Understandably, most DCs would rather spend their time helping patients rather than documenting the visit. 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 chiropractors for poor documentation. The OIG says that as much as 94% of chiropractic documentation is in error or missing key elements.
How certain are you that you’re among the 6% getting it right?
Given this climate, it’s essential to clean up your reporting duties. SOAP notes are the best place to start. Not only are they the basis of proper documentation, but they must clearly articulate medical necessity, show the promise of significant improvement, and report a clear beginning, middle, and end of care.
It sounds simple, but if it were, most chiropractic practices wouldn’t be getting it wrong.
Documentation habits often reflect the financial health and general organization of a practice. If your SOAP notes are a mess, there are almost always other shortcomings that compromise productivity and practice profitability.
Chiropractors are often rebels and not famous for following the rules. They question the status quo; they are change-makers. However, documentation is not an area that allows for creativity, improvisation, thinking outside the box, or overlooking detail in favor of the big picture.
This is where installing systems and using a time-tested integrated forms package can make a huge difference. When you have easy-to-follow procedures in place, your documentation requires far less effort. Keep your sanity—and keep your practice compliant and profitable.