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CHIROPRACTIC
Forms and Sample Letters
INTRODUCTION & GUIDELINES
Practice recordkeeping and effective use of the forms and letters
TABLE OF CONTENTS
Links to copies of each form & letter, completed samples and instructions
ALPHABETICAL INDEX
Alphabetical listing of all forms and letters with links to each copy
CUSTOMIZABLE FORMS
Links to blank copies of each form or letter in a Microsoft Word format
CLICK ON A BUTTON TO CHOOSE THAT SECTION
All Rights Reserved
Copyright © 2000.
CHIROPRACTIC FORMS AND LETTERS
INTRODUCTION & GUIDELINES
Click on a section below to view that information
■ Introduction & Guidelines
■ Recordkeeping and Use of Forms
■ Rules of Recordkeeping
■ Protection Strategy Checklist
■ Correspondence Guidelines
■ Managed Care Information
■ Authors’ Notes & Disclaimer
■ Copyright Information
■ References
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CHIROPRACTIC FORMS AND LETTERS
TABLE OF CONTENTS
Click on a category for a listing of available forms and letters
■ Patient Forms
■ Physical Exam Forms
■ Insurance–General Forms & Correspondence
■ Insurance – Medicare
■ Insurance – Workers Compensation
■ Diagnostic Forms
■ Minors – Forms & Letters
■ Informed Consent & Authorizations
■ Lab Requests
■ Daily Notes
■ Practice Forms
■ Managed Care
■ Compliance
■ Patient Correspondence
■ Professional Correspondence
■ References
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
PATIENT FORMS
To view a form from the listing, click on that form’s title
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Patient Sign-In Sheet
Patient Information Sheet
Health History Checklist
Confidential Case History Record
Social History Sheet
Patient’s Job Description
New Problem/Re-Evaluation Form
SOAP Notes – Daily Progress Notes
Progress Notes – Alternative Style
SOAP Notes – Alternative Style
Patient Satisfaction Survey
Difficulty In Performing Activities
Of Daily Living Form
Self-Help Activities Form
Financial Hardship Payment Agreement
Hazard Warning Form
Exercise Instructions
Home Care And Exercise Report
Safety Belt Exemption Letter
Disability Certificate – 2 Versions
Physical Education Excuse Letter – 2 Versions
Work/School Excuse Doctor’s Appointment Letter
Patient Refusal To Allow X-Ray Letter
Failure To Follow Advice Letter
To Parent/Guardian Of Minor Child
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
PHYSICAL EXAM FORMS
To view a form from the listing, click on that form’s title
■ Physical Examination Legend/Key
■ Physical Examination Form
■ Regional Examination Form — Cervical/Dorsal
■ Regional Examination Form — Lumbar/Pelvis
■ Pre-Employment Physical Examination Letter
(No Doctor-Patient Relationship Created)
■ Physical Examination Letter: Insurance IME
(No Doctor-Patient Relationship Created)
■ IME Examination Patient Report Form
■ Physical Examination Letter: Athletics
(No Doctor-Patient Relationship Created)
■ Personal Injury Questionnaire
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
INSURANCE FORMS
To view a form from the listing, click on that form’s title
GENERAL FORMS & CORRESPONDENCE
■ Release Of All Claims
■ Letter To Patient When Insurance
Company Rejects Claim
■ Letter To Insurance Company After Paper Review
■ Insurance Assignment, Information
Release And Payment Agreement
■ Assignment, Lien & Authorization
To Release Medical Records & Information
MEDICARE FORMS
■ Medicare Explanation Form
■ Medicare Supplemental Carrier Protest Letter
WORKERS COMPENSATION FORMS
■ Workers Compensation Authorization Form
■ Workers Comp History Form
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
DIAGNOSTIC FORMS
To view a form from the listing, click on that form’s title
■ Pregnancy Warning And Consent
To X-Ray Form
■ Imaging Request Slip
■ MRI History Sheet
■ Imaging Interpretation Form
■ X-Ray Warning Labels
■ Patient Refusal To Allow X-Ray Letter
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
MINORS - FORMS & LETTERS
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■ Consent To Treatment (Minor) Letter
■ Child Abuse/Neglect Report
■ Failure To Follow Advice Letter
To Parent/Guardian Of Minor Child
■ Work/School Excuse Doctor’s Appointment Letter
■ Physical Education Excuse Letter
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
INFORMED CONSENT
& AUTHORIZATIONS
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■ Informed Consent Form
■ Informed Consent To Chiropractic Treatment Form
■ Consent To Participate In Research
■ Publication/Photo/Video Consent
■ Authorization To Admit Observers
■ Authorization To Use Patient Name
In Newsletter/On Bulletin Board
■ Authorization To Release Patient Information
& Medical Records
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
AUTO ACCIDENT FORMS
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■ Personal Injury Questionnaire
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
LAB REQUESTS
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■ Laboratory Request Slip
■ Request For Cerebrovascular Ultrasound
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
DAILY NOTES
To view a form from the listing, click on that form’s title
■ Daily Notes Form (SOAP Notes) – Narrative Style
■ Daily Notes Form (SOAP Notes) – Alternative Style
■ SOAP Notes Form — Alternative Style
■ Daily Telephone Log
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
PRACTICE FORMS
To view a form from the listing, click on that form’s title
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Report Writing Checklist
Daily Telephone Log
Interview Checklist –Substitute Or Associate Doctor
Employment Interview Guidelines
Employee Confidentiality Statement Form
Determining Independent Contractor
Versus Employee Status Form
Credit Card Payment Form
Retirement Checklist
Equipment Replacement Log
Fax Transmission Cover Sheet
Doctor’s Request – Records From Previous Doctor
Patient’s Request – Records From Previous Doctor
Response – Patient’s Or Provider’s Request
For Records
Response – Patient’s Request For Records
(Alternative Version)
Response – Other Provider’s Request For Records
Response – Other Provider’s Request For Records
(No Patient Authorization)
Response – Attorney’s Request For Records
Confirmation – Doctor Declining To Accept Patient
Letter Advising Individual The Doctor
Will Be Unable To Accept Him As A Patient
Confirmation – Patient Discontinued Care Voluntarily
Confirmation – Phone Message Discontinuing Care
Failure To Follow Instructions Pre-Withdrawal Letter
Withdrawal Letter
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
REFERRAL FORMS
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■ Referral Letter To M.D.
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
MANAGED CARE
To view a form from the listing, click on that form’s title
■ Contract and Compliance Letter
Withdrawal from Network
■ Contract and Compliance Letter
Reimbursement for Services
not Covered by Contract
■ Contract and Compliance Letter
Acknowledgement
■ Back-Up Doctor Managed Care
Coverage Agreement
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
COMPLIANCE
To view a form from the listing, click on that form’s title
■ Compliance – Coding & Billing
■ Compliance – Audit Template
■ Billing Compliance Investigation Guidelines
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
PATIENT CORRESPONDENCE
To view a form from the listing, click on that form’s title
■ Patient Not Satisfied And Will Not Return Letter
■ Follow-Up Letter When Patient Does Not Comply
With Referral Instructions
■ Referral “Thank You” Letter
■ “Thank You” Letter To Patient
Who Sends Note Of Appreciation
■ Apology Letter — Patient Kept Waiting
■ Patient Re-Call Letter
■ Confirmation That Patient’s Symptoms
Are Being Addressed
■ Collection Letter — version one
■ Collection Letter — version two
■ Collection Letter — version three
■ Letter Writing Off Debt
■ Notice Of Associate Leaving
■ Introduction Of New Associate Letter
■ Notice Of Sale/Retirement
And Introduction Of New Doctor
■ Notice Of Office Closing
■ Letter Of Condolence To Patient
Seriously Injured During Treatment
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
PROFESSIONAL
CORRESPONDENCE
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■ Confirmation Of Telephone Call
To Lawyer’s Secretary
■ Pre-Deposition Letter To Patient’s Lawyer
■ Pre-Trial Letter To Patient’s Lawyer
■ Transmittal Letter Accompanying
“Letter Of Protection”
■ Letter Of Protection
■ Irrevocable Instructions To Attorney To Pay Doctor
■ Letter To Attorney Who Fails To Honor Lein
■ Letter To Lawyer Seeking Status Report
Of Malpractice Claim
■ Team Physician Role Limitation Letter
■ Referral Letter To M.D.
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CHIROPRACTIC FORMS AND LETTERS TABLE OF CONTENTS
REFERENCES
To view a form from the listing, click on that form’s title
■ Assessment And Outcome Instruments
and References
■ Medicare 2000 – New Information
■ Medicare Regional Offices
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those forms
To view a form from the listing
Click on that form’s title
A
■ Abuse Report
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Activities Of Daily Living Causing Problems
Activities Of Daily Living Which HelpThe Patient
Adjustment Log
Advice – Failure To Follow
Advice – Failure To Follow – Parent Of Minor Child
Advice – Failure To Follow – Warning Letter
Prior To Withdrawal
Advice – Failure To Follow – X-rays
Advice – Symptom List, Letter
Apology – Patient Kept Waiting
Appointment– Work/School Excuse
When Keeping Dr’s
Assessment – References
Assignment Of Benefits
Associate – Introduction To Patients
Associate –Notice Of Leaving
Athletic Examination
Attorney – Ignores Letter Of Protection, Letter To
Attorney – Instructions To Pay Doctor
Attorney – Letter Of Protection
Attorney – Pre-deposition Letter
Attorney – Pre-trial Letter
Attorney – Request For Records, Responding To
Attorney – Secretary Letter
Authorization – Patient Name In Newsletter
Or On Bulletin Board
Authorization – Release Information
And Medical Records
Auto Accident Exam Form
Authors’ Note
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G-H
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N-O
P-Q
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U-V
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X-Y-Z
MAIN MENU
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
B
■ Bill – Delinquent, Demand Letter
■ Bill – Forgiveness
■ Bulletin Board – Consent To Use Patient Name On
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U-V
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
■ Case History Form
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Checklist – Exercise
Checklist – Patient History
Checklist – Home Care
Checklist – Independent Contractors
Checklist – Interview
Checklist – Managed Care Checklist
Checklist – Protection Strategy
Checklist – Report Writing
Checklist – Retirement
Checklist – Risk Management
Child Abuse / Neglect Report
Child – Consent To Treatment
Child – Parent’s Failure To Follow Advice
Clinical Lab Request Slip
Collection Letter – Final
Collection Letter – Friendly
Collection Letter – Intermediate
Confidentiality – Employee Statement
Confidentiality – Fax Transmissions
Confirmation – Patient Discontinued Care Voluntarily
Confirmation – Doctor’s Discharge By Telephone
Consent – Bulletin Board, Name On
Consent – Informed
Consent – Observers
Consent – Minor’s
Consent – Photographs
Consent – Research
Consent – Video
Consent – X-ray
Credit Card Payment
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B
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
D
E-F
G-H
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J-K
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N-O
P-Q
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MAIN MENU
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Daily Notes – Narrative Style
Daily Notes – Alternative Style
Daily Notes – Alternative Style #2
Depreciation – Equipment Log
Deposition – Attorney Letter, Before
Disability Certificate
Dissatisfied Patient – Letter To
Discharge – Doctor, Letter Confirming
Doctor’s Request For Records
From Previous Doctor
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B
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
D
E-F
G-H
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J-K
L
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N-O
P-Q
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U-V
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MAIN MENU
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Employee Confidentiality Statement
Employee Independent Contractor, Differences
Employment – Interview Checklist
Employment – Physical Examination
Employment – Physical Examination IME
Equipment Replacement Log
Examination – Athletics
Examination – General
Examination – IME
Examination – Pre-employment
Exercise – Monitor
Exercise – Proficiency Test
F
■ Fax Transmission Cover Sheet
■ Financial Hardship Payment Agreement
■ Forgiveness Of Bill
A
B
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
D
E-F
G-H
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N-O
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MAIN MENU
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Hazard Warning
History – General Health
History – Red Flag Questions
History – Social
Home Care Checklist
Home Care Report
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
I
E-F
■ IME Patient Report
G-H
■ IME Report of Independent Examination
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J-K
L
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■ Independent Contractors Checklist
■ Informed Consent
■ Insurance – Assignment
■ Insurance – Intake Information
■ Insurance – Paper Review, Letter To Company After
■ Insurance – Rejection Or Reduction,
Letter To Patient After
N-O
■ Intake – General
P-Q
■ Intake – Examination—Athletics
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U-V
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X-Y-Z
MAIN MENU
■ Intake – Examination—IME
■ Intake – Examination—Pre-employment
■ Interview – Checklist. . .
Substitute Or Associate Doctor
■ Interview – Guidelines, Employees
■ Introduction – New Associate
■ Irrevocable Instructions To Attorney To Pay Doctor
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
J-K
E-F
■ Job Applicant – Interview Checklist
G-H
■ Job Applicant – Interview Guidelines
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J-K
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N-O
P-Q
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MAIN MENU
■ Job Description – Patient’s
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
L
E-F
■ Laboratory Request Slip
G-H
■ Locum Tenens (Back-up Doctor)
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J-K
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N-O
P-Q
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MAIN MENU
■ Lawyer, See Attorney
■ Lawyer’s Secretary–Confirmation Of Telephone Call
■ Legend – For Physical Examination Form
■ Letter Of Protection–To Attorney Fails To Honor Lien
■ Letter Of Protection – Sample
■ Letter Of Protection – Transmittal
■ Letter Of Protection – Lien Form
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
M
E-F
■ Managed Care Back-Up Doctor
G-H
■ Managed Care Contracting Checklist
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J-K
L
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N-O
P-Q
■ Managed Care Patient Information
■ Managed Care Compliance Letter –
Withdrawal from Network
■ Managed Care Compliance Letter –
Reimbursement Not Covered By Contract
■ Malpractice – Avoidance Checklist
■ Malpractice – Status Report,
Letter To Lawyer Seeking
■ Manipulation Record
■ M.D. – Referral Letter To
R
■ Medicare – Patient Explanation
S
■ Medicare – Regional Offices
T
U-V
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X-Y-Z
■ Medicare – Supplemental Carrier Letter
■ Medicare 2000, New Information
■ Mercy Document Disclaimer
■ Minor – Child Abuse Report
■ Minor – Consent To Treatment
■ Minor – Parent Failure To Follow Advice, Letter
■ MRI Request Form
MAIN MENU
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
D
E-F
G-H
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J-K
L
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N-O
P-Q
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MAIN MENU
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Narrative Reports
NCMIC Group Disclaimers
Neglect, Child, Report
New Problem Evaluation Form
Newsletter – Consent To Use Patient’s Name
Noncompliance – Parent Of Minor Child
Noncompliance – Pre-withdrawal Letter
Noncompliance – Referral,
Failure To Schedule Appointment
Noncompliance – Withdrawal Letter
Notice – Associate Leaving
Notice – Office Closing
Notice – Sale/Retirement And
Introduction Of New Doctor
O
■ Observer – Patient Consent To
■ Outcome Assessment Instruments
A
B
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MAIN MENU
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
P-Q
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Paper Review By Insurer – Patient Letter Following
Paper Review By Insurer – Protest To Insurer
Patient Satisfaction Survey
Patient – Declining To Accept
Patient – Discontinuing Care
Confirmation When Patient Picked Up Records
Patient – Dissatisfied, Letter To
Patient – Injured During Treatment, Letter To
Patient – Job Description
Patient – Kept Waiting, Apology Letter
Patient – Information Required For Chart
Patient – Re-call Letter
Patient – Request For Records
From Previous Doctor
Patient – Request For Records, Responding To
Patient – Research, Consent To
Patient – Sign-in Sheet
Payment Agreement
Personal Injury Information (Auto)
Photographs, Consent To
Physical Education Excuse
Physical Examination Form
P/I Cases – Pre-deposition Letter To Lawyer
P/I Cases – Pre-trial Letter To Lawyer
Pre-deposition – Letter to Lawyer
Pre-employment Examination Release Form
Pre-trial – Letter To Lawyer
Pregnancy – Warning And Consent To X-ray
Progress Report
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
R
■ Re-call Letter
■ Records Request Response – Authorization Missing
■ Records Request – Doctor Asking From
Previous Doctor
■ Records Request – Letter Responding To Doctor
■ Records Request – Letter Responding To Lawyer
■ Records Request – Letter Responding To Patient
■ Records Request – Patient’s Request To
Previous Doctor
■ Records Request – Release Authorization
■ Records Request – Retention Of
■ Referral – M.D.
■ Referral – “Thank-you” To Patient Making
■ Release – Of All Claims
■ Release – Of Records
■ Replacement Log, Equipment
■ Report – Child Abuse
■ Report – Narrative, Checklist
■ Research – Patient’s Consent To Participate
■ Response – Attorney’s Request For Records
■ Response – Doctor’s Request For Records
When No Patient Authorization
■ Response – Patient’s – Letter Of Appreciation
■ Response – Patient’s – Refusal To Allow X-rays
■ Response – Patient’s – Request For Records
■ Retirement Checklist
■ Retirement – Notice To Patients
■ Risk Management Checklist
■ Rules of Record keeping
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MAIN MENU
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
S
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Sale Of Practice – Notice
School Excuse – Appointment With Doctor
School Excuse – Physical Education
Seat Belts – Mandatory Use Exemption
Secretary – Lawyer’s Letter To
Self Help Activities
S.O.A.P. Notes – Narrative Style
S.O.A.P. Notes – Alternative Style
S.O.A.P. Notes – Alternative Style #2
Social History
Sign-in Sheet
Survey – Patient Satisfaction
Symptom List
A
B
C
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CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
T
■ Table Of Contents
E-F
■ Team Physician Role Limitation
G-H
■ Telephone Log
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J-K
L
M
N-O
P-Q
R
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U-V
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X-Y-Z
MAIN MENU
■ Trial – Letter To Attorney, Before
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G-H
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N-O
P-Q
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MAIN MENU
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
U
■ Ultrasound Cerebrovascular Request
V
■ Video – Patient Consent To
■ Visual Analog Scale
A
B
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
D
E-F
G-H
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J-K
L
M
N-O
P-Q
R
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X-Y-Z
MAIN MENU
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Warning Labels
Warning – Physical Limitations
Warning – Pregnancy
Warning – Withdrawal, Prior To
Warning – X-ray
Withdrawal As Doctor – Letter
Withdrawal As Doctor – Warning Prior To
Work Excuse – Disability
Work Excuse – Doctor’s Appointment
Work Job Description Form
Workers Compensation Authorization
Workers Compensation Exam Form
Writing Off Debt
A
B
CHIROPRACTIC FORMS AND LETTERS
ALPHABETICAL INDEX
Click on a letter of the alphabet to view a listing of those titles
To view a form from the listing
Click on that form’s title
C
D
E-F
G-H
I
J-K
L
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N-O
P-Q
R
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X-Y-Z
MAIN MENU
X-Y-Z
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X-ray
X-ray
X-ray
X-ray
X-ray
X-ray
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Consent To
Interpretation
Request Slip
Patient Refusal
Pregnancy Warning And Consent
Refusal To Allow
CHIROPRACTIC FORMS AND LETTERS
CUSTOMIZABLE FORMS
DOWNLOADING FORMS
IN A MICROSOFT WORD FORMAT
Besides the samples, you have the option to download
BLANK copies of each form or letter in a Microsoft
Word document format. This option will allow you to
customize each form or letter for your practice needs.
