Because chiropractors are naturally focused on the spine, it’s common for other body systems to get overlooked. Or more commonly, other systems are examined, but not documented, thinking those findings aren’t relevant.
A proper Evaluation and Management service should include a review of the relevant body systems that could affect the patient’s care outcomes or current complaint. This can help identify complicating factors or contraindications for the patient’s treatment.
A Review of Systems is simply a review of the systems related to the patient’s chief complaint. It’s one element of the patient’s History.
But it’s not enough to just have the patient fill out the intake paperwork with the review of systems on it. It must be discussed with the patient and comments noted during the consultation. This can be done by either annotating the patient’s intake paperwork and adding your signature, or by making notes in the electronic record within the initial visit note.
As you perform your review, consider these elements:
- Is the noted condition ongoing, past or previously resolved, or current?
- Is another provider managing this system?
- Are these factors contributing to the patient's condition?
- Are these factors a cause of the patient's condition?
Because the Review of Systems is so important in the care of the patient, it’s important to take the time to get all the details and make sure that information gets properly documented in the patient record.