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DOCUMENTATION

DOCUMENTATION. STEP BY STEP PROCEDURE TO GOOD RECORDS. INITIAL PATIENT FORMS. Name, age, sex, address, SS#, Married Consent forms Family history Medical history: surgery, medications Past traumas Visual Analog scale Oswestry forms. CONSULTATION. Go over forms and ask questions

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DOCUMENTATION

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  1. DOCUMENTATION STEP BY STEP PROCEDURE TO GOOD RECORDS

  2. INITIAL PATIENT FORMS • Name, age, sex, address, SS#, Married • Consent forms • Family history • Medical history: surgery, medications • Past traumas • Visual Analog scale • Oswestry forms

  3. CONSULTATION • Go over forms and ask questions • Confirm reason for visit • Past DC care - what kind, did it help?

  4. EXAMINATION • Chiropractic A) palpation B) inspection

  5. ORTHOPEDIC EXAM • Range of motion • Regional orthopedic tests

  6. NEUROLOGIC EXAM • Sensory • Motor • DTR • Cerebellar • Cortical

  7. RADIOGRAPHIC • When and why? • Who? • What views? • Repeat studies

  8. DIAGNOSIS • How to choose? • How many to use? • When to change?

  9. HOW TO CHOOSE • The diagnosis should be based primarily on the examination information. • Secondary information should be the nature of the incident. • Generally, the diagnosis should not be based on the radiographic findings.

  10. HOW MANY • HCFA forms only have space for 4 codes. • Optimize that space • List the primary diagnosis first • List neurologic diagnosis next • List complicating diagnosis last

  11. EXAMPLE 1 • Primary - 847.0 • Secondary - 723.4 • Complicating - Arthritis

  12. EXAMPLE 2 • Primary - 847.2 • Secondary - 724.3 • Complicating - Scoliosis

  13. EXAMPLE 3 • Primary - 722.10 • Secondary - 728.85 • Complicating - previous surgery

  14. WHEN TO CHANGE • When the soft tissue injury has reached MMI. • When your care is subluxation based. • When the patient is in active rehab. • When the condition has worsened. • When there is a new injury.

  15. CERVICAL SPRAIN/STRAIN • Subjective neck pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma/insult to region

  16. THORACIC SPRAIN/STRAIN • Subjective mid-back pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma/insult to region

  17. LUMBAR SPRAIN/STRAIN847.2 • Subjective low back pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma or insult to region

  18. LUMBOSACRAL SPRAIN/STRAIN=846.0 • Subjective low back/sacral pain • Affected joint movement painful • Spasm or hypertonicity • Tenderness by palpation • History of trauma or insult to region

  19. CERVICAL DISC722.0 • Subjective neck pain • Affected joint movement painful • Reduced neck motion • Spasm or hypertonicity in cervical spine • History of trauma • Positive cervical compression tests • Radicular symptoms

  20. LUMBAR DISC722.10 • Low back, buttock, and/or posterior leg symptoms with at least one of the following positive tests: A) SLR (+) at 30-70 degrees B) Bechterew’s test C) Lasegue’s test D) Kemp’s test E) Antalgic posture

  21. BRACHIAL PLEXUS LESION353.0 • Cervical rib • Costoclavicular • Scalenus anticus syndrome • Thoracic outlet syndrome

  22. BRACHIAL PLEXUS LESION353.0 • Tenderness at the supra-clavicular and/or lateral aspect of the lower cervical spine • At least one of the following test (+) A) Adson’s test B) Wright’s test C) Costoclavicular test D) Hyperabduction test

  23. ACUTE ACQUIRED TORTICOLLIS = 333.83 • Acute neck pain - no trauma • Spasms usually involving the trapezius or stenocleidomastoideus • Head tilt present

  24. MYOFASCITIS729.1 • A condition of chronicity • Circumscribed palpable nodule (trigger point) • Causes referred pain

  25. HEADACHES784.0 • Tension • Muscular • Vertebrogenic • Tenderness by palpation in the suboccipital and upper cervical region

  26. MIGRAINE, CLASSICAL346.0 • Aura consisting of at least one of the following: A) Visual disturbances B) Numbness or weakness on one side of the body C) Transient aphasia D) Vertigo

  27. MIGRAINE, CLASSICAL346.0 • Unilateral head pain • Nausea and/or vomiting

  28. COMMON MIGRAINE346.1 • Unilateral or bilateral head pain • Pain in the eye (stabbing) • Often aggravated by light or noise

  29. WHAT TO BILL? • Examination • X-rays • Manipulation codes • Modalities

  30. DAILY DOCUMENTATION • SOAP NOTES a) Inappropriate examples b) Good examples c) Computerized notes

  31. PROPER DAILY NOTES • SOAP FORMAT

  32. RE-EXAM DOCUMENTATION • What to do? • How often? • What to bill? • Now what? a) treatment plan change b) release from care c) referral

  33. RE-EXAM SHOULD INCLUDE • Brief consultation about current condition • Repeat (+) tests & significant (-) tests • Visual analog scale • Oswestry repeated • Have patient sign exam form

  34. RE-EXAMINE HOW OFTEN? • Every 10-12 visits • Every 4 weeks • Whenever there is a worsening of the condition • Whenever there is a new area of complaint • Upon release from care or MMI

  35. WHAT TO BILL? • Simple re-exam - 99211/99212 • New injury possibly - 99213 • Significant new injury - 99214 A) Major auto accident with multiple injuries requiring detailed history and detailed examination

  36. NOW WHAT? • Treatment plan needs to change • If patient is improving the following needs to happen: A) fewer weekly visits B) fewer modalities C) move towards active vs passive care

  37. NOW WHAT? • If the patient has not made significant improvement the following needs to happen: A) A change in the treatment B) Referral for second opinion to DC, MD, or DO C) Additional advanced testing - CT, MRI, EMG

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