Choose the “Blank Form” button on any sample form
to download that form to your computer.
PERSONALIZE THE FORMS
WITH YOUR LOGO & PRACTICE INFORMATION
Not only can you make changes to the forms, but you
can insert your logo and practice information (address,
phone number, etc.). Click on the button below for
easy-to-follow instructions.
PERSONALIZATION INSTRUCTIONS
FOR YOUR PROTECTION:
Using a form that asks inappropriate questions or that
contains information not pertinant to your practice can
be damaging if those records were ever reviewed during a malpractice claim. To protect yourself and your
reputation, make full use of these customizable forms
that can be adapted for your specific use.
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ACKNOWLEDGEMENT
This is a derivative work. It is with grateful appreciation to the authors of The Chiropractic Form
and Sample Letter Book, that this work was possible. Without their kind permission to draw
extensively from their original efforts in that project, this revision, designed to fill in the gaps that
passage of time always creates in practical response to an evolving industry such as health care,
would not have been possible.
Copyright© 2001, NCMIC Group, Inc., West Des Moines, IA
Previous copyright© 1999.
All rights reserved. NCMIC Group Limited License for Publication prohibits the photocopying
of this complimentary copy by the recipient for resale or use by anyone other than the original
recipient of this text. The sample forms and letters may be copied, altered, substituted, changed,
modified and/or revised. for use by the recipient in conjunction with his or her private practice of
chiropractic. For information or questions, contact NCMIC Group, Inc., 1452 29th Street, Suite
102, West Des Moines, IA 50266 or-call 1-800-247-8043.
Printed in the United States of America
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COMPLIMENTS OF NCMIC GROUP, INC.
As part of your attendance and participation in the Business Management Seminar presented by
NCMIC Group, Inc., you are receiving a copy of this book, The Chiropractic Forms & Letter Book
for new practitioners.
The book comes to you compliments of NCMIC Group, Inc., the parent company of NCMIC
Insurance Company, the nation’s leading provider of chiropractic malpractice coverage, today
insuring nearly one-half of all practicing doctors of chiropractic. This gift is simply another
embodiment of our total dedication to the chiropractic profession: “We take care of our own.”
Best wishes for your future success as you progress in your career as a concerned doctor
of chiropractic.
NCMIC INSURANCE COMPANY
NCMIC leads the field of chiropractic malpractice insurance. The company is a licensed carrier
meeting or exceeding stringent state licensing regulations in all 50 states and the District of
Columbia. NCMIC provides coverage for more than 26,000 chiropractors.
NCMIC has earned an “A” (Excellent) rating from A.M. Best Company for financial stability,
and an “A+” rating for strong financial security from Standard & Poor’s. This robust financial
condition enables NCMIC to meet the twin challenges of growth and diversification, translating
into more and better services and products.
In addition to funding scientific and clinical research and providing scholarships for students of
chiropractic, NCMIC offers Business Management Seminars, Legal Defense Counsel Seminars,
Risk Management Seminars and other forums to help advance the profession and its members.
800-247-8043
NCMIC FINANCE CORPORATION
NCMIC Finance Corporation (NFC) offers chiropractors the financial “tools” they need to
successfully manage the business side of the practice.
NFC works closely with doctors of chiropractic to find solutions to their borrowing needs. For
example, NFC finances X-ray machines, chiropractic adjusting tables as well as other office
equipment. Flexible payment schedules, low interest rates and no prepayment penalties are
benefits of working with NFC.
Other NFC business tools: The NCMIC Visa© Card that earns Magic Miles travel rewards with
no blackout periods…a VISA Business Line of Credit…long-term disability protection…business
owners’ insurance…give the practitioner flexibility in meeting financial needs.
800-503-0954
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TRIAD HEALTHCARE, INC.
TRIAD Healthcare, Inc., offers doctors of chiropractic ready access to efficient network of
HMOs, PPOs and other managed care organizations. TRIAD is helping make chiropractic care
more accessible to an expanding segment of the population by developing national contracts in
such lucrative markets as health insurance, Workers Compensation, auto liability, Medicare/
Medicaid, and wellness care.
TRIAD not only benefits health care consumers, it aids the chiropractic professional as well.
D.C.s participating in the TRIAD network are able to expand their patient volume and grow their
practices by providing professional services to covered plan members.
TRIAD brings to managed care a ready-made roster of practitioners who meet rigorous
credentialing standards and deliver cost-effective, outcomes-oriented care.
800-550-0540
NCMIC…NFC…TRIAD Healthcare…just three of the many ways we take care of our own.
NCMIC DISCLAIMER
This book contains neither legal nor accounting advice. The purpose of this book is to assist the
doctor, his or her lawyer and other advisors in the formulation of a comprehensive and wellconceived set of forms and letters, professionally reviewed and tailored to the reader’s practice. It
is a compendium of a variety of forms and letters that could be used, but certainly good practice
does not dictate the use of them all. The goal is to provide a broad assortment from which the
practitioner can pick and choose the forms and letters that will assist him or her in the clinical
management of his or her patients and the risk management of his or her practice.
The forms and samples contained herein have been developed from sources believed to be
generally appropriate for use by doctors of chiropractic. However, because of variances in state
statutes, educational philosophy, professional protocol and preference, NCMIC Group, Inc.,
assumes no responsibility as to the appropriateness for individual use or comprehensiveness for
individual scope of practice offered in a particular form or sample letter. Legal counsel should be
consulted for optimal guidance.
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AUTHORS’ NOTE
STYLE/GENDER
The author of any modern, non-fiction work is confronted with difficult choices: (1) He may
employ a style that observes strict sexual neutrality, employing such phrases as “him or her,” “his
or hers” and “he or she.” (2) He may alternate male and female pronouns, employing one then
the other throughout the text. (3) He may arbitrarily and uniformly employ one set of pronouns
throughout.
The first option is cumbersome, tedious and disruptive to readability. The second is confusing
both to author and reader. The third, though not perfect, is much simpler to read and follow.
In this work, the use of the male pronoun has no significance other than the readability and
simplicity referenced above. We hope this will offend no one and trust that it will be viewed as an
effort to avoid doing so and ultimately to aid the reader.
STYLE/PROFESSIONAL DESIGNATIONS
A similar risk of offending readers confronts authors of works directed to doctors of chiropractic.
“Chiropractor,” “physician,” “chiropractic physician,” “doctor,” “D.C.,” “health-care provider”
and “doctor of chiropractic” are all used in this text.
We recognize that certain of those designations are forbidden to chiropractors in some
jurisdictions and that the term “physician” is eschewed by some D.C.s as having allopathic
connotations. To heighten readability and avoid constant repetition, however, we have chosen to
make reference to doctors by using the entire panoply of designations.
Our use of the term “medical” is apt to annoy some. In a work of this magnitude, however, to
totally avoid its use would result in strained, artificial and cumbersome language. Our use of the
term is in its generic sense unless the context clearly dictates otherwise.
Likewise, some practitioners may debate the synonymous of: “manipulate/adjust,” “manipulation/
adjustment” and “manipulative therapy/chiropractic treatment.” Our understanding of the
uniqueness of the chiropractic adjustment as opposed to the mobilization maneuvers of D.O.s,
M.Ds and P.T.s does not dissuade us from using all combinations to avoid monotony, repetition
and reader boredom.
SCOPE
This book contains neither legal nor accounting advice. The purpose of this book is to assist the
doctor, his lawyer and other advisors in the formulation of a comprehensive and well-conceived
set of forms and letters, professionally reviewed and tailored to the reader’s practice. It is a
compendium of a variety of forms and letters which could be used, but certainly good practice
does not dictate the use of them all. The goal is to provide a broad assortment from which the
practitioner can pick and choose the forms and letters which will assist him in the clinical
management of his patients and the risk management of his practice.
PracticeMakers subscribes to the following statement from a Declaration of Principles jointly
adopted by a Committee of the American Bar Association and a Committee of Publishers: This
publication is designed to provide accurate and authoritative information in regard to subject matter covered.
The publisher is not, however, engaged in rendering legal, accounting, or other professional service. If legal
advice or other expert assistance is required, the service of a competent licensed person should be sought.
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GENERAL DISCLAIMER
To the extent that any portion or reference to the Mercy Conference Guidelines for Chiropractic
Quality Assurance and Practice Parameters is quoted herein, that document sets forth the following
disclaimer:
The reader is warned that this document contains guidelines or parameters for the practice of
chiropractic developed by a commission of thirty-five office (35) chiropractors established by the
Congress of Chiropractic State Associations (COCSA). It provides part of an ongoing effort by
the chiropractic profession to provide practitioners with improved guidelines for practice.
These guidelines, which may need to be modified, are intended to be flexible. They are not
standards of care. Adherence to them is voluntary. The Commission understands that alternative
practices are possible and may be preferable under certain clinical conditions. The ultimate
judgment regarding the propriety of any specific procedure must be made by the practitioner in
light of the individual circumstances presented by each patient.
It is not the purpose of this document, which is advisory in nature, to take precedence over any
federal, state or local statute, rule, regulation or ordinance which may affect chiropractic practice,
or over a rating or determination previously made by judicial or administrative proceeding.
This document may provide some assistance to third party payers in the evaluation of care, but is
not by itself a proper basis for evaluation. Many factors must be considered in determining clinical
or medical necessity. Further, guidelines require constant re-evaluation as additional scientific and
clinical information becomes available.
This document does not necessarily reflect the consensus of all members of COCSA, nor is it
intended to be an official policy statement of COCSA.
DISCLAIMER ON USE OF EXTRACT
Disclaimer to be used when quoting an extract or part only of these proceedings:
The reader is warned that the following is an extract or part only of a major publication suggesting
guidelines for the practice of chiropractic.
Any part of the publication is likely to be confusing and/or misinterpreted unless read in the
context of the full document, which includes detailed commentary, definitions, and explanation
of rating systems used.
It is recommended that you obtain a copy of the full publication.
ADDITIONAL REFERENCE SOURCES
It is suggested that each doctor obtain a copy of the practice statute and board administrative
rules in the state in which he/she practices. Many states have adopted rules for record keeping or
specific provisions for reporting of various issues which the doctor may encounter in everyday
practice. Statutes of limitations are also, often times, noted in state statues. It is important that
each practitioner be familiar with the law in the state in which he or she practices.
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INTRODUCTION
In the process of conducting seminars for chiropractic students, doctors and assistants, the
question is invariably asked: “What are the best forms available?” and “Can you give us samples of
letters you recommend?”
We found few forms which warranted our strong recommendation; none, without a great deal of
explanation on their proper use. Few forms appeared to have undergone any type of legal review.
Many forms actually hurt the doctor trying to defend a malpractice case or testifying on
behalf of a patient seeking damages for an injury.
For those reasons we began the systematic process of developing this Form and Sample Letter Book.
This text is intended to enhance the organization and maintenance of your patient charts,
assist you in providing high quality health care services, enhance your professional image
when dealing with other providers, patients and payers and to bolster your defense should you
be sued for malpractice.
Guidelines
Much has been written and debated about guidelines and the appropriate use of guidelines in
clinical practice. One such guideline is the Mercy Conference Guidelines for Chiropractic Quality
Assurance and Practice Parameters1. This document has become a legal treatise suggesting that
practitioners should be aware of the information contained in the document. Other guidelines
have been developed by state associations such as Florida and Texas, and still other guidelines
have been adopted by various state regulatory agencies and licensing boards. Other countries
recognizing the imperative of guidelines to the advancement of the chiropractic profession have
adopted guidelines, e.g. Canada, Australia, England consistent with the original consensus arrived
at in the Mercy Guidelines. Government agencies such as the Agency for Healthcare Policy and
Research (AHCPR), have developed guidelines for a variety of conditions including Acute Low
Back Pain. The CCP have developed guidelines focused on the Vertebral Subluxation in
Chiropractic Practice and still other guidelines have developed from insurance companies and
individuals dealing in utilization review.
Guidelines are recommendations arrived at by consensus and careful review of existing literature
and scientific evidence with expert opinion. As the guidelines grow in consensus, there is usually
a greater weight attached to the guidelines themselves. As this occurs, the guidelines take on the
legal status of being a “learned treatise” and are then used by the legal community to test whether
one’s professional conduct did or did not comport with these consensus guidelines. Simply
because guidelines exist is insufficient reason for a clinician to adopt them as valid. Oftentimes
practices which fall outside of adopted guidelines significantly increase the exposure for
malpractice. Care must be undertaken by each practitioner not to ignore evidence-based
guidelines in clinical practice because the legal community will most assuredly use any guideline
to demonstrate variations from the normal practice standard. Familiarity with and understanding
of all existing guidelines as well as their current relevance and applicability are the best protection
for any practitioner.
No specific guideline is advocated in this book to the exclusion of all others. The discretion of the
practitioner is paramount in selecting guidelines which are not only suitable, but ensure the
practitioner extensive knowledge that he or she is practicing within acceptable clinical and legal
parameters supported by credible and reliable references.
1 We will refer in this text simply as “Guidelines.”
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Larger Print Size
Many commercially available forms contain so much information on a single page that they are
barely readable. This is particularly troublesome when a form is intended to be filled out by the
patient whose mis-reading of instructions may lead him to provide inaccurate information.
Patients with vision difficulties may also give up in frustration and leave portions of the form
blank, or needlessly interrupt staff for assistance. Busy doctors and C.A.s are better served by
uncluttered, “large print” forms which reduce the likelihood of misinterpretation.
Guidelines and good common sense dictate that forms should be legible and intelligible. In
today’s age of third party accountability, it is no longer acceptable to maintain records for the sole
convenience of the doctor. The forms in this book meet the above criteria: not just for the patient
and doctor, but for anyone who has occasion and need to review your records.
How to Produce and/or Copy Quality Forms
This book not only offers you the ability to produce camera-ready forms by photocopying a clean
form directly from this book, now you can go directly to the “starting into practice website”
startingintopractice.com and download the forms you need directly from the website in a
Microsoft Word® document format. The book also explains WHY the form may be useful for your
practice, HOW to use the forms properly, WHAT the potential disadvantage may be and HOW
to avoid those disadvantages so the selection of forms and letters will be most effective.
We have found that doctors often continue to use obsolete forms, ask inappropriate questions and
continue using systems or procedures with little justification other than: “That’s what I’ve always
done” or “That’s what was in the packet of forms I bought.”
An understanding of the proper use of a form is as important as the form itself. The doctor who
is asked during a trial to explain the purpose of a form or portion of a form must have a reasonable
explanation or the credibility of his/her entire testimony will suffer.
We have sought to explain the thought process behind the ideas shared in the following pages.
Use P.R.N
These forms and letters are intended to give the doctor the opportunity to adopt those forms and
letters which are appropriate for immediate use, modify others and discard those which may not
be relevant to the doctor’s practice style.
We hope you will find them valuable, but we recognize that every practice is unique. Each form
and letter can be modified at the discretion of the doctor. The ability to obtain them in a Word
document format has made this process easier.
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PREFACE
Adapted from Risk Management in Chiropractic: Developing Malpractice Prevention Strategies, Health
Services Publication Ltd. 1990 (with permission).
RECORD KEEPING AND REPORTING
Records serve four primary purposes: first, to help provide quality clinical care by recording an
accurate case history, the results of examinations and tests and an account of the patient’s
response to treatment; second, to assist the doctor in reporting and testifying, if necessary, on
behalf of a patient seeking damages, worker’s compensation or disability benefits; third, to protect
the doctor from malpractice claims by furnishing documentation of what was or was not said and
done during examination and treatment; and fourth, to provide the information required by most
third party payors before they will pay for a doctor’s services.
It is important that notes be transcribed as quickly as possible, that all handwriting in a patient
file be legible, and that the doctor read pertinent file notes made by other staff members at the
earliest possible time.
Records written by others or transcribed from the doctor’s dictation must be reviewed promptly
to allow necessary amendments to be made expeditiously. Moreover, a record review conducted
while the patient and his problem are still “fresh” in the doctor’s mind also enables the doctor to
better consider the patient’s problems, treatment and response as reflected in the records.
Records Relating to Patient Treatment
The most crucial rule on the keeping of records is that the doctor faithfully, accurately and
thoroughly record what was done, the reasons for performing specific procedures or tests and the
results obtained. Such records can never be too thorough, too detailed or too accurate, provided
the doctor has a complete understanding of the information contained within the records. It may
be important, for example, to note the spinal segments manipulated and the adjusting technique
used. This may prove increasingly important as fear of “stroke litigation” moves more health-care
providers away from high velocity, low amplitude, extension-type, rotary cervical adjustments to
increasing reliance on “low force techniques” or other “diversified cervical adjustments” as viable
alternative techniques. The doctor may benefit from unequivocal documentation that the
adjustment performed two hours before a patient’s stroke was of the lumbar area rather than the
cervical spine.
PRINTED CLINICAL FORMS
For the busy practitioner, pre-printed forms can prove helpful and improve office efficiency by
reminding both doctor and patient of pertinent facts and occurrences which might otherwise be
forgotten. Exclusive reliance on such clinical forms without proper review, however, may create
more problems than are solved.
The doctor must, for example, address each condition that a patient indicates on a history or
intake form. Having elicited the information, the doctor cannot fail to act appropriately…
without significant risk. If the doctor wishes to appear concerned about a female patient’s
complete health profile by asking if she has headaches, neck and arm pain, loss of sleep, fatigue,
etc., then “ignores” the portion of his exhaustive questionnaire in which she reports painful
periods, heavy menstrual flow, fluid retention, etc., he invites error, criticism and potential liability.
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Master Your Forms
Doctors must read every form they use in their offices. No matter how basic this rule seems, many
doctors simply do not observe it. They allow forms to master them and their practices by using
them without any review, modification or critical evaluation. Moreover, the review of office forms
should embrace different perspectives. The doctor should evaluate his forms from the
viewpoint of:
• a patient
• an insurance claims adjuster
• a fraud investigator
• a cross-examining attorney
• a judge or juror
• the doctor’s peers
Hiring an attorney to review office forms may be valuable for reasons other that the legal advice
received. An “outsider’s” reaction to content and the impression forms impart may be revealing.
