Hands Heal

1. Hands Heal Chapter 5 Documentation: Intake Forms

2. Introduction Health Information Forms: For Wellness Care Health Information Form: For Curative Care Fees and Policies Health Report Pain Questionnaires Injury Information Form HIPAA Regulations for Electronic Transactions Amending the Forms

3. IntakeForms First step in gathering information Stepping stones to building relationship General questions Easy to use Do not require one-on-one attention Self-explanatory Filled out before initial session

4. IntakeForms Personalize forms Logo Business information (printed on every page) Name Address Phone number Top of each page Patient name Date

5. HealthInformationForms: For Wellness Care Brief health information forms Relaxation massage Spa therapies On-site massage Sports massage

6. HealthInformationForms: For Wellness Care Intake questions Address goals of health Quick and easy to use Ensure safety of patient Providing legal protection

7. Quick and Easy Charting Intake questions Yes/No answers Only positive answers recorded Checked off quickly Can be asked orally Client Make eye contact Make sure client understands question Make sure client is paying attention

8. Patient Safety Intake questions Ensure safety of client Identify health situations Contraindications Precautionary measures Designed to get right to health issues Information gathering questions

9. Patient Safety Yes answers Require additional information Precautionary measures Contraindications Specific to Work Environment Spa Allergies to scents/oils Sporting events Signs/symptoms of shock

10. Legal Protection Protection for practitioner Malpractice case Health screening considered Treatment appropriate Checked possible health complications Provide safe treatment

11. Legal Protection Intake form Have patient Fill out/answer oral questions Sign/Initial Date If practitioner completes form Patient to initial all entries Review all forms prior to treatment Verify completion of document

12. Health Information Form: For Curative Care Comprehensive health information form Personal identification and contact information Current health information Goals for health History injuries illness surgeries Contract for care

13. Personal Identification and Contact Information Personal Identification On every file Patient’s name Date of birth A date

14. Personal Identification and Contact Information Insurance reimbursement Patient’s name Claim number Date of injury (DOI) Record all possible contact numbers

15. Personal Identification and Contact Information Insurance reimbursement Patient’s name Claim number Date of injury (DOI) Record all possible contact numbers

16. Personal Identification and Contact Information Patient’s Address Useful for marketing Sending birthday cards Thank-you cards Emergency numbers Contact person in case of illness or accident

17. Personal Identification and Contact Information Primary health care provider (HCP) Fax Address Phone

18. Personal Identification and Contact Information On health information form Request permission to consult with HCPs Comply with Health Insurance Portability and Accountability Act (HIPAA) Written permission Let them know what information you are sharing With whom Why

19. Current Health Information Patient to List Prioritize Classify health concerns Identify how conditions are affecting daily life Address patient’s needs Clarify reasons for seeking manual therapy Justify treatment Subjective documentation critical

20. Health History Chart listing Surgeries Accidents Major illnesses Checklist of symptoms and conditions Identify major health crises Provides quick referencing Insight into origin of current conditions Identify factors that influence those conditions

21. ContractandConsentforCare Contract care Invitation for participation in treatment Share responsibility for result Delineates commitment to the healing relationship Goal is to empower patient Become active in healing process

22. Timing and Application Thorough history takes time Arrive 15-30 minutes before appointment to complete forms Mail/email forms to client Annual update Use as information database Designing treatment plan Identifying possible cautions for care Client contact

23. Fees and Policies Fee schedules Various services offered Cost for each service Delineate style or intent Categorizing like modalities Billable rates vs. payment-at-time-of-service rates Define each service clearly CPT (Current Procedural Terminology) Bundling Fraudulent billing practices

24. Payment Policies State payment methods available Clarify types of insurance reimbursement Be informed of specific risks/benefits of insurance billing Acceptable interest charges on past due accounts

25. Office Policies Written statements of office policies Make sure client reads them Require a signature Cancellation policies Right of refusal Set boundaries

26. Timing and Application Client Read/sign documents before 1st session Include policy statement with health information form Post fees and policies Help reinforce documents Demonstrate your professionalism Revisit fees and policies annually

