Notes Lecture

Human Beings possess the intelligence necessary to solve simple and complex problems, we think, we are able to reason, experience all levels of emotion, we have developed language and are able to use it for communication.
We are capable of adapting to our environment and the many changes that take palace around us.
We possess a lesser degree of instinct than the other creatures on our planet.
This has been lost to educated thinking and a number of other factors that highly developed civilizations operate under.

When a species fails to adapt to it’s environment due to too rapid and negative change they either are controlled by other species or they become extinct.

The dinosaurs that walked the earth a few million years ago were unable to adapt to their environment and they are now extinct.

We are capable of adapting to our environment.

It is time Chiropractors begins to realize that for us to survive as a profession we must adapt.
We can no longer march to our own drum while the rest of the world marches to it’s own drum.
We can however march to our own drum with the philosophy that sets us apart from the other health professions and march to the other drum to achieve the acceptance of the entire health field.
The survivors in Chiropractic practice are those of us that have not forgotten that we examine and treat the entire body and through our adjustment of subluxations and through removal of nerve interference we restore health to our patients.
We all profess that we have helped all types of conditions with our adjustments.
We all can speak about our successful cases. One thing we all don’t do is document our results and make a record of the many wonderful successes we have.
I am going to introduce some of you to documentation that you are already familiar with and others of you do not recognize at all as a necessary means of communicating your actions to others.
Isn’t it about time we start acting like Doctors of Chiropractic and participate in the Health Care Community with the same level of management and accountability as the rest of the professional world?
Every State Board of Chiropractic Examiners has enacted “Record Keeping” regulations.
The licensing boards of every state have implemented these regulations making the preparation of proper patient records mandatory for compliance with licensing and professional conduct.
The preparation of legible and complete office notes is no longer an option. 
If you want to be paid for your services, you must document all the necessary areas that will create a word-picture of what you have done for the patient that justifies your being paid. 
Insurance companies are going to require type written notes be submitted, or payment will be denied.
The check the blank notes are not going to be accepted and again you will not be paid for services.
Many Chiropractic Licensing boards are requiring notes to be transcribed. This can be very costly and time consuming.
You are practicing a healing art in which, compassion, understanding and patient well-being should be your primary concerns.
However, it is also a business like all other businesses with payroll, health benefits, rent, utilities, insurance and a host of other expenses all of which require money to satisfy the debt.
You must collect your fees to be able to keep the doors open and serve patients.
The rule of thumb in court, at an arbitration, a malpractice suit or before the licensing boards is;
“IF IT ISN’T WRITTEN IN THE NOTE, IT WASN’T SAID OR DONE”!!!
I am going to help you understand how to:
Take control of your practice.
Maximize your patient and insurance-based collections.
Make your practice successful and profitable!
If you invest the time you will be able to organize your documentation and like I do, leave your office at night with no uncompleted paperwork, a clear conscience and the feeling that a POST PAYMENT AUDIT IS A WALK IN THE PARK!
Why We Take Notes.
INTRODUCTION:
As doctors of Chiropractic we have responsibilities which reach far beyond those of other occupations and professions.   
Due to the very nature of our profession, being charged with the responsibility to minister to the most precious of human possessions, the health care needs of our fellow human beings, we are held to a higher standard.WHY WE KEEP RECORDS:
The following are some of the reasons we keep patient records:
· The higher standard of obligations and the responsibilities we are charged with by our profession are why we are referred to as doctors and not technicians.
· To have a permanent record to refer to in the future.
· To allow for continuation of care in the absence of the original treating doctor.
· To be able to track the patient’s progress or lack of progress and alter treatment as necessary based on the noted results of treatment.
· To enable an outside party to evaluate, monitor and determine the need for the treatment-Insurance Consultant or another treating physician etc.
· To protect and defend you against any possible malpractice claims in the legal arena.
The Chiropractic Board of Examiners has established certain rules of practice, which are the minimum standard for licensees to follow.The failure of a licensee to adhere to these rules is considered to be professional misconduct, which may result in disciplinary action.
Your Chiropractic license confers a set of professional obligations upon you, which we will attempt to familiarize you with.
In this presentation we will address the minimum standards for record keeping by a licensee.
13:44E-2.2 Patient Records: (Page 55-58 of the State Board of Chiropractic Examiners Manual)
A contemporaneous, permanent patient record shall be prepared and maintained by a licensee for each person seeking chiropractic services, regardless of whether any care is actually rendered or whether any fee is charged. 
Licensees also shall maintain records relating to billings made to patients and third party carriers for professional services.  All patient records, bills and claim forms shall separately reflect the care or services rendered. 
Such records shall include, as a minimum:
1. The name, address, date of birth of the patient and if a minor, the name of the parent or guardian.
2. The patient complaint/reason for visit.
3. A pertinent case history.
4. Findings in appropriate examination.
5. Diagnosis/analysis.
6. A care plan.
7. Any order for tests or consultations including the clinical indications and the results thereof.
8. The dates of each patient visit.
9. A description of care or services rendered at each visit together with the name of the licensee or other person rendering the care.
10. Notations of significant changes in patient’s condition and/or significant changes in care plan.
11. Periodic notation of patient status regardless of whether significant changes have occurred.
12. An itemized statement of the amount billed and received on patient’s account.
The above regulations are those, which have been approved by the New Jersey Board of Chiropractic Examiners. The licensing boards of every state have implemented similar regulations making the preparation of proper patient records mandatory for compliance with licensing regulations.