A form which offends or confuses patients undermines the doctor-patient relationship. A form
that seeks insurance and financial information first and treatment information second,
communicates to the patient that his “wallet biopsy” is more important to the doctor than are
his problems and complaints. Not every form is appropriate for every practice. Doctor input is
indispensable.
Tailor Your Forms
Doctors should tailor forms to their practices. If there is a portion of a form not needed, never
used or which requests information the doctor has never found helpful, that portion should be
removed from the form. Modifying and reprinting are not very expensive. Many doctors, however,
will continue to use an inappropriate form and merely cross through any offending portion — or
worse, ignore it. The latter practice leaves subsequent readers to speculate as to why entire areas
of the form contain no entries and whether the doctor addressed subjects in those portions at all.
Perception Problems With New Patients
The battery of intake forms for new patients should never leave the impression that the doctor’s
first, foremost and omnipresent concern is reimbursement. The receptionist or business manager
can obtain reasonable and necessary biographical and financial information at the first visit
without communicating that impression.
It is reassuring to the patient if his first visit begins with identification of his problem or complaint
and only then moves to financial information as a clearly secondary concern. When the doctor
commences the clinical interview, the focus should shift back to considerations of patient care.
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Be Mindful of Patient Illiteracy or Physical Handicaps
Doctors forget sometimes that not all patients are able to understand, read, or even see the
questionnaires, forms, case history, liens and other paperwork required prior to treatment.
Cataracts, Parkinson’s, other neurological deficits, or extreme pain may materially impair the
patient’s ability to provide meaningful information.
Separate Treatment and Administrative Records
Doctors who feel compelled to routinely gather accident, insurance, and referral information
should record that information in a file kept exclusively for that purpose. If the file contains no
treatment information and is not a part of any individual’s patient record, perhaps it will not be
subject to a routine subpoena or request for production of documents. The best procedure,
however, is to omit such information entirely or elicit it orally without documenting it, since a
carefully worded subpoena will include all records wherever maintained in the office.
There is some information about an accident which affords insight into the nature and dynamics
of the injury and will always be helpful to a doctor’s treatment. For instance, a doctor will wish to
know the angle from which a blow was struck where the victim was seated in the vehicle involved.
These facts about the accident are easily distinguishable from the reimbursement-oriented
questions about police investigations and insurance adjusters.
Failure to Keep Appointments and Other Patient Noncompliance
Records should reveal not only what happened, but also what did not…such as a patient not
cooperating, following instructions or performing self-help activities.
Every doctor has encountered patients who do not keep one or more appointments or otherwise
fail to comply with the doctor’s instructions and to cooperate in their treatment. These problems
are frustrating. They may be more of a problem to chiropractors than to many other practitioners
because chiropractic patients tend to be extremely “symptom conscious.” They cooperate and
appreciate the care given until they enjoy relief from their immediate complaint. Then the doctor
does not see them again until their symptoms return.
Frustration turns to incredulity when such patients forget the relief they have enjoyed or suffer an
exacerbation and wrongfully blame the doctor. Sometimes this results in a malpractice suit. There
may never be a satisfactory solution to the problem of patient noncompliance; but from a risk
avoidance perspective, the only course of action is to document the patient’s shortcomings.
“DNKA” (Did Not Keep Appointment) should appear in the doctor’s records to document any
patient failure to keep an appointment. “DNKA” need not be harsh condemnation, but missed
appointments can have a profound effect on patient response and should be recorded. This
acronym could be followed with the appropriate explanation, for example, “sick child, rescheduled for tomorrow.”
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Noteworthy Noncompliance
A patient’s failure to fully participate in his own well-being should be fully charted. Patient
shortcomings warranting notation include:
• failure to perform at-home therapy or exercise,
• refusal to adopt weight reduction or other recommended life style change, or
• resistance to advice, including: taking time off from work, avoiding lifting, foregoing
housework, driving, and sexual or other physical activities that might aggravate his condition
during rehabilitation.
A doctor who treats accident victims may find that documentation which best serves his risk
management concerns is injurious to the patient’s claim against the person causing his injury.
Sometimes the conflict cannot be resolved. The doctor, however is not an advocate…but rather
the expert reporting the facts and his opinion to treatment and condition of a patient.
Document Patient Noncompliance
No doctor is required to condone missed appointments or other instances of patient
noncompliance that can hinder treatment. When a doctor does not point out such shortcomings
and insist on compliance, he does a disservice to the patient. Failure to document
noncompliance and record that the patient has been warned about its possible deleterious
effects is a disservice to the doctor. If the noncompliance reaches the point of jeopardizing “good
quality care,” the doctor should formally discharge the patient with an appropriate letter of
withdrawal. A doctor who does not note such problems, intending to avoid reflecting poorly on
the patient, may inadvertently provide that same patient an alternative source of recovery: a
malpractice claim against the doctor.
The warning that doctors should document missed appointments is not given just for defensive
purposes, but also to enable the doctor and patient to cooperate in seeking optimal results. If the
doctor has not reviewed the records sufficiently to realize that a pattern of missed appointments
is developing, neither he nor the patient is likely to take remedial action.
HOW LONG SHOULD A DOCTOR RETAIN RECORDS?
Doctors are in error when they assume they can safely destroy records after the statutory
limitations period prescribed in their state. The question “When can I safely discard my records?”
is one that lacks a simple answer and probably has none that is accurate under all circumstances.
The malpractice statute of limitations (the law establishing the time beyond which a suit cannot
be brought) varies from state to state. The impact of “the statute” also varies considerably
depending on statutory exceptions and judicial interpretation. Sometimes short periods are
extended almost indefinitely by various exceptions, or in the case of an infant, until he reaches
adulthood.
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Maintain Records Indefinitely
With so many variables in statutes of limitations and the unpredictability of statutory changes, the
only safe course is to never dispose of records. Doctors should consider storing records
indefinitely or microfilming them.
OFFICE PROCEDURES AND EFFECTIVE USE OF FORMS
Office Staff Must Assure That the Doctor Reviews Patient Records
CASE STUDY
Dr. Robert Bilderback, an orthopedic surgeon, was the treating physician for Ortho Priestley who
had suffered a knee injury. The patient history included a detailed report of the knee injury but
no complaint of any back problem. Bilderback placed Priestley on a regimen of physical therapy
in preparation for knee surgery. That therapy included the use of weights under the supervision
of two therapists in the doctor’s employ. Priestley’s subsequent malpractice claim included an
allegation that Bilderback’s inappropriate use of traction aggravated her pre-existing condition.
In a classic example of how not to defend a malpractice case, the doctor attempted to absolve
himself by stating that had the patient complained to him that she was experiencing back pain, he
would have examined her back. He protested, “She never complained of back pain to me.” The
doctor’s therapists, however conceded that Priestley had complained to them and that the
patient’s complaints had been recorded in her chart.
The court concluded that the “defendant did not examine notations made by his therapists or,
if he did examine them, he ignored the complaints of pain.” In addition to his failure to
instruct his therapists properly, increasing the amount of weight from 7-1/2 to 15 pounds, during
a time the patient was persistently complaining of numbness in the legs and back and of extreme
pain, was apparently negligent. The therapists inexplicably continued to make notations of
Priestley’s complaints without personally bringing to the physician’s attention that the increasing
weight seemed contraindicated.
Excellent clinical documentation is worthless if unseen by the treating physician. It can even be
potentially damaging to him as the Bilderback case shows. The lesson learned from that case is
not that doctors should stop making written notations, but rather that systems should be
implemented to ensure that the doctor reviews those notes. Habitual initialing or other
distinctive marking by the physician on each day’s progress notes, X-ray films, and test results will
assure that he can identify his mark and later testify that it confirms that he made an appropriate review.
Office staff can make this a “fail safe” system by never filing X-rays or lab results which do not
bear the doctor’s identifying mark. These procedures are especially needed in multi-doctor offices
or when several staff people are assigned to the file. This will allow the staff to corroborate the
doctor’s testimony that he had reviewed the item in question. It will also assure that one of a series
of films is not overlooked. If an open-mouth view does not develop properly, for example, is
retaken but not available for the doctor’s review with the other films, the doctor may not realize
the omission and adjust the patient. The possibility of a fractured odontoid process or other
potentially serious condition makes it imperative that the doctor institute some procedure to
prevent such an oversight.
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Document Treatment Plan
In response to the information obtained from intake forms, the doctor has the following options:
(1) render treatment appropriate to the facts and circumstances revealed by the patient; (2)
determine if the condition indicated occurred in the distant past or has already been treated by
another health-care provider; (3) determine if the patient is receiving treatment or intends to
consult an appropriate physician for one or more conditions indicated.
Under any of these three options, it is mandatory that the doctor show in his records how the
problem was addressed. It is advisable that he mark or initial each affirmative response on a
questionnaire to show that it was discussed with the patient. He should also note on the form
those conditions for which his treatment is not appropriate, with facts about each condition
experienced and by whom it was, or is, being treated. If the patient has not received treatment for
any such conditions, the doctor should recommend that the patient do so, explain why it is
important, and document the giving of that advice. For a condition the doctor deems
inappropriate for his care and which is, or might become serious, a follow-up letter to the patient
offering to make a referral is prudent.
The best way to assure compliance is for the doctor or staff member to schedule the appointment
with the appropriate specialist. Not only does this provide quality service to the patient, it is
helpful with patient management, assures an ongoing professional relationship with other
specialists, and is essential as a defense to a charge of “failure to refer.”
It is never safe to ignore patient complaints that have been recorded in the chart. If the doctor’s
record does not show that a woman with a complaint of dysmenorrhea had been evaluated by a
medical physician, for example, that doctor will have considerable exposure on a subsequent claim
of “failure to refer,” if an undetected ectopic pregnancy ruptures a fallopian tube. The doctor’s
adamant claim: “I know we discussed it” or “I didn’t think it was important” will not elicit
sympathy from a jury under the circumstances described.
EXAMPLES OF BAD FORMS AND PROCEDURES
The authors anticipate that the forms included in this book will serve the majority of needs of
practicing physicians. To the extent “old” forms are not discarded, there are some in existence which
are so ill-conceived or inappropriate that a warning is necessary.
Poorly designed forms may create misconceptions. There are forms which elicit a full page of
information about the patient’s accidental injury and the collision in which it occurred. In a bottom
corner, there is a space for the doctor to note: “By whom referred?” This raises the question: “Who
cares and why?” The most likely reason for such questions invite unfavorable inferences.
Doctors often ask if the patient has an attorney so that they can refer to the personal injury attorney
of their choosing if the patient has not already hired someone. Frequently, the doctor is “keeping
score” of how many patients have been referred to him by which attorney’s. Doctors have occasionally
entered into exclusive cross-referral arrangements. Sometime doctors have office incentive programs
to reward patients for making frequent referrals.
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These situations are increasingly problematic because of the evolving legal and ethical scrutiny to
which all referral relationships are being subjected. Cross-referral arrangements can be illegal if
there are improper collusive inducements such as “kick-backs” involved. This information simply
does not belong on the same form with treatment-related questions. A discreet inquiry during
consultation provides the same information and does not afford counsel, in a later personal injury
or malpractice action, an opportunity to use the form to suggest impropriety.
A similar, but worse, form is the one that contains treatment related history at the top of the page
and ends with the following questions:
********************************************************************************************
1.Your insurance company:
2. Insurance company of the person responsible for accident:
3. Was anyone issued a traffic citation?
4. Have you been contacted by an insurance adjuster?
5. Do you have an attorney?
********************************************************************************************
These questions have nothing to do with treatment.They deal only with reimbursement and make
the doctor appear greedy. Moreover, they are unlikely to provide useful information even for
their intended purpose.
The request to identify “Your insurance company?” is entirely too vague. Most patients will have
several insurance companies, with most of the coverage irrelevant for the doctor’s treatment or
billing purposes. The question seeking to identify the insurance company of the person
“responsible” for the accident can elicit nothing useful. Of what significance is it to the doctor that
the patient thinks someone else is liable? Doctors are not in a position to bill directly to the other
driver’s insurance company, and very few carriers will pay anything without a complete release.
Likewise, the question about issuance of a traffic citation will neither help the doctor treat nor
help him get paid. Why would a doctor solicit that information? The likely reason is to learn
whether a patient is the “innocent” party who probably has a viable personal injury claim against
someone else. Anticipating payment from the proceeds of a personal injury claim, is however,
usually ill-advised and often unnecessary. Cross-examining attorneys can use this form to plant
doubt in jurors’ minds about the doctor’s motives in asking such questions.
Respect Patient Privacy
In like fashion, there may be a few questions about a patient’s sex life which may elicit useful
information and are therefore appropriate. Even when such questions are relevant, however, it is
probably good policy to include them on a separate form and use that form only in appropriate
cases. Recorded apart from other clinical information and used only in extraordinary
circumstances, questions of this type might help a chiropractor assess the need to refer to a
psychiatrist, gynecologist or urologist.
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A review of one multi-page form reveals several sections seeking detailed information on the
patient’s history and complaints that could be useful for the doctor to know. Unfortunately, that
thoroughness also carries over into an almost completely unnecessary series of questions about
the patient’s sexual history. With prying and embarrassing questions, the form demands that
patients report experiences in every type of conventional, and most types of bizarre sexual
practice.
If such a form appeared in the records of a doctor charged with malpractice, the damage could
be irreversible. Even if useful information is contained on the same pages, why would a doctor
risk having a jury shocked by such a graphic invasion of privacy? Once records are turned over to
counsel for the opposing party, there is no assurance that a form will not end up in the jury room.
The impression such voyeuristic questions would have on a jury deciding a malpractice suit
alleging sexual improprieties could lose the case.
An Exceptionally Bad Idea: “OEI” (Omissions and Errors Included)
Professional literature and periodicals contain many imaginative schemes and creative artifices
contrived to avoid malpractice exposure. They are also touted at various seminars and comprise
the bulk of many “practice management” strategies. There is no shortage of new contrivances.
A letter to the editor of a prominent medical journal recently proposed a potentially far more
disastrous ploy than those described above. The author of that letter denied that it was possible
to protect oneself from malpractice exposure by maintaining “complete records.” He protested:
“It is impossible to write down every word, discussion or rationale of treatment. Such a record
would take much longer that the actual examination and consultation.” The author also
bemoaned shortcomings in using dictation equipment because of transcribing errors likely when
using medical vocabulary.
While these observations have some validity, this doctor’s solution was the addendum to his
signature of the initials “OEI” signifying “Omissions and Errors Included.” According to its
proponent, such a disclaimer reveals that the record is a “general outline of what has been done
and that inaccuracies may be present.” This, the writer claims, “turns a rigid document into a
flexible one…”
With exquisite understatement the editors of the journal responded that the practice “could get a
doctor into trouble on the witness stand.” That not only could happen, it is certain that skillful
cross-examination would humiliate any practitioner who resorts to this obvious effort to relieve
himself of the responsibility of careful, accurate and definitive recitation and review of the record
of what he has done and why.
Maintain Thoroughness and Professionalism
The use of “OEI” and other such artifices invites an opposing attorney to suggest to a jury that
any physician who is so lax in his recordkeeping that he acknowledges that his documents contain
omissions and errors likely provides equally deficient patient care.
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The now common practice of sending professional correspondence bearing the notation
“dictated but not read” is similarly objectionable. Perhaps such letters are appropriate for some
commercial usages, but they have no place in professional correspondence. One can infer that a
doctor so casual with his correspondence may take similar shortcuts with patients. More
importantly, if patients, attorneys — even other providers — receive a letter with such a
disclaimer, they do knot know what is reliable and what may be a transcription error.
In the worst-case scenario, a letter to a subsequent physician containing a significant error might
have major implications for the patient’s future care. The doctor does not have the luxury of
ignoring his duty to eliminate such avoidable risks to his patients.
Doctors are admonished most strongly: read you letters and your treatment notes carefully. In
good business practice and in risk reduction, there is no substitute for thoroughness and
professionalism.
PROTECTION STRATEGY: Follow the Rules of Record Keeping
Records, no matter how thorough and accurate, will be of no benefit to the doctor involved in
malpractice litigation if they are not perceived by judge and jury as being a faithful, complete and
honest account. Any loss of credibility can be fatal to the doctor’s case.
A protection strategy for preservation of the credibility of records involves adherence to rules for
record keeping. Please review these rules very carefully and be certain staff is fully informed of
these rules as well.
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RULES OF RECORD KEEPING
RULES
(1) Do not erase. Whether an erasure results from immediate recognition of an error or is made
later for the sake of accuracy, it can adversely affect a doctor’s credibility. The safe way to make a
change is to cross through the erroneous information (without obliterating it), insert the
correction, initial it, and date it. This is not foolproof, however. A jury could still believe the
stricken-through information was accurate and the insertion was not. That danger is reduced by
the doctor’s clear intent to be candid. The method of alteration shows that he did not believe
he could deceive anyone, which supports the inference that deception was not his goal.
Another procedure that can be used after an inaccurate entry has been lined-through is to note:
“error: see below (date)” and then move to the first available lines to record the entry properly,
stating that it is a correction. The doctor should date and initial the information. This method of
correcting entries has the benefit of added credibility due to entry sequence. Subsequent entries
will follow it in due order. There is no reason to infer that the record was improperly altered at
some later, more critical, date. Revisions or additions to data should not be entered after receipt
of a records subpoena or once it becomes probable that there will be litigation in which records
will be relevant.
(2) Maintain records in ink. Making notes in pencil invites suspicion that records have been
altered and suggests the possibility that ease of alteration was the doctor’s goal. “Penciled” notes
are scrutinized more carefully than those entered with ink, and an expert can easily detect the best
concealed erasure. The use of ink will help void the appearance of impropriety.
(3) Do not skip lines or leave spaces. Records which contain one or more lines between entries
suggest that space was left to allow additions should the need arise. That suspicion will be
heightened if a doctor routinely leaves three lines between entries and continues to do so until the
day in question. If the crucial entry takes all the space and the last two and a half lines tend to
exonerate the doctor, it will appear that the records were falsified. When the doctor can show that
the entries in this patient’s record (and all patient records in his office) are routinely and
uniformly made without spaces, he creates the clear impression that his records are accurate.
(4) Do not “squeeze in” notes. The caveat that doctors not “squeeze” notations within records
is a corollary to Rule 3. If no lines are skipped and no blanks are left (other than reasonable and
uniform margins), there will be no room for subsequent or additional entries. If entries are
routinely scribbled in margins, inserted with arrows and wedges, written between existing lines,
etc., it is frequently impossible to tell what was original and contemporaneous or at what time
various changes were made. When an entry is unusual and made to conform with Rule 7, a
“squeezed-in” note is acceptable. If such entries become the rule rather than the exception, the
doctor’s records will offer little support for his testimony.
(5) Do not indent. Indenting at the beginning of paragraphs or upon a new date will leave blank
spaces which create the problems discussed above.
