment, and resources used while you were being cared for. When medial documentation is thorough, includes details, and is accurate, it prevents uncertainty and improves communication between healthcare providers.
If you have been injured due to your job, due to being in a car accident, or due to anything else that has prevented you from working, it is pertinent that chiropractors document the medical care they give you. If this is not done, you will not receive any compensation for your treatment and for being out of work. Your chiropractor will need to document details of the severity of your symptoms, document all treatment provided, and make sure they provide accurate billing information. All of these details will help prove you received injuries due to your job or car accident, as well as the severity of them. Your chiropractor can also figure out a rough estimate of the amount of time it may take you to recover, how much damage you sustained, and the mental strain you have experienced.
Details are always important, especially when it comes to medical care. It is imperative for medical professionals to give specific details for every visit they have with a patient. Dr. Elsey at North County Pain Relief does an exceptional job at documenting every encounter. He understands the importance of making sure all details are included in his patients’ charts in order to keep his patients safe and they receive the care they deserve. If you want to make sure that your medical charts are thoroughly complete with all the details of your visits, Dr. Elsey is the right chiropractor for you. Contact his office today at (314) 731-4201 to make an appointment with him so you can receive the best care around.