27. Health Report Snapshot of client’s health Provide map of client’s symptoms Location of pain/stiffness/numbness Rate pain Loss of function Analog scales

28. Health Report Word values Number scale Heath care outcomes Function and pain

29. Human Figures Provide variety of ways to gather information Multiple choice forms One-on-one communication Pictures to draw on Analog Scales Method of measurement Reliable/more accurate than numerical rating scale 0-10 Mild, moderate, severe

30. Timing and Application Quick easy update Demonstrates progress Success of treatment Evaluate every 30 days/6-8 sessions

31. Pain Questionnaires Reliable/effective tool Measuring extent/nature of patient’s injury Its improvement with treatment Questions regarding patient’s ability to Sit/Stand Wash/Dress Walk/Sleep Read/concentrate

32. Pain Questionnaire Revised Oswestry Low Back Pain and Disability Index Lower back Vernon-Mior Neck Pain and Disability Index Upper extremities

33. Pain Questionnaire Patient Specific Functional and Pain Scale Identify top ADLs limited by condition Rate function 0-10 scale Repeat measurement periodically over time

34. Pain Questionnaire Providing reliable means to measure change in physical condition Documenting nature and extent of injury/need for care Illustrating improvements in function/result of treatment

35. Pain Questionnaire Supporting reasonableness/necessity of treatment Satisfying provider’s duty to monitor changes based on subjective/objective findings Aiding provider In writing reports or testifying at depositions/trials In assessing residual limitations relating to ADLs Graph changes over time for visual progress, and for writing case reports

36. Timing and Application Pain Questionnaires Easy to use Involve minimal time commitment No need to use all three Use on initial session Reevaluation every 30 days or 6-8 sessions

37. Scoring A value is assigned to each answer Ten sections per questionnaire Six possible answers per section Top answer pain value of 0 Bottom answer pain value of 5

38. Scoring Assign each section a score 0-5 Add all ten scores together Highest possible score (worst pain) 5 or total score 50 Multiply this number by two to reach overall rating of disability Disability percentage

39. Rating Scale

40. Injury Information Form Information form records specific data Assist in substantiating patient’s claim Providing information required by insurance companies Mechanics of the injury Symptoms Daily activities affected by injuries Any possible health complications resulting from incident

41. Injury Information Form Goal to gather information Substantiate injuries are significant Were incurred as result of incident Justify care

42. Personal Identification and Contact Information Five identifiers Name Date Date of birth (DOB) Insurance ID or Claim # Date of injury NOT included Address Phone numbers

43. General Information Page One Injury information On-the-job MVCs Other personal injuries Page Two Only involved in MVCs

44. Type of Injury Differentiate between Workers’ compensation/personal injury cases Establish whether a record of incident is on file Records helpful in substantiating particulars surrounding injury Police report (MVCs) Incident report (Workers’ compensation)

45. Description of the Injury Information provided by patient About onset of injury Presence/severity of symptoms Functional limitations Prompt patients to be specific as possible when describing how injuries occurred Focus on how patient got hurt rather than how collision occurred

46. Symptoms Have patient Record all symptoms since incident Establish a timeline for onset of injuries Timeline will help chart progression of injuries and healing

47. Effects of Injuries on Daily Activities Patient’s ability to function in day-to-day activities Loss of time at work Restrictions of responsibilities (light duty) Loss of productivity Inability to participate normally in exercise Self-care Household responsibilities Anything that detracts from patient’s quality of life

48. Pre-existing Conditions Establish presence of pre-existing conditions right away Health information Health history Documentation states symptoms were present before Pre-existing symptoms exacerbated by current injury Easier for attorney/claims adjuster to conclude Symptoms were a direct result of collision or work injury

49. Motor Vehicle Collision Information Mechanism of Whiplash Highlight mechanisms that influence severity of whiplash injury Severity of injury critical to establish extensive, on-going treatment required Return patient to pre-injury status

50. Motor Vehicle Collision Information Symptoms Check list specific to head trauma sustained or neurological damage Information influences type of care you provide Type of referrals you suggest External proof Visible trauma - take pictures