(6) Line through blank spaces. Any space remaining to the right of an entry should be “lined
through” with a straight, unbroken line to the margin.
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(7) Make additions and changes appropriately. While a doctor should strive for perfection in
record keeping, there will be a need, from time to time, to add or change an omitted or incorrect
noted fact or observation. When additions are necessary, well maintained records will have no
lines or space to accommodate them. The record will show that there is no intent to deceive. Any
inaccurate or obsolete statement should be lined through, not erased, “whited-out,” or hidden
beneath an adhesive label. The omitted or updated information may be written between the lines
or in the margin. Then it should be dated and initialed by the person making the entry. The
method described in Rule 1 may also be used.
Do “properly” made amendments and additions to the record merit full credibility? That will
always depend on the circumstances. An addition made the day before his deposition or after the
doctor has been served a subpoena to produce records will always be questioned. The records of
a doctor whose files never contain a stale entry may enjoy as much credibility as if no change
had been made. The better kept the doctor’s records, the greater help they can give.
If the person making the amended entry knows at the time that the change might be relevant to
issues of patient care and physician competence, there is good reason to have two people initial
the entry. Even if the doctor is not the one who makes the change, his initials should always
accompany such an “important” change to verify that he has seen and approved it. The
employee making the change might have done so in the best of faith, but that may be difficult to
verify if the doctor is unaware of the change and the employee is no longer available when the
patient subsequently brings a malpractice action.
(8) Properly identify the record. Each record should include the date and the time the entry
was made. Each successive page or card should record the patient’s name and the date. That step
affords protection in two ways. First, it minimizes the risk of misplacing a page, thus reducing the
likelihood that any part of the record would need “reconstructing.” A reconstructed record is
seldom satisfactory and has little credibility. Second, it also reduces the risk that a sheet or card
from another patient’s file could get mixed-in and accidentally copied and passed along to
outsiders, thereby breaching that patient’s right of confidentiality and reflecting poorly on the
doctor’s professionalism.
(9) Fill in all blanks. A doctor should fill in all blanks, especially on pre-printed forms. It is
important that everything be completed with no spaces, blanks or omissions that can imply
some error or oversight. Many forms, for example, will contain an exhaustive list of neurologic
and orthopedic tests. Seldom is the entire range of listed tests appropriate for any given patient.
To avoid doubt about which tests were actually performed, it is important that those not given be
marked in some distinctive fashion on the record. Even more importantly, doctors should assure
that the result of every test is shown even if the finding is normal.
A normal finding may be crucial evidence in a subsequent malpractice claim. When there is
merely an empty space associated with a test, the doctor may find it impossible to recall whether
the results were normal or the test was simply not given. The doctor should note it, even if it is
normal. It is also desirable to show the date a test or group of tests was administered together
with the doctor’s initials. If a test is not administered, “N/A” (not applicable) is an appropriate entry.
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A doctor must be sure that a test is not appropriate, however, since he will have to defend his
decision not to use that test if later sued.
(10) Don’t say anything disparaging about the patient. The patient has the right to copies of
his records. If a patient should consider filing a malpractice claim, one of the first things he’ll do
is request a copy of his records. Even if the doctor is prudent enough to carefully review the
records before releasing them, should he discover something disparaging, there is nothing that he
can then safely, legally, or ethically do to avoid the embarrassment and other harmful effects.
(11) Avoid judgmental words. Words which judge or evaluate should be avoided. Use of words
as “routine,” “inadvertent,” “unfortunately,” and “unexplainably” invite further clarification and
make it appear that the doctor is indecisive and provides less than optimal, individualized care.
Doctors often use the term inadvertent to characterize something that was accidental or
unexpected such as a patient injury or mishap in the office, While the word does mean
“unintentional,” it is also defined as “inattentive or heedless.” No doctor wants to characterize
himself as inattentive or heedless concerning some unfortunate and perhaps unavoidable
occurrence.
Doctors often use the word routine to describe something that is “normal” or “standard.” There
are two reasons to avoid the word. To a jury, it conveys the suggestion that the patient’s case,
condition, and treatment were so routine that they did not demand attention, thought, or
individualized care. To the patient, the word suggests that his situation merited no special
handling. No patient wants to be thought of as “routine.” All patients think that their cases are
unique and entitled to the doctor’s individualized handling. On this point, the patients are correct.
When a doctor begins to think of cases as routine, he is laying the foundation for the boredom
and resulting carelessness that can lead to valid malpractice claims.
(12) Identify the record keeper. Each entry should be followed by the signature of its author.
First initial, surname and position should be included.The inability to identify who made an entry
in a patient file can be embarrassing when seeking to testify for a patient in a personal injury case.
Inability to identify a former employee to decipher unintelligible entries can be harmful to the
patient and complicate a malpractice.
(13) Don’t enter data prematurely. No entry should ever be made before the procedure is
actually performed. Standard procedures encourage the filling out of insurance forms, for
example, before an X-ray series is actually performed. Filling them out in advance, however, can
create confusion and, if for some reason the tests are nor performed but the form is inadvertently
sent in to an insurance company, fraud charges can result.
(14) Maintain legibility. The usefulness of records is virtually negated if they must be
interpreted. Printing, with capitals at the beginning of sentences and standard punctuation is best.
While personalized “short-hand” is permissible, a legend must be available and provided to those
with a legal right to the records.
(15) Be consistent. Whatever system is used should be consistent throughout the records.
Variance in spacing, for example, suggests that there may have been an alteration.
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(16) Avoid or explain contradictions. Some duplication of information on various forms is
inevitable. If the information is not the same everywhere it appears, it will create questions. If a
person indicates on a history form that he is a smoker, for example, the protocol sheet for his
thermographic examination must include the time of his last tobacco use.
(17) Document unusual events. All unusual events such as a patient disorientation, falls or
equipment failures should be recorded.
(18) Avoid ambiguous words. Entries such as “better today” may convey very different
impressions depending upon the reader. The doctor should add some description of what he
observed, what the patient said, which prompted the conclusion that he was “better.”
(19) Record all patient contact. Each patient contact with doctor or staff should be recorded
Conversation, whether personal or by telephone, should be logged if it pertains to clinical matters.
The entry should identify the means of communication, the date and time, who initiated the
contact, the details of the conversation and particularly any instructions given the patient.
(20) Don’t criticize other providers. Evaluation of the services of other care-givers has no
place in the record. It will serve to encourage litigation and possibly embroil the doctor in that
litigation as a witness, Suspicions of inadequate care are appropriately reported to the disciplinary
or licensing board for its investigation.
(21) Exclude frivolous remarks. Attempts at humor or other entries which do not bear upon
patient care should be avoided. Frivolous comments suggest a lack of professionalism. They can
prove extremely embarrassing and unnecessarily provoke a patient who gains access to his
records.
(22) Don’t use two different pens on the same day’s entry. Even if the ink color is the same,
two pens will likely have inks which have radically different components. Lawyers are very much
attuned to having documents examined for alteration. Different pens, particularly if the inks were
manufactured a long time apart, can make it appear that the doctor altered the records.
(23) Don’t alter records. Even a good, decent, honest doctor may be tempted to add notations
to a patient file after notice of a malpractice claim. He may well have no intention of fabricating
or distorting anything. Rather, he remembers events or conversation which were not noted in the
file and which will make the record more accurate. The temptation to make any alteration must
be resisted. The price of detection may well be the loss of a case that otherwise could have been
won. A doctor completely destroys his credibility with jurors when they find out that he attempted
to “doctor the file.”
(24) Initial reports (X-ray, lab, consultant’s) before filing. This simple expedient will assure
that important information is not overlooked and filed away prematurely. It will also allow the
doctor to testify, if necessary, that he knows that he reviewed a particular report because: “That
is my mark on the top of the page.” That testimony can be corroborated by employees who verify
that they are not allowed to file anything without that mark.
(25) Don’t use computer generated notes unless they are individualized. It is easy to get
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lazy with computerized office notes and establish a standard “scanning” for each day. Unless
records are individualized, the reports a doctor generates using them will be virtually identical. A
regulator, insurance agent, lawyer or other reader will soon identify a doctor whose reports appear
“canned.” If an adversary were able to put several patients’ daily notes on acetates and display
them together to reveal that they are identical, it could raise questions as to the doctor’s quality
of care.
(26) Maintain a legend for any codes used. Many doctors use various codes and symbols in
maintaining their records.There is nothing wrong with doing so as long as someone else reviewing
the records can decipher them. Failure to maintain and provide legends for codes has been made
a disciplinary offense in some states.
(27) Be certain that the release of records authorization in the chart is current and valid.
Beware of authorizations which purport to revoke prior authorizations. Some lawyers will have
their clients sign such revocations. If a doctor released information thereafter to anyone other than
the recipient named in that release, he has violated the patient’s right to confidentiality. Some
authorities suggest the authorization should not be more than 90 days old. It is best to check with
your state board.
(28) Keep financial and clinical information separated. The appearance that a doctor is
primarily interested in his own remuneration is created when every form has questions about
insurance, liens, assignment and other compensation details. The doctor must be aware, however,
that financial records are part of the health care record including:
• patient account ledgers
• billing statements
• explanation of benefits…proof of payment
When the health care record is subpoenaed or otherwise requested, the doctor should consult
with counsel to determine whether the financial and administrative records must be furnished.
(29) Individualize the forms used. The best form for any doctor is one that “fits” his practice.
The doctor using forms is encouraged to take them and tailor them to meet his needs, practice
style and routine.
(30) Maintain records forever. With all the exceptions to the statute of limitations, using that
time frame as a guideline for record retention may leave the D.C. without records to defend
himself in a lawsuit. Additionally, many states have mandated a minimum retention time which
must be conformed to.
(31) Review and archive files. “On periodic file review, outdated portions may be removed and
stored in an archive file. A permanent note should be kept in the active file indicating that the
patient has additional records.”
(32) Document patient noncompliance. No doctor is required to condone missed appointments
or other instances of patient noncompliance that can hinder treatment. When a doctor does not
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point out such shortcomings and insist on compliance, he does a disservice to the patient. Failure
to document noncompliance and record that the patient has been warned about its possible
deleterious effects is a disservice to the doctor. If the noncompliance reaches the point of
jeopardizing “good quality care,” the doctor should formally discharge the patient with an
appropriate letter of withdrawal.
(33) Proof-read correspondence and reports. The now common practice of sending
professional correspondence bearing the notation “dictated but not read” is unseemly. Perhaps
such letters are appropriate for some commercial usages, but they have no place in professional
correspondence, One can infer that a doctor so casual with his correspondence may take similar
shortcuts with patients.
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RULES OF RECORD KEEPING
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Do not erase
Maintain records in ink
Do not skip lines or leave spaces
Do not “squeeze in” notes
Do not indent
Line through blank spaces
Make additions and changes appropriately
Properly identify the record
Fill in all blanks
Do not say anything disparaging about the patient
Avoid judgmental words
Identify the record keeper
Do not enter data prematurely
Maintain legibility
Be consistent
Avoid or explain contradictions
Document unusual events
Avoid ambiguous words
Record all patient contact
Do not use “white out”
Do not use adhesive labels to cover up anything
Do not criticize other providers
Exclude frivolous remarks
Do not use two different pens on the same day’s entries
Do not alter records
Initial reports (X-ray, lab, consultant’s) before filing
Do not use computer generated notes unless individualized
Maintain a legend for any codes used
Be certain that the “Release of Records Authorization” in the chart is
current and valid
Keep financial and clinical information separated
Individualize the forms you use
Keep records forever
Review and archive files
Document patient noncompliance
Proof-read correspondence and reports
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RULES OF RECORD KEEPING
WHO LOOKS AT YOUR RECORDS?
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Patients
Your staff
Insurance company reps.
Attorneys
BWC reps.
Other providers (reviewers!)
Self insuring employers and admin.
Examining board
Juries
Legislators
Managed care organizations
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PROTECTION STRATEGY CHECKLIST
It is increasingly clear that doctors of chiropractic no longer have the luxury of a complacent belief
that a malpractice suit “Can’t happen to me.” What can a practitioner do to survive today’s hostile
practice environment?
The following checklist is a compendium of general topics with which a doctor seeking to reduce
malpractice risk should become familiar.
The first section of this book deals with FORMS designed to assist the doctor and staff in
effectively and efficiently organizing sound practice policies and procedures. Additionally, the
systematic use of the accompanying forms and letters will help the doctor and staff obtain the
necessary information needed to assess and treat the patient and provide an adequate record of
actions, evaluations and recommendations.
Please read this book in it entirety in order to gain a complete overview of an easy process to
obtain relevant clinical and practice management information to enhance your practice skills,
document your clinical interventions, improve your office efficiency and reduce the potential risk
for malpractice.
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PROTECTION STRATEGY CHECKLIST
• Train and re-train staff.
• Stay abreast of the profession’s changing standards.
• Exceed continuing education requirements.
• Subscribe to and study professional and medi-legal journals and sources.
• Learn about professional liability insurance and insurance mistakes to avoid.
• Follow the rules of record keeping
• Obtain an adequate informed consent.
• Refer and obtain consultations often.
• Know what to do when a claim “won’t go away.”
• Cooperate fully with your defense team.
• Prepare in advance for the day you are sued.
• Maintain adequate malpractice insurance coverage.
• Avoid sexual banter, innuendo and relationships with office staff and patients.
• Maintain equipment properly.
• Review your malpractice coverage annually.
• Avoid false, misleading or deceptive advertising.
• Use prudent collection and “debt” forgiveness practices.
• Use the forms and letters in this book.
• Carefully read Risk Management in Chiropractic.
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MANAGED CARE INFORMATION
BACKGROUND
Managed care has become ingrained in every concept of health care delivery. In the future, all care
will be “managed” in some fashion. The emphasis of managed care initially was to bring costs
under control. As the progress of managed care continues, quality will become a significant aspect
of determining how care is delivered. Determining quality is not a process which has been fully
developed and will continue to evolve as the process of health care moves forward.
OBJECTIVES
These forms are guides to provide the doctor with concepts and information he/she may which to
review before undertaking a managed care contract.
PRACTICE SUGGESTIONS
• Review the material and become informed on the issues surrounding the contract.
• Know the extent to which the managed care organization will have control over your patients.
• Realizing that some managed care contracts are more onerous than others, you must determine
what provisions are important to challenge and which do not make any significant difference in
the overall contract.
• Prepare a checklist of information which is required by most managed care organizations that
are seeking National Committee for Quality Assurance (NCQA) or Utilization Review
Accreditation Commission (URAC) accreditation. Have them readily available so processing
contract applications will be less burdensome.
• Undertake to have a practice profile to determine the geographic boundaries from where your
patients are drawn. This will help in determining the managed care contracts which are more
significant and those that are less important in which to participate.
• Become an advocate in helping patients to understand the issued surrounding managed care
and provide them with materials which they can use to become influential to their employer or
insurance company.
• Understand the process and work with it rather than attempting to fight the managed care
process. Despite the fact that managed care is changing and the process is dynamic, there will be
accountability required of all providers as the health care system moves forward.
POTENTIAL DISADVANTAGES
• Some practices may be able to survive outside of a managed care environment. The vast
majority, however, can not. It is important to be realistic.
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• Not being prepared to participate in managed care plans may forfeit an opportunity to expand
your practice or increase your current marketshare.
• Providers have recognized that managed care will impose some restrictions on their practices
and demand accountability. However being prepared for what is required will go a long way
toward increasing your opportunities to participate in many managed care plans.
• Managed care will in all probability expand to every market. It has already overtaken the
indemnity market and soon will be fully integrated into the workers’ compensation market and
finally in the auto insurance market. The demands of society, government, employers, payers, and
patients all will require participation and accountability.
• Those who choose to ignore the obvious presence of managed care will do so at the peril of
becoming a non-participating provider.
CONTRACTING PROCESS CHECKLIST
1. Investigate the MCO to see if it is compatible with your practice style.
2. Analyze the provider agreement carefully.
3. Review all relevant documents and appendixes attached to the contract.
4. Get confirmation of all discussions about the contract in writing.
5. Sign the final agreement and maintain a copy for your file.
Important Issues
• How many established patients are currently signed by this MCO?
• How may established patients will switch to this MCO, if this information is available?
• Are the new patients a “desirable” addition to the practice?
• How many new patients could possibly be derived from the MCO?
• Will this expand my market share?
Administrative Issues
• Does the MCO mandate specific forms I must use?
• What types of records will I have to keep?
• Will this MCO impose any special paperwork on my office staff?
• Will I have to change my practice hours or appointment procedures?
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Economic Issues
• How much money will signing this contract mean to my practice?
• Will I be paid fee-for-service, on a capitation basis, or other arrangements?
• What liabilities will this contract create based on “at risk”/withholds or other specific
determinations of the IPA or MCO?
Clinical Issues
• Is the clinical mandates of practice this MCO seeks to create one I can accommodate?
• Do I know whether the credentialing requirements of the network insure the reputation for
good quality care?
• Are the clinical guidelines and rules used to make decisions based upon evidence-based criteria?
Legal Issues
• What are the grounds for termination from this contract agreement?
• Are these reasonable provisions for appeals from any determination by this MCO?
Who Owns the MCO?
• Publicity traded company or chain
• Commercial insurance company
• Blue Cross/Blue Shield plan
• Physician group
• Hospital or group of hospitals
• Independent
• Chiropractic group
• Other
Who Manages the MCO?
• Are there chiropractic boards of directors?
• Are providers and consumers included on the board?
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• Who are the chiropractic directors and what are their backgrounds?
• Does the company have a chiropractic QIC committee?
• Does the chiropractic entity have a track record of accomplishment within the profession?
General Information
• How many subscriber group contracts does the MCO have and are they with large employers,
small employers or individuals?
• How long has the MCO been in business?
• What are its growth projections?
• Is it solvent?
• Does it have the proper infrastructure to compete?
• Is the MCO a chiropractic entity or does it have other goals or objectives?
Is the MCO recognized in the profession?
• What do its marketing materials say?
• What do its consumer marketing materials say?
• What is its potential to increase market share for your practice?
• How many chiropractic physicians are currently under contract with it?
• Where are they located?
• Does the MCO have an opportunity to gather data for advancement?
• Is the MCO advanced in its technology?
• Can the MCO negotiate for national, regional and local contracts?
• Are the goals and objectives of the MCO to advance the profession?
• Does the MCO limit the number of providers in the network?
• Is there provider and patient satisfaction with the MCO?
• Does the MCO advocate “affinity programs” or discount programs for chiropractic benefits?
• Is the MCO program for chiropractic services included in the core benefit or as an additional
add-on service?
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INFORMATION PATIENTS NEED TO KNOW
10 Important Questions to Ask When Choosing a Health Care Plan
Health Care Needs
1. What are your family’s specific health care needs?
What are your present and future needs?
