Informed consent

• Done with every new patient or with a new c/c
• Risks
• Benefits
• Alternatives

Documentation

• Done for third party review
• Peer review
• State board review
• Insurance
• Law
• To protect your self
• Attorneys
• Substantiate necessity of treatment
• Other Dr. covering your practice/death
• Quality assurance/Utilization review
• Improve clinical competency & quality of care

Ethical responsibility

• Truthful
• Accurate
• Complete
• Failure to do so is "Unprofessional conduct"

Informed refusal

• When the patient refuses treatment after education and then get them to sign stating that they refused treatment

Confidentiality

• Only a patient can request file release
• Files are the Dr.’s property
• Only parents can get children’s files but emancipated children (married) only patient not parent can get records.
• Watch for attorney’s
• Can not refuse to release records or X-rays if they have not paid due to hindering care.

Records Retention

• Every state law is different 10 years is very good, and then they are burnt or shredded
• Storage on microfilm is good but fax can be a problem due to leakage.
• There is a statute of limitations that is they have two years after they become legal age or 18.

Mercy Guides

• Apply to all chiropractors
• Abbreviations can be used but must have a key
• All notes must be in a SOAP format.

• Express written consent for treatment
• Patient may seek damages for disclosures by the Dr.
• Right to confidentiality may be waved in the cases of law

Appropriate Terminology for Recording Exam Findings:

POMR- Problem oriented medical record

• Uses soap format
• S = What the patient says or c/c Quote the patient when necessary and any questions that you have ask the patient and then put see history and ROS
• O = All objective lab findings or ROS and exam findings go here. Written material is see physical exam, etc.
• A = Diagnosis is made here as well as any remarkable or unremarkable findings, as well as any ICD-9 codes that accompany the diagnostic findings. (ICD-9 codes are used for diagnosis). [CPT codes are treatment codes and billing codes] Any prognosis is placed in the notes here.
• P = Treatment plan and current procedures being used are placed here. The type of adjustment and level is placed here, any therapeutic modalities are also mentioned here.
• "E" = Exit status how the patient feels when leaving and then how long the relief lasts

Follow up visit

• S = How they are today and how have they been since the last visit have them rate the pain again
• O = ROM for any area of the adjustment, George’s maneuver, listing and restricted motion, also list tenderness and hypertonicity and soft tissue crepatice.
• A = Diagnosis and the codes as well as progress of the patient.
• P = List what you did for the patient and any instructions that is given for home.

New c/c or exacerbated complaint

• S =