Documentation & Coding Guidelines

This quick tutorial provides an overview of chiropractic documentation requirements. As a Chiropractic Assistant, you must understand why the provider must document and why the documentation must be completed correctly. Even if you do not have scribe duties in the clinic, a basic understanding of the guidelines can be advantageous in creating a compliant clinic….

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Anatomy of a Patient Chart

This Rapid Tutorial provides an overview of the flow of documentation as it occurs in a typical chiropractic practice. The CA has a vital role in establishing complete and compliant documentation. Being comfortable with the documentation process is beneficial for all CAs, regardless of his/her role in the practice. Documentation is collected from the first…

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EHR vs. Paper Documentation

Download Support Tool The patient’s health record, whether paper, electronic or a combination of the two, is a legal record. The patient has unprecedented rights as to the use, privacy, and protection of this record. Therefore, it must be handled with care and respect. Your clinic may be set up as an electronic health record…

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Managing Paperwork

Efficient Systems & Procedures In an efficient office, there is a system and procedure for everything. This makes training for team members easier and downtime or non-patient-related time more effective. Do you find yourself “scrounging” to find patient paperwork each time a new patient walks in the door? While this may be frustrating for you,…

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The Foundation of Documentation

Documentation is one of the critically important moving parts of a chiropractic practice. Proper documentation, from the moment the patient presents for care, is essential to the success of the practice. Documentation affects virtually every role in the chiropractic practice. In this step, the Chiropractic Assistant or staff member will learn the sheer magnitude of…

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The Patient’s Health Record

Medical Record Compliance  We’ve all heard the adage, “If it wasn’t written down, it didn’t happen.” Encounters between doctors and patients are “written down” in the patient’s health record. That record is one of the most important assets owned by the practice. It is the final, legal document that describes the conditions and treatment of…

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