Where do you want to go for your health care — a clinic, a medical center, a private practice?
What health care centers are conveniently located for you?
Will you need evening or weekend appointments?
Are you a strong proponent for complementary and alternative care?
Covered/Excluded Services
2. Will the plan’s benefits and services meet your specific needs?
Is the list of covered and excluded benefits and services understandable?
Review that list and compare it to your specific needs.
Do you have existing medical conditions that require specialized medical care?
Ask if medical conditions that you have now are covered by the plan.
Do you have specific needs such as mental health, prescriptions, well baby care, chiropractic
or eyeglasses?
Choice
3. Is your choice of doctors limited by the plan?
Ask for a list of participating physicians.
Does the plan require you to have one physician (a gatekeeper) coordinate all your care?
Is the physician of your choice accepting patients under the plan?
Will you be seen by the same physician or care giver every time?
Do you have direct access to your doctor of chiropractic?
4. Is your choice of hospitals limited?
Ask for a list of participating hospitals.
Does the hospital you want to use participate in the plan you are choosing?
Cost
5. What is the monthly premium?
Find out how much the plan requires you to contribute to the cost of health insurance
each month.
Is chiropractic included with your premium or must you pay extra?
6. What is a reasonable estimate to the out-of-pocket costs per year?
Are there co-payments, deductibles or other out-of-pocket costs?
Is there a limit on the total amount of out-of-pocket costs per year?
Are there dollar amount limits on the total amount of coverage the plan will provide each year?
Is there a limit on the amount of chiropractic services?
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Quality
7. Does the plan provide quality health care?
Ask your chiropractor for their opinion of the plan.
If you know someone who belongs to the plan, ask them what they think about the care they
have received.
Are the physicians who belong to the plan given financial incentives to limit care?
What is the plan’s grievance procedure?
What is the plan’s procedure for reviewing decisions on whether care is medically necessary?
Procedures and Questions
8. Will you need the plan’s approval before seeking care?
What are the plan’s rules on seeking care and seeing specialists?
Does the plan cover visits to out-of-network doctors; if so how much extra will you have to pay?
Does the plan require you to be responsible for referral forms, claim forms or other paperwork?
9. What should you do if you need health care and you are outside the plan’s service area?
Will the plan refer you to a doctor in the area in which you are located?
Will the plan cover the cost of services rendered by a doctor outside of the plan’s network
service area?
10. Who do you call if you have a question?
Does your managed care organization do patient satisfaction surveys to determine your
opinion of your provider?
WHAT YOU SHOULD KNOW ABOUT THE PPO/MCO
You will be better able to evaluate your probable advantage in joining a network if you know how
many subscribers/enrollees are in the plan and how many D.C.s are servicing it (enrollee-provider
ratio), e.g., how many patients are you likely to receive through the MCO plan? This ratio by itself
will not tell you all you need to know, by any means.You should also know:
• Are the enrollees geographically close to my office?
• Do I already have many of the enrollees as patients?
This is additionally important because if you do, and you choose not to join
the network, you will lose all of these patients to the D.C.(s) in the area who
does join it.
• How much of a discount do I have to agree to?
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At the end of the year, the PPO will be able to review all of its provider chiropractors, observe the
number of PPO-contracted patients for which you have rendered care, determine the types of
diagnostic tests which you have ordered, evaluate the frequency and duration of office visits for
which you have scheduled each patient, review the cost for each case and compare all of this data
regarding a given provider to data from all other providers in the PPO network. In this manner,
the PPO will determine your practice profile.
This practice profile will enable you to compare your practice patterns with all other practitioners
in the network. The “Provider Feedback” will greatly enhance your ability to measure your
practice profile with your colleagues’.
MANAGED CARE CHECKLIST
Checklist of Pertinent Data Which Should Be Readily Available to Send in to Managed
Care Organizations for Enrollment
It would be helpful to assemble this information in advance.
1. A copy of your chiropractic license — check date to be certain it is current.
2. A copy of your diploma from your college of graduation.
3. A copy of the cover sheet to your chiropractic malpractice insurance policy — check the date
of current issue. Minimum required liability limits in most states is $1,000,000/3,000,000
claims made or occurrence.
4. A blank copy of your history and examination forms, progress exam forms, patient
questionnaires and evaluation forms which are used in your office.
5. Completed Physician’s fee profile if requested.
6. Curriculum Vitae
7. A list of managed care organizations in which you are participating.
8. Practice profile, solo, group, corporation, multi-disciplinary, partnership, with
documentation for all practitioners as listed above.
9. A copy of all applications should be kept on file.
By having the information readily available, it will be easy to complete applications for managed
care organizations as they become available, thus saving time and avoiding unnecessary delay in
processing.
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MANAGED CARE CONTRACT
COMPLIANCE LETTER
BACKGROUND
Many managed care contracts have very specific language relating to the liability of the specific
plan to pay for services which it determines to be “chiropractic necessary” care. This often means
the plan is not responsible for care that extends beyond the definition of necessity, after the patient
ceases to improve or has reached Maximum Chiropractic Benefit (MCB) or “Maximum
Therapeutic Benefit.” Most plans do not pay for care that is deemed to be maintenance,
experimental, preventive or that is not shown to have significant benefit.
OBJECTIVES
This form should be used when the doctor has determined that the managed care plan does not
provide for reimbursement for services he has determined, or which the plan could determine to
be maintenance care.
APPLICATION
Contracts which contain such language should be identified and letters of understanding between
the doctor and the patient should be instituted as a normal practice protocol.
PRACTICE SUGGESTIONS
• Each of the following letters should be reviewed carefully by the doctor and staff along with the
specific provisions of the managed care contract.
• Significant misunderstanding can result from a lack of clear policy regarding the payment
responsibilities between the doctor and the patient.
• Often malpractice claims can arise from a patient’s misunderstanding of what their
reimbursement responsibility is. It is imperative that no vague or unclear understanding exist
between the patient and the doctor.
• Many times managed care plans will consider doctor compliance and patient satisfaction in
recredentialing criteria and physician profiling. Having clear office policy established for each
patient in each and every managed care entity will help immeasurably in the overall management
of patients in managed care plans.
POTENTIAL DISADVANTAGE
A lack of incorporation of proper forms and letters can and often does result in patient
dissatisfaction and ultimately can lead to allegation of malpractice or a letter to the board of
examiners or managed care entity alleging wrongdoing.
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MANAGED CARE CONTRACT
COMPLIANCE LETTER
WITHDRAWAL FROM NETWORK LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Dear Patient:
On
, I will cease my participation in the healthcare network of
ABC, Inc. I am providing this letter to you so that you do not experience any interruptions in
your medical care and so that you can make appropriate arrangements for your care.
Currently, the course of treatment authorized by ABC network, and that portion of the
treatment which has not been completed is as follows:
E
L
P
M
My office will complete this course of treatment and your financial responsibility will be limited
to co-payments, and deductible and co-insurance amounts under the terms of your health
insurance.
You, however, may require services beyond the course of treatment approved by ABC
network. If you do, I would be happy to continue to treat you as a private paying patient of my
practice. As a private paying patient, you would be personally responsible for the charges
associated with your care which I would be happy to discuss before we proceed with the care.
Unless we have agreed upon other arrangements, payment will be expected at the time services
are rendered. Depending upon the terms of your health insurance, reimbursement may or may
not be available to you.
A
S
In the event you wish to continue with a physician who participates in the ABC Health Care
Network, I would be happy to work with you and ABC to make an appropriate referral.
I would appreciate it if you would acknowledge receipt of this letter by signing a copy of it, and
returning it to me.
I ACKNOWLEDGE THAT I HAVE
RECEIVED A COPY OF THIS LETTER.
Yours very truly,
RICHARD ROE, DC
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MANAGED CARE CONTRACT
COMPLIANCE LETTER
BACKGROUND
Many managed care contracts have very specific language relating to the liability of the specific
plan to pay for services which it determines to be “chiropractic necessary” care. This often means
the plan is not responsible for care that extends beyond the definition of necessity, after the patient
ceases to improve or has reached Maximum Chiropractic Benefit (MCB) or “Maximum
Therapeutic Benefit.” Most plans do not pay for care that is deemed to be maintenance,
experimental, preventive or that is not shown to have significant benefit.
OBJECTIVES
This form should be used when the doctor has determined that the managed care plan does not
provide for reimbursement for services he has determined, or which the plan could determine to
be maintenance care.
APPLICATION
Contracts which contain such language should be identified and letters of understanding between
the doctor and the patient should be instituted as a normal practice protocol.
PRACTICE SUGGESTIONS
• Each of the following letters should be reviewed carefully by the doctor and staff along with the
specific provisions of the managed care contract.
• Significant misunderstanding can result from a lack of clear policy regarding the payment
responsibilities between the doctor and the patient.
• Often malpractice claims can arise from a patient’s misunderstanding of what their
reimbursement responsibility is. It is imperative that no vague or unclear understanding exist
between the patient and the doctor.
• Many times managed care plans will consider doctor compliance and patient satisfaction in
recredentialing criteria and physician profiling. Having clear office policy established for each
patient in each and every managed care entity will help immeasurably in the overall management
of patients in managed care plans.
POTENTIAL DISADVANTAGE
A lack of incorporation of proper forms and letters can and often does result in patient
dissatisfaction and ultimately can lead to allegation of malpractice or a letter to the board of
examiners or managed care entity alleging wrongdoing.
>>
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MANAGED CARE CONTRACT
COMPLIANCE LETTER
REIMBURSEMENT FOR SERVICES NOT COVERED BY CONTRACT LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Mr. John Doe
1 Main Street
Hanesville, Fl 00122
MM/DD/YR
Dear Mr. Doe:
E
L
I have recommended certain professional services for you from which it is believed that you will
derive therapeutic benefit. These services, however, are not covered under the terms of your
health insurance, and no reimbursement from your health insurer is available, under your
current plan.
P
M
Therefore, in the event you choose to proceed with the care that I have recommended, you will
be personally responsible for the charges associated with the care. This is so even if the results
are not what is expected. If this creates a hardship for you, I would be happy to discuss
alternative payment arrangements.
A
S
If you have any questions concerning the care that has been recommended or the charges
associated with the care, you are encouraged to discuss your questions with me. If you wish to
proceed with the care, I would appreciated it if you would sign the accompanying
acknowledgement .
Yours very truly,
Richard Roe, DC
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MANAGED CARE CONTRACT
COMPLIANCE LETTER
BACKGROUND
Many managed care contracts have very specific language relating to the liability of the specific
plan to pay for services which it determines to be “chiropractic necessary” care. This often means
the plan is not responsible for care that extends beyond the definition of necessity, after the patient
ceases to improve or has reached Maximum Chiropractic Benefit (MCB) or “Maximum
Therapeutic Benefit.” Most plans do not pay for care that is deemed to be maintenance,
experimental, preventive or that is not shown to have significant benefit.
OBJECTIVES
This form should be used when the doctor has determined that the managed care plan does not
provide for reimbursement for services he has determined, or which the plan could determine to
be maintenance care.
APPLICATION
Contracts which contain such language should be identified and letters of understanding between
the doctor and the patient should be instituted as a normal practice protocol.
PRACTICE SUGGESTIONS
• Each of the following letters should be reviewed carefully by the doctor and staff along with the
specific provisions of the managed care contract.
• Significant misunderstanding can result from a lack of clear policy regarding the payment
responsibilities between the doctor and the patient.
• Often malpractice claims can arise from a patient’s misunderstanding of what their
reimbursement responsibility is. It is imperative that no vague or unclear understanding exist
between the patient and the doctor.
• Many times managed care plans will consider doctor compliance and patient satisfaction in
recredentialing criteria and physician profiling. Having clear office policy established for each
patient in each and every managed care entity will help immeasurably in the overall management
of patients in managed care plans.
POTENTIAL DISADVANTAGE
A lack of incorporation of proper forms and letters can and often does result in patient
dissatisfaction and ultimately can lead to allegation of malpractice or a letter to the board of
examiners or managed care entity alleging wrongdoing.
>>
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MANAGED CARE CONTRACT
COMPLIANCE LETTER
ACKNOWLEDGEMENT LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555)123-4567
FAX (555) 123-4568
ACKNOWLEDGEMENT
1.
I acknowledge that:
E
L
a.
The following chiropractic care (“Recommended Care”) has been prescribed
for me:
(insert care plan)
b.
The charge for the Recommended Care is: $
c.
The Recommended Care is not covered by my health insurance, and,
therefore, I will be personally responsible for the charges of the
Recommended Care.
A
S
P
M
2.
I understand that payment is expected when services are rendered unless other
arrangements have been made.
3.
I understand that I will be financially responsible for the Recommended Care
whether or not the anticipated results and benefits are achieved.
Signature of patient
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PATIENT SIGN-IN SHEET
GUIDELINES
Patient sign-in sheets are part of the permanent record regarding any patient encounter. It is
important that these sign-in sheets be appropriately utilized.
BACKGROUND
It is surprising how often a disgruntled patient will claim that he was billed for services rendered
on a day he was not in the doctor’s office. Insurance company reports, coupled with a patient
complaint to the disciplinary board can cause even an honest doctor untold problems.
OBJECTIVES
A key function of the document is to preserve the patient’s handwritten verification that he was
in the office on a given date. If the patient denies being in the office on particular date but his
signature appears on a sheet with several other patients’ signatures bearing the date, the doctor
will be able to demonstrate that it is the patient who is mistaken about the date.
A weekend stumble or other seemingly minor incident may not make much of an impression on
the patient, but can be important to the doctor’s assessment of his care. The form’s “change in
condition” section will remind the patient to provide that information.
PRACTICE SUGGESTIONS
Unless a patient’s disability requires it, the receptionist should not sign in for the patient. If
someone other than the patient signs in for him, much of the benefit of this protection strategy is
lost.
If the patient cannot sign in for himself, a family member, friend or staff member should sign his
name but clearly indicate that it is not the patient’s signature. (ie: Jane Smith for Howard Jones).
If this is not done, there is an additional risk that the patient will contend that not only was he not
in the doctor’s office that day, but the doctor made a clumsy attempt or forge the patient’s
signature. Routine handwriting analysis under such circumstances would, of course, confirm the
patient’s allegation that the signature was not “genuine.” Whenever the entry is made by someone
other than the patient, it may prove helpful to have him initial the entry.
The receptionist must check the form each time a patient signs in so pertinent notes can be
referred to the doctor.
Failure to somehow conceal the names of patients who “signed in” earlier in the day may cause
annoyance as a perceived breach of confidentiality. “Mrs. Smith,” the mother of an orthopedist,
may not want it to get back to her son that she is seeing a chiropractor! This risk can be minimized
by using a cover which can slide down over the names after each sign-in. If a cover is used, care
should be taken to ensure that the information on the top of the form is visible, or imprinted, on
the outside of the cover sheet. The receptionist should also present the form to each patient and
collect it immediately after use rather than simply allowing it to lie in plain view on the reception desk.
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Review of the form at a staff meeting affords a good opportunity to remind personnel of the
importance of monitoring patients’ conditions and keeping the doctor advised of all relevant
information whether gathered formally such as with this form, or informally during casual
conversation.
FREQUENCY
Each patient should sign in at each office visit.
POTENTIAL DISADVANTAGES
If a patient indicates a new injury but does not receive a re-examination or other appropriate
inquiry, the doctor has documented his own negligence. The staff person responsible for having
the form filled out is also responsible to see that pertinent information is relayed to the doctor.
Failure to do so is negligence. The D.C. is responsible for that negligence just as he is accountable
for any other acts of negligence by members of his staff. If the receptionist ignores a pertinent note
and does not bring it to the doctor’s attention, he is still responsible.
There are also those who are just offended by the process generally — reminded perhaps of
“taking a number” in the bakery shop.
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PATIENT SIGN-IN SHEET
PLEASE
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555)123-4567
FAX (555) 123-4568
January 1, 0000
PLEASE SIGN IN AND PUT A NOTE IN THE BOX TO THE RIGHT OF YOUR
NAME IF YOU HAVE HAD A FALL, ACCIDENT OR OTHER CHANGE IN
YOUR CONDITION SINCE YOUR LAST VISIT.
NAME
P
M
Mary Jane Doderline
John Brendager
Wendy Lee Johnson
A
S
Mary Jane Greene
John Davidson
Richard Jones
Carole Ann Zellner
E
L
FALL, ACCIDENT OR
CHANGE IN CONDITION
SINCE LAST VISIT?
No
No
fell down yesterday
No
No
No
auto accident last month-not hurt
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PATIENT INFORMATION
GUIDELINES
The Patient File
When a new patient enters the office, a file is created which becomes the foundation of the
patient’s permanent record. Adequate systems may include personal patient data (e.g., name,
address, phone numbers, age, sex, occupation); insurance and billing information; appropriate
assignments and consent forms; case history; examination findings; imaging and laboratory
findings; diagnosis; work chart for recording ongoing patient data obtained on each visit; the
service rendered; health care plan; copies of insurance billings; reports; correspondence; case
identification…for easy storage and retrieval of patients’ documents.
Doctor/Clinic Identification
Basic information identifying the practitioner or facility should appear on documents used to
establish the doctor-patient relationship. This can be pre-printed on forms, affixed by rubber
stamp or adhesive labels or typed on handwritten in ink. Basic information should include:
•
•
•
•
•
•
practitioner’s name/specialty
specialty designation (if applicable)
facility name (if different)
legal trade name (if applicable)
street address and mailing address (if different)
telephone number(s)
Patient Identification
Clear identification of the patient is necessary. This information can be obtained with ease by
using pre-printed forms for completion by the patient. Identifying information may include:
•
•
•
•
•
•
•
•
•
•
case/file number (if applicable)
name…
birthdate, age
name of consenting parent or guardian…
copy letter of guardianship…
address(es)
telephone number(s)
social security number…
radiograph/lab identification…
contact in case of emergency
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•
•
•
•
•
•
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sex (M or F)
occupation…
marital status
race
number of dependents
employer, address, phone number
spouse’s occupation
BACKGROUND
As one of the first forms encountered when a patient enters the office, this becomes particularly
important in the event of a dispute arising from a concern if the patient had actually been in the
office or not.The sign-in sheet will become an integral art of the patient record and will be critical
in the event the need to validate any office visits becomes necessary.
PRACTICE SUGGESTIONS
• It is far easier to get all needed information at the outset than to “fill in gaps” later. Intake should
be handled by a capable and thorough employee.
• Whenever feasible, intake forms should be filled out by the patient. This minimizes the
possibility of misunderstanding, or mistranscription by a CA. The patient, however, can still
misunderstand, so it is important that the intake staffer field questions and re-read for
obvious omissions or inconsistencies.
