Helpful Documentation Tools

Download Reference Documents Sometimes, when reviewing records to be sent, it’s clear that the note(s) were not properly signed and authenticated. In this instance, all is not lost. Even Medicare provides a way to offer Signature Authentication after the fact. If you have not already reviewed the module in this course regarding signatures, please do...
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The Case Summary Template

Using a Case Summary Template When fulfilling a records request, regardless of the entity requesting the information, we recommend that you always include a Case Summary Letter. The template image shown on the right will help you tell the story of what occurred during treatment and illustrate the case management involved. It should serve as...
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Your Amendment Rights

Medical Record Addendums Despite best efforts and good intentions to complete perfect documentation at the time of service, errors and omissions can occur. When that happens, the situation has its own documentation requirements. Failure to properly amend a medical record can make it appear that someone was trying to falsify documentation, and that may be...
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What Do They Want From Me?

A Records Request: A Common Occurrence So, you check the office mailbox – a few EOBs, checks from patients, a menu from the local pizza place, and (sigh) a love note from an insurance company requesting records for a patient. Before panic sets in, understand that this is a common occurrence in the chiropractic profession....
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How Do You Respond to a Records Request?

When is a simple request for records not really a simple request for records? Almost every time. When a payer is asking for notes, whether for a current claim, or a retroactive review, it means something. It could be random, or it could be targeted and focused. Because you may not know, this is the...
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