You probably have a clinical protocol that you generally follow as you address each patient's issue. Is it in writing? It should be.
It all starts with this simple formula: H + E = Dx -> Treatment Plan.
In other words, the patient's history, plus your exam findings, equals your diagnosis, which naturally yields your treatment plan. Outcome Assessment Tools record the patient's progress, document the medical necessity of your care and show evidence of delivering functional improvement.
When your visit-by-visit documentation follows this treatment plan, you can rest assured that the reimbursement gods will smile mightily upon you.
The way you approach each patient's case is based on your preferences. You've acquired these based upon your initial training, how long you've been in practice, your clinical experience with other patients and your overall patient care philosophy. There are many ways to achieve the desired functional goals. But every chiropractor takes a slightly different path.
Codify your standard "route" as your written standards of care. Create a written protocol that helps you decide what to do, essentially putting in writing the "Best Practices" you've developed over time. Write out your standard approach to the length of treatment, number of visits and adjunctive procedures you generally utilize for the various conditions and their severity. Doing so makes it easier to create a patient's written treatment plan.
The more efficient you are at managing new, and returning patients with new conditions, the more people you can help. Standardize your written protocols and watch your practice grow.
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