• Natural parents will not have a “letter of guardianship.” When the patient is an infant, the
“parental consent” form must be used. At that time the doctor should request a copy of custody
or guardianship.
• The doctor should consider all clinically relevant information and incorporate this information
into forms and records he finds appropriate for his practice.
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PATIENT INFORMATION
Patient Name:
File No:
Jane Smith
1463
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
WELCOME
The doctor and staff of ROE CHIROPRACTIC OFFICE welcome you and want to provide you with the best possible
care. We will conduct a thorough history and physical examination to decide if we can assist you. If we do not believe that
your condition will respond to chiropractic care, we will not accept you as a patient but will refer you to another health
care provider, if appropriate.
E
L
INSURANCE
This office will process your insurance forms upon request. We will do our utmost to provide sufficient information to
your carrier to obtain payment for your treatment. We have found that, in some instances, however, insurance companies
will deny or reduce payment despite our best efforts to demonstrate the necessity for care. In the event that full payment
is not made for any reason, you must understand that you are responsible to make payment in full.
P
M
PATIENT IDENTIFICATION
Name
Street
Jane Marie Smith
142 Walters Drive
Mansville, NY 12345
Name or Nickname I prefer to be called
A
S
City, State and Zip
555-55-5555
Social Security #
Male ( )
X
( ) Female
Contact incase of emergency, name:
Telephone #
Marie
234-5678
678-9101
in this office
Telephone (Home)
(Work)
Ok to call there? (
) Yes
No (
.
X)
sales representative
Occupation
Date of Birth
10/31/52
Age
40
Mrs. Matilda Marling
234-5555
not applicable
Name of Parent of Minor Patient (If applicable)
ACCEPTANCE AS PATIENT
I understand and agree that the doctors of ROE CHIROPRACTIC OFFICE have the right to refuse to accept me as a patient
at any time before treatment begins. The taking of a history and the conducting of a physical examination are not considered
treatment, but are part of the process if information gathering so that the doctor can determine whether to accept me as a patient.
January 1, 0000
Date
Jane Marie Smith
Signature
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HEALTH HISTORY
GUIDELINES
• The use of forms can assist in tasks such as obtaining case history, noting examination
findings and charting case progress. Use of forms is at the discretion of the individual
practitioner but should favor comprehensiveness and completeness rather than brevity.
• The process by which one determines the diagnosis should be adequately recorded and
interpretable.
• When possible, history questionnaires, drawings and other information personally completed
by the patient should be included in the initial documentation.
• The history plays a critical role in the diagnostic process. A well performed history will
appropriately identify the region to be examined and the extent of the condition.
• Important elements of the history may include:
• date history taken
• present complaint/chief complaint
• description of accident/injurious event or etiology
• past history, family history, social history (work history and recreational interests,
hobbies as appropriate)
• review of systems (as appropriate)
• signature or initials of person eliciting history.
BACKGROUND
A critical step in formulating a differential diagnosis is taking a thorough patient history. While a
patient’s recent past often reveals the source of his presenting complaints, precursors to
immediate symptoms are only a portion of the total picture. The chiropractor who does not know,
for example, that the patient has suffered fractured ribs in an automobile accident may employ
excessive force during thoracic adjustments or may use a technique or table positioning which is
undesirable under such circumstances.
Interviewing Skills are Required
The busy practitioner too often loses sight of the clinical and psychological importance this
introduction may have for a new patient and delegates the task of history-taking to an employee.
Doctors should remember that interviewing a patient to gather a complete history is not a simple,
routine task to be thrust upon the newest staff member after minimal training. Since the entire
professional relationship evolves from this introduction, it must provide an adequate foundation
for diagnosis and treatment.
Whoever takes the initial history must be adequately trained to elicit needed information from the
patient. Pre-printed forms must be used only as the starting point in the history-taking process.
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PRACTICE SUGGESTIONS
• History forms are often given to patients in the waiting room where they are surrounded by
strangers.That environment may make them reluctant to ask questions where others can overhear
any conversation. Sufficient privacy must be afforded that the patient will be comfortable asking
questions and providing complete answers to any he may be asked.
• The doctor is best able to recognize the significance or implications of a certain response and
to know when to probe for more details. Interviewing skill is essential if all important information
is to be gathered from the patient. What is clinically significant to the doctor might be a matter of
little consequence to the patient. A simple “Have you been involved in any accidents?” is
inadequate if a patient accepts “minor” collisions as an unavoidable part of his job and does not
really consider them “accidents.” Likewise, the factory worker who routinely bends, lifts and
twists while carrying heavy loads does not think that his everyday activities are traumatic. From a
clinical standpoint knowing that the patient engages repeatedly in such activities is critical to
proper diagnosis, treatment and case management.
• Even if staff members record the intake information, the doctor is responsible for conducting a
thorough follow-up inquiry to reduce the possibility of oversight. The doctor who makes his own
supplemental notes in the records will find that practice helpful in refreshing his memory even
years later.
• The following forms and case history records should be carefully reviewed by the doctor. We
suggest that the forms/letters be modified and adapted to your practice style. After these
forms/letters are reviewed and revised to your personal preference, they can be taken to a local
printer and made into two-sided forms, carbonless forms where appropriate, and four-page forms
when necessary for insertion into the patient’s record.
POTENTIAL DISADVANTAGES
WARNING: A “yes” answer to any question on the history checklist should cause the doctor to
initiate additional questions and appropriate tests. Likewise, failure to properly and thoroughly
investigate any response on the confidential case history form which would suggest further
examination and referral, will create the impression of negligence and increase the likelihood of
risk to the practitioner.
* The following pages, “Onset of Signs and Symptoms”, is taken from the monograph Current
Concepts in Vertebrobasilar Complications Following Spinal Manipulations, by Allan C. J. Terrett.
B.App.Se. Faculty of Biomedical and Health Sciences RMIT University, Bundoora, Australia.
The onset of vertebrobasilar ischemia are manifested by signs and symptoms listed in the first
nine questions of the History Check List (see following pages). Exercising caution and good
clinical judgement when these signs and symptoms are checked YES is an excellent way to reduce
the incidents of VBI. (Reprinted with permission.)
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ONSET OF SIGNS AND SYMTOMS
The time between the application of SMT and the onset of ischemic symptoms and signs can
vary from immediately to several days later. The interval is probably related to the mechanism of
injury. When brainstem ischemia is due to vasoconstriction, symptoms would be expected
immediately; whereas those (other than the pain of dissection) due to thrombus and/or embolus
formation resulting from a vessel wall dissection and/or vessel occlusion would only become
symptomatic after some time.
A review of 183 cases reveals that the time between SMT and the onset of symptoms was given
in 136 cases (74%).
Analysis shown that symptoms began:
1. 69% during SMT
2. 3% within moments or minutes of SMT
3. 9% within on hour of SMT
4. 8% 1-6 hours after SMT
5. 5% 7-24 hours after SMT
6. 6% 24 hours or more after SMT
Signs and symptoms of vertebrobasilar ischemia (VBI) produced by SMT usually occur in the
practitioner’s office (72%), and should be immediately recognized by the practitioner
The major signs and symptoms of VBI are the 5 Ds and 3 Ns:
1. Dizziness/vertigo/giddiness/light headedness
2. Drop attacks/loss of consciousness
3. Diplopia (or other visual problems/amaurosis fugax)
4. Dysarthria (speech difficulties)
5. Dysphagia
6. Ataxia of gait (walking difficulties/incoordination
of the extremities/ataxia/falling to one side
7. Nausea (with possible vomiting)
8. Numbness on one side of the face and/or body
9. Nystagmus (involuntary rapid, rhythmic eye movement)
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MAKE YOUR FORMS RELEVENT
Patient Name:
Date of Birth:
Date:
Case No.
Do you have vertigo (dizziness)? DIZZINESS
Yes ___
CKS
A
T
T
A
Do you pass out easily (faint or loss of consciousness)? DROP
Yes ___
A
I
P
O
L
Do you have double vision or have you lost sight in one eye? DIP
Yes ___
A
I
R
Do you have any slurred speech or difficulty with speech? DYSARTH Yes ___
Do you have or have you ever had difficulty in arranging DYSPHAGIA Yes ___
words properly?
Do you have any difficulty walking, with coordination ATAXIA
Yes ___
or falling to one side?
Do you have any nausea or vomiting? NAUSEA
Yes ___
SS
E
N
B
M
Do you have numbness on one side of your face or body? NU
Yes ___
MUS
G
A
T
S
Y
Do you have any visual disturbances or rapid eye movement? N
Yes ___
Do you have a headache or head pain that is unlike any
Yes ___
you have had before?
Do you have headaches for hours or days?
Yes ___
Do you have a history of stroke in your family?
Yes ___
Do you have chest pain?
Yes ___
Do you have any change in bowel or bladder habits?
Yes ___
Do you have a sore that does not heal?
Yes ___
Do you have any unusual bleeding or discharge?
Yes ___
Do you have any thickening in your breasts or elsewhere?
Yes ___
Do you have indigestion or difficulty swallowing?
Yes ___
Do you have a change in any wart or mole?
Yes ___
Do you have a nagging cough or hoarseness?
Yes ___
Do you have night sweats?
Yes ___
Do you have pain in neck, jaw or face?
Yes ___
Do you have a drooping eyelid or change in your pupils?
Yes ___
Do you have any ringing in your ears?
Yes ___
Do you take birth control pills?
Yes ___
[ ] High blood pressure medication
[ ] Blood thinners
[ ] Other
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
No ___
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HISTORY CHECKLIST
Patient Name:
Date of Birth:
Date:
Wallace Genter
5/21/51
January 1/0000
Case No.
Do you have vertigo (dizziness)?
Do you pass out easily (faint or loss of consciousness)?
Do you have double vision or have you lost sight in one eye?
Do you have any slurred speech or difficulty with speech?
Do you have or have you ever had difficulty in arranging
words properly?
Do you have any difficulty walking, with coordination
or falling to one side?
Do you have any nausea or vomiting?
Do you have numbness on one side of your face or body?
Do you have any visual disturbances or rapid eye movement?
Do you have a headache or head pain that is unlike any
you have had before?
Do you have headaches for hours or days?
Do you have a history of stroke in your family?
Do you have chest pain?
Do you have any change in bowel or bladder habits?
Do you have a sore that does not heal?
Do you have any unusual bleeding or discharge?
Do you have any thickening in your breasts or elsewhere?
Do you have indigestion or difficulty swallowing?
Do you have a change in any wart or mole?
Do you have a nagging cough or hoarseness?
Do you have night sweats?
Do you have pain in neck, jaw or face?
Do you have a drooping eyelid or change in your pupils?
Do you have any ringing in your ears?
Do you take birth control pills?
What prescription medication are you taking if any?
[ ] High blood pressure medication
[ ] Blood thinners
Aspirin
[ ] Other
14021
Yes
Yes
Yes
Yes
Yes
✓
_____
_____
_____
_____
✓
_____
E
L
A
S
P
M
No
No
No
No
No
_____
_____
✓
_____
✓
✓
_____
_____
✓ No _____
Yes _____
Yes _____
✓
Yes _____
Yes _____
Yes _____
No _____
No _____
✓
No _____
✓
No _____
✓
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
Yes _____
✓
Yes _____
Yes _____
Yes _____
Yes _____
No _____
✓
✓
No _____
No _____
✓
No _____
✓
No _____
✓
No _____
✓
No _____
✓
No _____
✓
✓
No _____
No _____
✓
No _____
✓
No _____
✓
No _____
✓
No _____
✓
No _____
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Have you ever had cancer?
Yes
No
Does your pain ever wake you from a sound sleep?
Yes
No
Are you losing weight now without trying?
Yes
No
Are you coughing up blood or noticing it in your stools or urine?
Yes
No
Have you had any loss of bladder or bowel control?
Yes
No
Yes
No
E
L
Are you seeing any other doctor now for any reason?
Note:
Are you taking any medication or over-the-counter drugs?
P
M
Please indicate type (aspirin, etc.)
Aspirin
What was the date of onset of your last menses?
Smoker
Alcohol
A
S
Yes or
Yes or
✓
✓
SOCIAL HISTORY
No, If Yes, how many packs
No, If Yes, how much
FAMILY HISTORY
Did you mother or father have any of the following:
Put an M for mother, F for father, and B for both.
(M ) High Blood Pressure
(M ) Heart Attack
( ) Emphysema
( ) Seizure-Convulsions
( ) HIV Positive
( ) Asthma
( ) Diabetes
( ) Kidney Disease
Comments:
( ) Ulcer or Stomach Problems
( F ) Stroke
( F ) Arthritis-Rheumatism
( ) Mental Illness
( ) Thyroid Disease
( ) Circulation Problems
( ) Cancer
Yes
✓
No
✓
✓
✓
✓
✓
✓
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SHOW AREA(S) OF PAIN OR UNUSUAL FEELING
Mark the areas on this body where you feel the described sensations.
Use the appropriate symbols.
Mark areas of radiation.
Include all affected areas.
NUMBNESS
-------------
PINS & NEEDLES
00000
00000
00000
BURNING
XXXXX
XXXXX
XXXXX
ACHING
*****
*****
*****
E
L
STABBING
/////
/////
/////
Please mark on the pain scale from Zero to 10 the pain you feel with this condition.
10 being the worst pain you have felt with this condition.
P
M
Pain Chart
A
S
right
Neck-Shoulder-Arm-Pain
On a scale of zero to 10, I rate my
discomfort as follows:
(
X0
)
0
no pain
4
X 00
Mid Back Pain
On a scale of zero to 10, I rate my
discomfort as follows:
(
0
no pain
left
X
X Low Back and Leg Pain
X
7
X right
On a scale of zero to 10, I rate my
discomfort as follows:
0
no pain
left
January 1, 0000
)
10
severe pain
XX
XX X
(
Date:
10
severe pain
Wallace Genter
Signature
)
10
severe pain
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_________________________________________________________________________________________________
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_______________________________________________________________________________________________________________________________________
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_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
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_______________________________________________________________________________________________________________________________________
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_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
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WORKERS’ COMPENSATION AUTHORIZATION
BACKGROUND
Workers’ compensation statutes and procedure vary widely from state to state.To receive payment
the doctor must comply with the law and applicable administrative rules. Some statutes permit
treatment only after a certain number of days have lapsed after injury. Others give the insurance
carrier total control over the worker’s care/treatment.
Every state requires some form of employer authorization for treatment of work-related injuries.
The doctor should consult with his state association or legal counsel to learn the precise
requirements in his state. Treatment rendered without proper authorization may result in delayed
payment, claim denial, or both.
PRACTICE SUGGESTIONS
• The rules and requirements of some workers’ compensation plans are quite detailed. How many
times (if at all) the patient has the right to change treating doctors without permission, for
example, is specified in some laws. Familiarity with that type of provision will allow the doctor to
treat workers with greatly reduced risk of having the carrier deny claim.
• Many state associations offer continuing education seminars which seek to explain the
compensation system and its requirements. Attending such programs would likely be well advised
before venturing into this specialized area of practice.
• Workers’ compensation can constitute a substantial portion of the doctor’s practice income.
Cultivating employer relationships is essential to increase practice growth in this intensely
competitive area. The doctor who frequently updates the employer on the injured worker’s
progress will provide essential information to permit the employer to better plan for job coverage
and scheduling during the patient’s absence. The D.C. who faithfully keeps the employer/carrier
informed will increase his chances of being placed upon a “preferred provider” list for that
company.
OBJECTIVE
This form, properly signed by an authorized individual, will permit the doctor to commence
treatment with reasonable assurance that the compensation carrier will pay for the care.
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WORKERS’ COMPENSATION AUTHORIZATION
To:
DR. RICHARD ROE
Date of accident:
December 15, 0000
Worker:Wilbert
Lance Doderfield
Employer’s Name:
Employer’s Address:
Employer’s Phone:
A.B.C.Stamp Company
1234 Anylane Road, Redline, PA 12222
234-5679
Insurance Carrier:
Address:
Phone:
Transfer Insurance Company
1000 Market Place, Philadelphia, PA 19999
888-7654
E
L
P
M
Foreman or Immediate Supervisor: William Dentlock
The above employee has advised me of his work-related injury. This is your authorization to
render him treatment.
A
S
William Dentlock
Print Name
William Dentlock
Signature
Supervisor
Title–Authorized Representative of Employer
Date
December 17, 0000
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WORK/COMP HISTORY FORM
BACKGROUND
Each type of injury may require some unique and specific information. Therefore it is important
to determine if the patient has had a work related injury in order to properly determine the
appropriate requirements for work related injuries. Specific laws may apply to work injury and
therefore doctors should be familiar with their state statute relative to any specific requirement.
PRACTICE SUGGESTION
If staff members record the intake information, it is imperative that the doctor be responsible for
conducting a thorough follow-up inquiry to reduce the possibility of any oversight.
Many patients fail to inform the staff when making appointments that they were injured on the
job. This is often an important factor to note in order to allow adequate time for examination and
consultation.
POTENTIAL DISADVANTAGES
Often failure to know the patient has been involved with a work related injury prevents the doctor
and staff to accumulate all the necessary relevant reporting information and may cause the
examination to overlook diagnostic tests or physical examinations which may significantly impact
upon the outcome of care.
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WORK/COMP HISTORY FORM
12/12/0000
John Jones
Name:
Date of Accident:
United Carrier Co.
1. Name of employer at the time of accident:
14 yrs.
2. Length of time worked there prior to accident:
Lifting boxes and cartons
3. Type of work being done at time injury:
Lifted a pallet of boxes. Last box was heavy and I
had to lift it high. Felt pain when I lifted it above my head.
4. In your own words, please describe accident:
E
L
5. Have you been treated by another doctor for this accident?
If yes, please list doctor’s name and address:
What type of treatment did you receive?
How long were you treated by this doctor?
6. Are you: ( ) improved
( ) unchanged
7. What types of medicines are you taking? Aspirin
P
M
Yes
X
No
( X ) getting worse
Do these medicines help? ( )Yes
( X ) No
( ) Don’t know
8. Have you had physical therapy? ( )Yes
( X ) No If yes, how often?
( ) Daily ( ) Every other day
( ) Several times a week ( ) Weekly
( ) Every other week
( ) Monthly
( ) Other
9. Prior to this accident, have you ever had any of the physical complaints similar to what
you have now?
( ) Yes
( X ) No
( ) Don’t know
If yes, describe:
A
S
Were these similar complaints the results of previous accident(s)?
( ) Yes
( ) No
( X ) Not Applicable
see above
Please provide details of accident(s):
10. Have you had any other serious accidents which required medical care?
( X ) Yes
( ) No
10 years ago I had hernia from lifting
Describe:
11. Have you had any serious illnesses that required hospitalization?
( X ) Yes
( ) No
see #10
Describe:
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12. Have you had any surgeries?
