Conclusive Documenting, Evidence of a Referable Chiropractor

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In a court of law, your opinion in the area of personal injury is highly regarded. As a chiropractor you are considered an expert based on your skill, experience, training, and education in the area of biomechanics. Your opinions in matters concerning any trauma or accident are proof of damage and may be the only chance of retrieving a settlement for your patient.

As you may already know, managing a personal injury claim or workman’s compensation case can be more laborious than other types of care. The demand for greater note-taking and record-keeping are strictly scrutinized; however, this is an opportunity for your professionalism to shine. Your image in the eyes of your patient, as well as the attorneys and other professionals will be center stage, and you have an opportunity to make a lasting impression.

While you are not the one on trial, your record-keeping standards are. They are the pieces of evidence that the attorneys will be attempting to rip apart as they break down the case. And your recollection of every detail of the patient’s specific care may not be crystal clear. You must fall back on the quality of your notes to leave you a complete story of that patient’s incident and their recuperation.

There are several areas of great importance that are of interest regarding your patient’s case:

  • Are the patient’s conditions related to the accident?
  • Is the treatment that you provided related to the problem caused by the accident?
  • Are all your diagnoses prioritized and supported? Do they take into account any prior or underlying medical or accident history.
  • Is the prognosis of restrictions, limitations, permanent disabilities and future medical costs because of complications caused by the accident?

In truth, the quality of your patient records and documentation are an important cause of the success of most cases since most—if not all—courts assume that if it is not in writing, then it did not happen. It is important for you to go into as much detail as possible not only during the initial consultation and history, but also in the follow up care, making sure to accurately record your patient’s status and progress as well as their eventual graduation to a supportive care program.

The mistake that many doctors make is trying to maintain the required level of consistent documentation without the help of a sufficient software system. Doctors that attempt to manage these detailed cases without the proper systems not only compromise their professionalism, but jeopardize their patient’s case. Nearly all consistency problems are easily managed with a good practice management software system. A good software system enables you to be very organized in both the process and the frequency that you record information, as well as reminding you to fill out needed questionnaires and do re-exams. This kind of attention and detail in your documentation will impress your patients as well as other professionals you encounter.

Establishing yourself as an authority in the area of personal injury can act as a tremendous practice builder. Good note-keeping with the help of software will produce a win-win situation, as your documentation will be faster and more complete, and lawyers in your community will be drawn to you because you make their job that much easier.

Dr. Meinhofer is a customer sales representative for Integrated Practice Solutions, the makers of the ChiroTouch Chiropractic Software; a complete practice management software system designed to make your job easier and your patients experience better.