April 2018

April 2018

Good Documentation is Your Best Defense

Understandably, most DCs would rather spend their time treating their patients than filling out paperwork. But documentation isn’t just an annoyance, it’s legally necessary, and it’s imperative for the survival of any practice.

The OIG (Office of the Inspector General) and its investigatory branch, the OAS (Office of Audit Services), are pursuing suspected fraudulent or misreported claims more aggressively than ever in the wake of the OIG’s latest report slamming DCs for poor documentation. The OIG says that as much as 94% of chiropractic documentation is in error or missing key elements. Are you sure you’re among the 6% who are getting it right?

Given this current climate, it’s essential for doctors to prioritize that dreaded paperwork. SOAP notes are the basis of proper documentation, but only if they clearly articulate medical necessity administered to a patient expected to achieve significant improvement, and only if they report a clear beginning, middle, and end of care.

It sounds simple, but if it actually were, 94% of chiropractic practices wouldn’t be getting it wrong.

How DCs handle documentation is an integral part of the financial health of their practice. And often, how doctors handle documentation is a reflection of the general organization of their practice. If your SOAP notes are a mess, it’s likely that so are the rest of your documentation and practice procedures.

Chiropractors are not, by nature, great at following rules. They question the status quo; they are change-makers. That’s why they went into chiropractic in the first place. But safe and compliant documentation is an area that doesn’t allow for creativity, improvisation, thinking outside the box, or overlooking details in favor of the big picture.

This is where installing systems and using reliable documentation makes a huge difference. When you have easy-to-follow procedures in place, all that paperwork becomes, if not enjoyable, much less effort. You keep your sanity—and you keep your practice compliant and profitable.