( X ) Yes
(
Hernia
If yes, list type of surgery and date:
Table of Contents
) No
13. Have you had any nervous or mental illnesses? ( ) Yes
( X ) No
Have you had psychiatric care? ( ) Yes
( X ) No
14. Have you received a medical discharge from the Armed Forces?
( X ) Yes
( ) No
15. Have you returned to work since this accident? ( ) Yes
( X ) No
If you have returned to work since your accident,
please fill out the information below:
DATE
E
L
EMPLOYER
Full-Time
Part-Time
Light Duty
Reg. Duty
OCCUPATION
P
M
Current Medical Complaints
BACK PAIN:
1. Currently, I have pain in my: ......................(
2. My pain began: ..........................................(
3. I have pain: ................................................(
4. My pain goes into my: ................................(
5. I have tingling and/or numbness in my: ......(
6. My pain is worse when I:
cough or sneeze ....................................(
sit..........................................................(
bend......................................................(
walk ......................................................(
lift ........................................................(
push ......................................................(
pull ......................................................(
7. My back pain is worse with sexual activity ..(
8. My pain wakes me up during the night ......(
9. Changes in the weather affect my pain ........(
A
S
NECK PAIN: Complete only if applicable
1. My neck pain began: ..................................(
2. I have pain: ................................................(
3. My pain goes into my: ................................(
4. I have tingling and/or numbness in my: ......(
low back
X)) gradually
X
) sometimes
) right leg
) right leg
X) Yes
X)) Yes
X) Yes
Yes
X) Yes
X
Yes
X)) Yes
X) Yes
X
X)) Yes
X Yes
)
)
)
)
(
(
(
(
(
(
(
(
(
(
(
(
(
(
(
)
)
)
)
)
X
X
mid back
( ) upper back
suddenly
all of the time
left leg
( ) both ( ) neither
left leg
( ) both ( ) neither
X
) No
) No
) No
) No
) No
) No
) No
) No
) No
) No
gradually
sometimes
right arm
right arm
(
(
(
(
)
)
)
)
suddenly
all of the time
left arm
left arm
( ) both
( ) both
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NECK PAIN (continued):
5. My pain is worse when I:
cough or sneeze
bend forward
lift
push
pull
turn my head
6. My pain wakes me up during the night
7. Changes in the weather affect my pain
8. I have neck stiffness
9. I have headaches
10. If I do get headaches, they occur:
(
(
(
(
(
(
(
(
(
(
(
Print
Table of Contents
) Yes
) Yes
) Yes
) Yes
) Yes
) Yes
) Yes
) Yes
) Yes
) Yes
) sometimes
(
(
(
(
(
(
(
(
(
(
(
)
)
)
)
)
)
)
)
)
)
)
E
L
No
No
No
No
No
No
No
No
No
No
all of the time
OTHER PAIN:
Please describe any current medical complaints which you are experiencing and were not
previously covered on this questionnaire, or list any additional comments you wish to make
Difficulty with bowel movements
regarding your condition.
P
M
pain when sitting or straining
JOB DESCRIPTION:
A
S
(In terms of an 8-hour workday, “occasionally” means 33%, “frequently” means 34% to 66%
and “continuously” means 67% to 100% of the day.)
1. In a typical
Sit:
Stand:
Walk:
8-hour
1
1
1
workday, I: (Circle # of hours / activity)
2
3
4
5
6
2
3
4
5
6
2
3
4
5
6
2. On the job, I perform the following activities:
Not At All
Occasionally
Bend/stoop
Squat
Crawl
Climb
Reach above
shoulder level
Crouch
Kneel
Balancing
Pushing/Pulling
7
7
7
Frequently
8
8
8
hours
hours
hours
Continuously
(
(
(
(
(
)
)
)
)
)
(
(
(
(
(
)
)
)
)
)
(
(
(
(
(
)
)
)
)
)
(X )
(X )
(X )
(X )
(X )
(
(
(
(
)
)
)
)
(
(
(
(
)
)
)
)
(
(
(
(
)
)
)
)
(X )
(X )
(X )
(X )
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3. On the job, I lift:
Not At All
Up to 10 pounds ( )
11 to 24 pounds ( )
25 to 34 pounds ( )
35 to 50 pounds ( )
51 to 74 pounds ( )
75 to 100 pounds ( )
Occasionally
( )
( )
( )
( )
( )
( )
Frequently
( )
( )
( )
( )
(X )
(X )
( X ) Yes
Continuously
( )
( )
( )
( )
( )
( )
4.
Do you have to bend over while doing any lifting?
( ) No
5.
Are your feet used for repetitive movements, such as in operating foot controls?
( X ) Yes
( ) No
6.
Do you use your hands for repetitive actions, such as:
Simple Grasping
Firm Grasping
Right Hand (X ) Yes ( ) No
( X ) Yes ( ) No
Left Hand ( X ) Yes ( ) No
( X ) Yes ( ) No
P
M
E
L
Fine Manipulation
( ) Yes ( ) No
( ) Yes ( ) No
7.
Are you required to work on unprotected heights?
Describe:
8.
Are you required to be around moving machinery?
Describe:
Forklift
9.
Are you exposed to marked change in temperature and humidity? ( X ) Yes ( ) No
Describe:
Cement Floor, Large overhead doors
A
S
( ) Yes
( X ) No
( X ) Yes
( ) No
10. Are you required to drive automotive equipment?
Describe: Forklift
( X ) Yes
( ) No
11. Are you exposed to dust, fumes and/or gasses?
Describe: See #10
( X ) Yes
( ) No
12. Please list any additional comments:
Signature
John Jones
Date:
12/28/0000
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PERSONAL INJURY QUESTIONNAIRE
BACKGROUND
Each type of injury may require some unique and specific information.Therefore it is important
to determine if the patient has been involved in an auto accident in order to properly determine
if extra time is needed for examination and patient interview. Specific laws may apply to
personal injury auto accidents and therefore doctors should be familiar with their state statute
relative to any specific requirement.
PRACTICE SUGGESTIONS
If staff members record the intake information, it is imperative that the doctor be responsible
for conducting a thorough follow-up inquiry to reduce the possibility of any oversight.
Many patients fail to inform the staff when making appointments that they were involved in an
auto accident. This is often an important factor to note in order to allow adequate time for
examination and consultation.
POTENTIAL DISADVANTAGES
Often failure to know the patient has been involved in an auto related injury prevents the doctor
and staff from accumulating all the necessary relevant reporting information and may cause the
examination to overlook diagnostic tests or physical examinations which may significantly
impact upon the outcome of care.
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PERSONAL INJURY QUESTIONNAIRE
Richard Dobias
4430 Kathy Road
Self Employed
Prudential
Raymond Charles
6/23/58
(610) 866-2469
Bethlehem
PA
18017
123 Belaire Nephs, PA 18071
123-123-123
Rob M. Blind
Nationwide
789-789-789
Name
Date of Birth
Phone
Address
City
State
Zip
Employer’s Name
Employer’s Address
Your Ins. Co.
Policy #
Agent’s Name
Driver/Other Vehicle
Ins. Co.
Policy #
Have you retained an attorney? ( ) Yes ( X ) No Name
Were there any witnesses? ( X ) Yes
( ) No
Name(s)
NATURE OF ACCIDENT:
1. Date of Accident:
Time of Day
2. Were you: ( X ) Driver
( ) Passenger
( ) Front Seat
( ) Back Seat
3. Number of people in your vehicle?
Other Vehicle?
4. What direction were you headed? ( ) North
( ) East
( X ) South
( ) West
on (name of street)
5. What direction was the other vehicle headed?
( ) North
( ) East
( X ) South
( ) West
on (name of street)
6. Were you struck from:
( X ) Behind
( ) Front
( ) Left side ( ) Right side
7. Were you knocked unconscious?
( ) Yes
( X ) No. If yes, for how long?
8. Were police notified?
( X ) Yes
( ) No
9. In your own words, please describe accident:
I. Sawet
11/13/0000
10:00 a.m.
E
L
1
Lehigh Street
P
M
Lehigh Street
hit in the back
1
I was stopped waiting to turn left when I was
A
S
10. Did you have any physical complaints BEFORE THE ACCIDENT? ( ) Yes ( ) No
If yes, please describe in detail:
11. Please describe how you felt:
a. DURING THE ACCIDENT:
b. IMMEDIATELY AFTER THE ACCIDENT:
c. LATER THAT DAY:
d. THE NEXT DAY:
12. What are your PRESENT complaints and symptoms?
Surprised-Shocked
Nervous
Stiff and Sore
Stiff- A lot of neck and shoulder pain
and I have headaches
Neck pain, can’t turn head, shoulders hurt
13. Do you have any congenital (from birth) factors which relate to this problem?
( ) Yes ( ) No. If yes, please describe:
14. Do you have any previous illnesses which relate to this case?
( ) Yes ( X ) No
If yes, please describe:
15. Have you ever been involved in an accident before? ( ) Yes (X ) No. If yes, please describe,
including date(s) and type(s) of accidents, as well as injuries received.
>>
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16. Where were you taken after the accident? Lehigh Valley Hospital
17. Have you ever been treated by another doctor since the accident? (X ) Yes ( ) No. If yes,
Emergency Room Doctor
please list doctor’s name and address:
What type of treatment did you receive?
X-Rays, told to take tylenol and see my family
doctor.
18. Since this injury occurred, are your symptoms: ( ) Improving (X ) Getting Worse (
19. CHECK SYMPTOMS YOU HAVE NOTICED SINCE ACCIDENT:
X❏ Headache
X❏ Neck Pain
X❏ Neck Stiff
❏ Irritability
❏ Numbness in Toes
❏ Face Flushed
❏ Feet Cold
❏ Chest Pain
❏ Shortness of Breath
❏ Buzzing in Ears
❏ Hands Cold
❏ Dizziness
❏ Fatigue
❏ Loss of Balance
❏ Stomach Upset
❏ Sleeping Problems
❏ Head seems Too Heavy
❏ Depression
❏ Fainting
❏ Constipation
❏ Back Pain
❏ Pins & Needles in Arms
❏ Lights Bother Eyes
❏ Loss of Smell
❏ Cold Sweats
X❏ Nervousness
❏ Pins & Needles in Legs
❏ Loss of Memory
❏ Loss of Taste
❏ Fever
❏ Tension
❏ Numbness in Fingers
❏ Ears Ring
❏ Diarrhea
❏
E
L
Both of my shoulders hurt
Symptoms Other Than Above
20. Have you lost time from work as a result of this accident? (
complete this question.
P
M
11/12/0000
a. Last Day Worked:
Contractor
b. Type of Employment:
c. Are you being compensated for time lost from work?
please state type of compensation you are receiving?
(
X ) Yes
(
) No. If yes, please
) Yes ( X ) No. If yes,
21. Do you notice any activity restrictions as a result of this injury? ( X ) Yes (
If yes, please describe, in detail:
.
) Same
A
S
) No.
I can’t work. Some simple things I do every day like getting out of bed and getting dressed take longer
because of pain.
22. Other pertinent information:
Signature
Richard Dobias
Date:
11/24/0000
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CONFIDENTIAL CASE HISTORY RECORD
USE OF WELL CONSTRUCTED FORMS
• The use of selected forms can assist in obtaining an appropriate case history, noting
examination findings and charting case progress. The use of any form to obtain patient
information is at the discretion of the individual practitioner but should favor
comprehensiveness and completeness rather than brevity.
• When possible, drawings and other information personally completed by the patient should
be included in the initial documentation.
• The case history plays a critical role in the diagnostic process. A well constructed case history
will appropriately identify the region and extent of the condition in many instances.
• Important elements of the history may include:
• date history taken
• present complaint/chief complaint
• description of accident/injurious event or etiology
• past history, family history, social history (work history and recreational interests,
hobbies as appropriate)
• review of systems (as appropriate)
• past and present medical/chiropractic treatment and attempts at self-care.
• signature or initials of person eliciting history.
BACKGROUND
A critical step in formulating a differential diagnosis is taking a thorough patient history. While a
patient’s recent past often reveals the source of his presenting complaints, precursors to
immediate symptoms are only a portion of the total picture. The chiropractor who does not know,
for example, that the patient has suffered fractured ribs in an automobile accident may employ
excessive force during thoracic adjustments or may use a technique or table positioning which is
undesirable under such circumstances.
Interviewing Skills are Required
The busy practitioner too often loses sight of the clinical and psychological importance this
introduction may have for a new patient and delegates the task of history-taking to an employee.
Doctors should remember that interviewing a patient to gather a complete history is not a simple,
routine task to be thrust upon the newest staff member after minimal training. Since the entire
professional relationship evolves from this introduction, it must provide an adequate foundation
for diagnosis and treatment.
Whoever takes the initial history must be adequately trained to elicit needed information from the
patient. Pre-printed forms must be used only as the starting point in the history-taking process.
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PRACTICE SUGGESTIONS
• History forms are often given to patients in the reception area where they are surrounded by
strangers. That environment may make them reluctant to ask questions where others can
overhear any conversation. Sufficient privacy must be afforded that the patient will be
comfortable asking questions and providing complete answers to any he may be asked.
• The doctor is best able to recognize the significance or implications of a certain response and
to know when to probe for more details. Interviewing skill is essential if all important
information is to be gathered from the patient. What is clinically significant to the doctor might
be a matter of little consequence to the patient. A simple “Have you been involved in any
accidents?” is inadequate if a patient accepts “minor” collisions as an unavoidable part of his job
and does not really consider them “accidents.” Likewise, the factory worker who routinely
bends, lifts and twists while carrying heavy loads does not think that his everyday activities are
traumatic. From a clinical standpoint, knowing that the patient engages repeatedly in such
activities is critical to proper diagnosis, treatment and case management.
• Even if staff members record the intake information, the doctor is responsible for conducting a
thorough follow-up inquiry to reduce the possibility of oversight.The doctor who makes his own
supplemental notes in the records will find that practice helpful in refreshing his memory even
years later.
• The following forms and case history records should be carefully reviewed by the doctor. We
suggest that the forms/letters be modified and adapted to your practice style. After these
forms/letters are reviewed and revised to your personal preference, they can be taken to a local
printer and made into two-sided forms, carbonless forms where appropriate, and four-page
forms when necessary for insertion into the patient’s record.
POTENTIAL DISADVANTAGES
WARNING: A “yes” answer to any question on the history checklist should cause the doctor to
initiate additional questions and appropriate tests. Likewise, failure to properly and thoroughly
investigate any response on the confidential case history form which would suggest further
examination and referral, will create the impression of negligence and increase the likelihood of
risk to the practitioner.
>>
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CONFIDENTIAL CASE HISTORY RECORD
Case No.
9423
Please fill out the following form in as much detail as possible.
Please print
Date
Name
Samantha Yobolonski
Address
1234 State Road
City
Bakerstown
30
Weight
Employer
Married
P
M
6/4/70
Date of Birth
120
Office Phone
[email protected]
E-mail Address
Age
Occupation
A
S
NBS News
S
GA
00137
555-123-4568
screen writer
W
Address
Sex (M)
(F)
X
D
1280 Century Ave., Bakerstown, GA
Children
N/A
Name of Spouse
Is any other member of your family being treated in this office?
Have you ever had chiropractic care before?
For what problem?
Zip
Samuel Johnston
Referred by
X
E
L
State
555-123-4567
Home Phone
January 4, 0000
N/A
no
no
N/A
Were the results satisfactory?
Yes
No
N/A
X
Major complaints and symptoms — please be as specific as you can. Ask the doctor or nurse
for help if you need assistance in filling out this section.
Chronic headaches across my eyes, over sinus area and at the base of my skull. Light bothers me.
Headaches are stabbing in nature getting more severe each month. No accidents.
How do you believe your problem (pain) began?
unknown
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on and off
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a year ago
When did you first notice this problem/pain?
Have you lost any work?
Print
12/15/0000
Day and date you last worked
no
Have you ever had this condition before or a similar condition?
When?
N/A
reading, noise, light
dark room, ice pack
What positions or activities relieve your condition?
yes
Have you ever been treated by a Medical Physician for this ailment?
What positions or activities aggravate your condition?
Where?
E
L
Bakerstown, Ga
Describe the type of treatment
P
M
migraines
6 months
Dr. John Jones
Diagnosis of previous physician
Length of time under care
Family physician’s name
pain pills, new headache medicine
poor
Results
A
S
Please send a report to my family physician.Yes
No
X
Will this case be covered by any insurance company? Major Medical
Blue Cross/Blue Shield
Workers’ Compensation
Medicare
X
Auto
Other
Have you ever been in any accidents, auto, fall down stairs, fall from ladder, etc. (even as a
No
child)?
When?
seafood
Are you allergic to anything you are aware of?
Are you presently taking any medication (aspirin included)? Yes
If yes, name them
Tylenol
Have you ever broken any bones? (fractures)
What operations have you had?
no
D&C
X
Any dislocations?
No
collar bone
1998
Year
Year
Year
Have you ever had any cosmetic surgery, breast implants, etc.?
Have you had any surgery to replace hip, knee, etc.?
no
yes
Year
Year
1995
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Give dates you have had any of the following?
1999
Blood tests
1999
N/A
CT Scan
N/A
Radiation Treatment
Table of Contents
(if exact date is unknown, give approximate)
Urinalysis
1999
MRI
Print
Ultrasound
N/A
X-Ray examination
eye examination
Other special treatment
E
L
Bakersville General
At what hospital or office were these tests taken
Dr. Jones
12/10/0000
Name of doctor who ordered tests
Date of last menstrual period
P
M
Do you have any reason to believe that you may be pregnant? Yes
Do you have any health problems not listed above?
no
Do you faint easily?
Do you take vitamins?
N/A
Yes X
No
A
S
Do you exercise regularly?
Yes
No
multiple
If yes, please list them
X
No
X
What kind of exercise?
Stairmaster
Habits: (please check)
Cigarettes
Alcohol?
Hobbies
Quantity
X
N/A
1 per week
Reading
Quantity
Coffee?
Quantity
X
Tea?
Quantity
Have you been treated for any health condition by a physician in the past year?
If yes, what condition?
Have you lost or gained weight in the past year?
no
Use this space for any additional information you may wish to discuss
N/A
3 cups daily
no
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Have you had or do you now have any of the following symptoms which are or have been
of significant distress to you? Please indicate with the letter N if you have these conditions
now (within the past 12 months) or P if you ever had these conditions in the past.
