Academy of Chiropractic
MD Referral Program
Clinical Pillar – Documentation and Coding – Apprentice
William J Owens Jr DC DAAMLP CPC
“If you do NOT have a plan, you are part of someone else’s” – Terrance McKenna
Effective Reporting to the MD
In the “MD” world any doctor that is not a family physician is considered a specialist. Regardless of your personal feelings related to chiropractic’s place in the healthcare environment, we are looked upon as specialists (this is based on conversations with MDs all over the country and the review of interviews published in peer reviewed research journals). Since we are considered specialists, it is important that we follow some of the reporting “rules” of the Medical Specialists. If we want to obtain referrals for MDs, we need to speak their language and report to them in a manner that they understand. If you DO NOT want referrals from the medical community than simply ignore these facts…Over the years the best method of reporting in the chiropractic office from a Compliance and Clinical reporting standpoint is a hybrid between form based notes and dictation even in an EMR System. Dictation is important because it allows you to DESCRIBE what is going on with the patient and is not part of a canned note. It allows you to “Cover ALL the Bases” and customize the report to each patient. The SOAP note comes into play when you are recording visits between evaluations and should be specific to carrying out your treatment plan. The treatment plan does not change between evaluations, unless of course there is an emergent situation or the patient is responding faster than expected Evaluations MUST be done every 30 days.
Here is an easy to follow outline:
Initial Report, Re-evaluations and Release from Care – DICTATED (SENT TO MD) – Do not send SOAP to the MD
Treatment Notes – not shared with the MD
These are ALSO marketing tools, that is why I will be working with you hard to ensure you have a reporting foundation in your practice. In today’s practice environment it is not just compliance, it is reporting on an interprofessional basis which is critically important to medical providers from a reimbursement standpoint. There will be much more on that as you progress through the curriculum.
Attached or posted on the website is the Comprehensive Evaluation Form*…This template was designed over a 3 year period and includes every body part and function for all patients, with the personal injury and workers compensation patients in mind (after that, managed care is a piece of cake!) It includes normal’s in range of motion of every joint in the body, motor, sensory, and orthopedic tests and has “built in” areas for determining necessity for testing to ensure payment. It is extremely thorough and designed to “walk the doctor through” the evaluation process in the shortest time possible without compromising clinical accuracy.
The information on this FORM is also the outline for dictation…Just follow the FORM from beginning to end to create your initial, re-evaluation and final reports when dictating. Once you do this a few times, your proficiency will increase dramatically. Right now it takes me 4 minutes to dictate an initial report. The transcriptionist has the ability to SLOW down your voice on the recording so you can talk rather fast…
For those of you that may not have a transcriptionist, for my larger medical legal narrative reports or expert witness consulting reports I am using (NAME HERE). I use and prefer for my regular patients my EMR System, Software Motif, if you have a need to discuss, please set up a time to talk with me and we can work on it together. If you are dictating or even using a Scribe in your practice for your EMR, MAKE SURE YOU REVIEW EVERY REPORT…DO NOT USE the phrase “Dictated but not read”, EVER…
Okay, so those are the reporting templates and they are included in your membership. If you need those or other intake forms email me and I will send a downloadable link.. This has been proven to be a successful model in the medical specialty world and in chiropractic. Do not try to re-invent the wheel; it has been done for you, this is what I do every day. The information in the FORM has been created to make sure you are protected from a COMPLIANCE standpoint and will ensure your “language” for the MD is complete and accurate.