Now
N
Headaches N Frequency 2-3 month
N
Neck Pain
N
Stiff Neck
Sleeping Problems
N
Back Pain
N
Nervousness
Tension
N
N
Irritability
Chest Pains
Dizziness
Shoulder/Neck/Arm Pain
Pins & Needles in Arms
Pins & Needles in Legs
Numbness in Fingers
Numbness in Toes
High Blood Pressure
Difficulty Urinating
Allergies
Weakness in Arms
Weakness in Legs
Shortness of Breath
Fatigue
Depression
N
Lights Bother Eye
Loss of Memory
Ears Ring
Face Flushed
N
Buzzing in Ears
Past
P
Now
N
Past
P
Loss of Balance
Fainting
Loss of Smell
Loss of Taste
Diarrhea
Feet Cold
Hands Cold
Arthritis
Muscle Spasms
Frequent Colds
Stomach Upset
Constipation
Cold Sweats
Fever
Sinus Problems
Diabetes
Hemorrhoids
Leg Cramps
Colitis
Gall Bladder
Indigestion
Belching
Vomiting
Shoulder Pain
Swelling Joints
Knee Pain
Hayfever
Menstrual Difficulties
E
L
P
M
A
S
I understand and agree that health and accident insurance policies are an agreement
between the insurance carrier and myself, and that all services rendered me are charges
directly to me, and that I am personally responsible for payment. I also understand that if
I suspend or terminate my care and treatment, any fees for professional services rendered
me will be immediately due and payable.
PATIENT SIGNATURE
SOCIAL SECURITY NUMBER
Samantha Yobolonski
000-00-8888
DATE
January 4, 0000
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SOCIAL HISTORY
GUIDELINES
• The history plays a critical role in the diagnostic process. A well performed history will
appropriately identify the region to be examined and the extent of the condition.
• Important elements of the history may include…past history, family history, social history
(work history and recreational interests, hobbies as appropriate).
OBJECTIVES
1. In cases in which the doctor anticipates a need to testify (personal injury, workers’
compensation, Social Security Disability) this form will assist in assessing the impact that the
patient’s injury has had on his everyday life. That information will make the doctor a more
effective expert witness.
2. The information gathered by this form will also provide the D.C. with insight into aspects
of the patient’s lifestyle which may adversely affect his recovery. Without specific inquiry, many
patients will not mention some of their social and recreational activities which may be
important.
3. In a malpractice context, failure to learn about a patient’s regular physical activity and to
warn against those contraindicated may be negligent.
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SOCIAL HISTORY
PATIENT NAME:
Homer Dryfuse
DATE:
January 4, 0000
Please indicate beside each activity whether you engage in it:
Often = “O”
Sometimes = “S”
Never = “N”
SOCIAL HISTORY
S
N
S
N
N
O
O
S
N
N
N
N
N
N
N
N
N
N
N
N
Horseback riding
Bowling
Golf
Volleyball
Baseball/softball
Handball
Racquetball
Basketball
Walking (mile or less)
Walking (more than mile)
Jogging (mile or less)
Dancing
Scuba diving
Back packing
Swimming
Aerobics
Resistance training
Free weights
Exercise machines
Football
S
N
S
N
N
S
S
S
S
N
N
E
L
P
M
A
S
O
S
O
S
N
Tennis
Gymnastics
Skiing
Water skiing
Hunting
Fishing
Lawn mowing
Weed eater use
Snow shoveling
Gardening
Child care
Age(s)
Weight(s)
Climbing stairs
Alcohol 2 per day
Alcohol 14 per week
Medication
Tobacco
Other
FAMILY HISTORY
Please indicate if any of the following is currently or has contributed to some stress or
personal lifestyle changes within the past five years.
✓
Marriage
Birth of a child
Divorce
Death of spouse
Marital separation
Death of a family member or friend
Handicapped household member
Caregiver to family member
Spousal abuse
Dependence problems
Alcohol
Drugs
Change in jobs
Loss of job
Retirement
Change in living conditions
Change in residence
Change in financial status
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PATIENT’S JOB DESCRIPTION
BACKGROUND
The nature of a patient’s employment may have a significant effect on his response to treatment,
his attitude toward self-help and the likelihood of injury, disability or exacerbations.
Job satisfaction and worker attitude have been shown in recent years to be two of the most
important factors in worker injury, speed of recovery, and probability of disability.
OBJECTIVES
Clinical. These questions should assist the doctor in deciding whether the patient’s job is such
that he should not return to work.
Testimonial. In cases resulting from a workplace or auto injury, the doctor is likely to be called
upon to voice an opinion about patient disability. Familiarity with the physical requirements of
the patient’s job is essential to arriving at a rational and credible conclusion.
Risk management. If the patient returns to his job and re-injures himself, he may claim that
the second injury was caused by the doctor’s negligent failure to restrict his work. If the doctor
has not even familiarized himself with the patient’s job, it will be virtually impossible for him to
convince a jury that he was not negligent.
APPLICATION
Patient job descriptions should be obtained on every patient who is employed outside the home.
For homemakers see the “Activities of Daily Living” form which the doctor may use to discuss
limitations on homemaking.
POTENTIAL DISADVANTAGES
The doctor must give serious consideration to the effects of a patient’s workplace activity. If the
doctor has information which should alert him that a patient’s return to work would cause an
unreasonable risk of re-injury, the doctor must properly caution the patient. Failure to do so
may result in the doctor being held liable for any second injury the patient may suffer.
If the doctor orders a patient off work and the patient refuses to comply for economic or other
reasons, it can adversely affect his claim. If the doctor’s records are used to reduce a patient’s
claim, it will certainly make him angry and he may blame the doctor for the devaluation of his
claim.
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PATIENT’S JOB DESCRIPTION
PATIENT NAME:
James Mullin
To properly evaluate the effect that your continuing to work will have on your recovery, we
need to know the details of your usual workday as well as other tasks you are required to
perform even occasionally. Please provide answers to all questions. If you do not believe a
question applies to you, please mark it “n/a.” (Not Applicable)
What is your job?
Computer Serviceman
Please give a brief description of your daily job duties. Include activities which you are
occasionally asked to perform.
Install software, hardware, troubleshoot problems.
E
L
USUAL JOB TASKS How much time of each work day do you spend:
3 hr.
Standing . . . . . . . . . . . . . . . . . . . Type of surface (i.e. outdoors, concrete,
. . . . . . . . . . . . . . . . . . . . . . . . . wood) all of the above
4 hr.
varied
Sitting. . . . . . . . . . . . . . . . . . . . . Type of chair
short
1 hr.
Walking . . . . . . . . . . . . . . . . . . . What distance
1 hr.
Bending . . . . . . . . . . . . . . . . . . . How often per hour 10-15 minutes continuous
1 hr.
Stooping . . . . . . . . . . . . . . . . . . . How often per hour 10-15 minutes continuous
N/A
Crawling . . . . . . . . . . . . . . . . . . . How often per hour
N/A
?
Twisting
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
How
often
per
hour
?
Raising arms
N/A
N/A
above head. . . . . . . . . . . . . . . . How often per hour
often
20-80 lbs.
Lifting . . . . . . . . . . . . . . . . . . . . Maximum weight
. . . . . . . . . . . . . . . . . . . . . . . . . How often per hour once or twice
1-3 hrs.
auto
Driving . . . . . . . . . . . . . . . . . . . . Type of vehicle
5 hr.
Operating equipment . . . . . . . . . . What kind
computer
P
M
A
S
JOB SATISFACTION
Are you satisfied with your job? yes
Do you dread going to work each day? no
Is your job rewarding? yes
Have you changed jobs often in the past five years? yes
no
Is your job in a noisy environment?
Do you feel stress on your job? yes
Describe Computer breakdowns cause customers to become angry.
GENERAL
Do you work with others who can assist you to perform heavy work?
X No
Yes
Are there “light duty” tasks available for you to request during your recovery?
Yes
X No
January 4, 0000
Date
James Mullin
Signature
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PHYSICAL EXAMINATION FORM —
LEGEND/KEY
GUIDELINES
A legend of the codes or abbreviations should appear on the form or be available in the office
in order that another practitioner or interested person can interpret and use the information.
The legend can also be used for interoffice communications and as a dictation aid.
BACKGROUND
Doctor’s records should be neat, organized, and complete. Each entry in charts should be
legible. The use of abbreviations or codes is acceptable provided the “key” or “legend” is
available for review.
OBJECTIVE
The important aspect of providing a legend is to ensure the fact that the records and
information can be interpreted by another person. Coded records which can only be read by the
treating doctor can be a source of challenge in litigation. Having legends will ensure accurate
review of the records.
Legends should be sent with request for records in order to ensure proper interpretation.
>>
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PHYSICAL EXAMINATION FORM —
LEGEND KEY
A
assistance
ASAP
as soon as possible
A&P
auscultation and percussion
ausc
auscultation
AAA
abdominal aortic aneurysm
ax
axillary
abd
abdomen
BE
below elbow
abd
abduction
bil
bilateral
abn
abnormal
BK
below knee
AC joint acromioclavicular joint
BLE
bilateral lower extremities
Acl
anterior cruciate ligament
BP
blood pressure
add
adduction
BPM
beats per minute
ADL
activities of daily living
BR
bedrest
AE
above elbow
BUE
bilateral upper extremities
AJ
ankle jerk
c/o
complaints
AK
above knee
CA
cancer
AM
morning
CAD
coronary artery disease
AMB
ambulation
CAP
cervical adjustment prone
ant
anterior
CAS
cervical adjustment supine
AP
anteroposterior
CAT
computerized axial tomography
approx
approximately
CBC
complete blood count
appt
appointment
CC
chief complaint
AROM
active range motion
cer
cervical
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PHYSICAL EXAMINATION FORM —
LEGEND KEY
CHF
congestive heart failure
Dx
diagnosis
chr
chronic
EKG
electrocardiogram
CN
cranial nerve
EMG
electromyography
CNS
central nervous system
EMS
electrical muscle stimulation
comp
complaint
ER
external rotation
cont
continued
eval
evaluation
COPD
chronic obstructive pulmonary disease
exam
examination
CP
cold pack
exer
exercise
CR-W
crutch walking
ext
extension
CTS
carpel tunnel syndrome
FC
foraminal compression
D
day
FH
family history
dc
discharge
FIX
articular disfunction
DD
differential diagnosis
flex
flexion
DDD
degenerative disk disease
FMD
family medical doctor
decr
decreased
FS
full spine
DFM
deep friction massage
ft
foot
DJD
degenerative joint disease
FWB
full weight bearing
DM
diabetes mellitus
Fx
fracture
dor
dorsal
G/H
glenohumeral
DTR
deep tendon reflexes
GB
gallbladder
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PHYSICAL EXAMINATION FORM —
LEGEND KEY
H/A
headache
L&A
light and accommodation
HEP
home exercise program
L/S
lumbosacral
HNP
herniated nucleus pulposus
lat
lateral
HP
hot pack
LB
low back
HR
heart rate
LBP
low back pain
ht
height
LE
lower extremity
HTN
hypertension
LLE
left lower extremity
Hx
history
LMP
last menstrual period
hyper
hypertrophied
LOB
loss of balance
hypo
hypotrophied
LUE
left upper extremity
ICS
intercostal space
lum
lumbar
incr
increased
MBA
maximum benefits obtained
inf
inferior
MCP
metacarpal phalangeal joint
inspir
inspiration
Med
medicine
IR
internal rotation
MFR
myofascial release
JRA
juvenile rheumatoid arthritis
min
minute
jt
joint
mo
month
KE
kinetic exercise
mob
mobilization
KJ
knee jerk
mod
moderate
L
left
MP
motion palpation
>>
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PHYSICAL EXAMINATION FORM —
LEGEND KEY
MRI
magnetic resonance imaging
PAL
palpation
MS
multiple sclerosis
Path
pathology
MTP
metatarsal phalangeal joint
PD
pelvic drop adjustment
MVA
motor vehicle accident
percuss
percussion
NAD
no acute distress
PF
Patrick-Fabere test
NED
no evidence of disease
PH
past history
neg
negative
PI
present illness
neuro
neurological
PM
afternoon
NKA
no known allergies
PMH
past medical history
no
number
pos
positive
noct
nocturnal or at night
post
posterior
norm
normal
PP
palpatory pain
NWB
non-weight bearing
PR
pulse rate
OA
osteoarthritis
prn
as often as necessary
occ
occasional
PROM
passive range of motion
OM
otitis media
PT
physical therapy
OOB
out of bed
pt
patient
Orth
orthopedic
PTH
electrical muscle stim with heat
P
prone
R
right
P-A
posterior anterior
R/O
rule out
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PHYSICAL EXAMINATION FORM —
LEGEND KEY
RA
rheumatoid arthritis
T/L
thoracolumbar
ref
referred
T/O
throughout
rehab
rehabilitation
TRAP
trapezius
rep
repetition
TTS
tarsal tunnel syndrome
resp
respiratory
TX
treatment
RLE
right lower extremity
Tx
traction
ROM
range of motion
U
seated
rot
rotation
UE
upper extremity
RUE
right upper extremity
UR
utilization review
S
supine
US
ultrasound
SCM
sternocleidomastoideus muscle
v.s.
vital signs
SHLD
shoulder
vert
vertebrae
SI
sacroiliac joint
w/
with
SLR
straight leg raise
w/o
without
SP
side posture adjustment
WB
weight bearing
STC
short term care
wk
week
std
standard
WNL
within normal limits
surg
surgical
wt
weight
sympt
symptoms
Yr
year
T
thoracic
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PHYSICAL EXAMINATION
GUIDELINE
• Objective information relative to the patient’s history is obtained …examination of the area of
complaint and related areas…Gathering and recording this information may be facilitated by
use of pre-printed and formatted examination forms…Such evaluations may include:
•
•
•
•
•
vital signs
physical examination
neuromusculoskeletal examination
instrumentation
other chiropractic examination procedures
• The use of forms can assist in tasks such as…noting examination findings…Use of forms is
at the discretion of the individual practitioner but should favor comprehensiveness and
completeness rather than brevity.
• All relevant information from every reassessment and re-examination must be recorded in the
patient file.
BACKGROUND
Seeking to standardize an examination form is a formidable task. Preferences in format,
sequence, contents, detail and style vary greatly. Rather than attempting to craft a generic form
which would displease the fewest readers, your authors have set out some examples which may
be used in whole or in part as many best sit the doctor’s examination protocol.
ATTRIBUTION
The following form headed “PHYSICAL EXAMINATION” is reprinted with permission from
the records of Dr. Gary A. Tarola, D.A.B.C.O., Rt. 100, Schantz Rd., Fogelsville, PA 18051.
The forms headed “REGIONAL EXAM FORM” are reprinted courtesy of National College of
Chiropractic, 200 E. Roosevelt, Lombard, IL 60148.
The “INFORMED CONSENT FORM” on page 148 is reprinted courtesy of Charles Theister,
DC, JD.
The “S.O.A.P. NOTES” on page 165 is reprinted courtesy of Steve Savoie, DC.
PRACTICE SUGGESTIONS
Additions from other forms or as generated by the doctor should allow for a customized tool
which will assist the doctor in performing a comprehensive examination and efficiently
documenting its results.
79
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PHYSICAL EXAMINATION
DATE:
Bartholomew Jacobson
NAME
5 ‘11”
HEIGHT
WEIGHT
42
AGE
195
B.P
120/82
R
January 4, 0000
M
SEX
✓ PULSE 80 BPM TEMP
L
STANDING
High Mastoid R N L
Antalgic Posture C L Flex. R L
High Shoulder R N L Trendelenberg
+ - R L
High Hip
+ - R L
R N L Heel Walk (L5)
Antalgic
Scoliosis
Spasms
Gait
Lumbar
Toe Walk (S1)
+ - R L
Romberg
+N/-AR L
Kyphosis inc.
Antalgic-left
Adams
Kemp’s Test + - ; Right side
dec.
thoracic
C L
dec
Left side
E
L
Lbp R L
LBP R / L
Lp
LP
R L
✓C
L
Minors Sign P A
R/L
N/A
Dejerine Triad + - C T L
P
M
Lordosis inc.
lumbar list
N/A
N/A
Range of Motion Pain Grades — 1: mild, 2: moderate, 3: severe, 4: very severe, S = Sharp, D = Dull
Cervical Active
Flexion
1
Extension
1
Lat. Flex (R) 1
(L) 1
Rotation (R) 1
(L) 1
SEATED
2
2
2
2
2
2
3
3
3
3
3
3
4:
4:
4:
4:
4:
4:
Loc. of Pain
/45
/30
/40
/40
/80
/80
S/D
S/D
S/D
S/D
S/D
S/D
A
S
N/A
EENT: NAF
HEART: NAF
LUNGS: NAF
ABDOMEN: NAF
N/A
Cervical Passive Loc. of Pain
Lumbar Active
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
4:
4:
4:
4:
4:
4:
/45
/30
/40
/40
/80
/80
N/A
S/D
S/D
S/D
S/D
S/D
S/D
Bechterew’s + - Lbp. Lp. R L RX LX
Cervical Compression + - R L (LOP)
Cervical Distraction-Pain Inc. Pain Dec.
Barre-Leiou Sign + - R
L
N/A
2
2
2
2
2
2
3
3
3
3
3
3
4
4
4
4
4
4
Loc. of Paiv
20 /90 RtLB/leg
0 /30 RtLB/leg
0 /20 RtLB/leg
20 /20
30 /30
30 /30
Allen’s Test
Wright’s Test
Adson’s Test
Costoclavicular Test
+
+
+
+
S/D
S/D
S/D
S/D
S/D
S/D
-
R
R
R
R
N/A
REFLEXES (Wexler Scale)
Biceps
Triceps
(C5.6) R
(C7) R
L
NL/A
Radial (C5.6) R NL/A
Patellar (L4)
R+ L+
2
2
2 L +2
NL/A
Ankle (S1.2) R +
Babinski
R
Other
R
N/LA
L
L
L
L
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SENSORY (Level of Dermatome)
increased
N/A
Upper: R
Lower: R
DYNAMOMETER-Rt
decreased
L
L
/
R
R
N/A/
Lt
L
S1 calf L5
L
/
PREFERRED SIDE
/
R
L
CRANIAL NERVES
I
II
normal
III
IV
V
VI
X
Abnormal
VII
VIII
IX
X
XI
E
L
MENSURATION
Short Leg
Thigh
R
R
L
L
Calf
Arm
Straight Leg Raise + - R
Bragard’s Test
30 oL
oLbp. Lp. Milgram’s Test
+ - R L
Gaenslen’s Test
Localized Spinal Tenderness:
N/A
REMARKS:
L
+ - R L
+ - R L Soto Hall/Lindners/Brudzinsky + - R L
- R L
Lower Extremity Pulses: NAF
PERCUSSION
N/A
C- 1 2 3 4 5 6 7
L- 1 2 3 4 5
T- 1 2 3 4 5 6 7 8 9 10 11 12 SI - Rt. Lt.
Rt. Lumbo sacral- sciatic notch
Nachaias Test + - LS SI R
Yeomans Test + - R
L- 1 2 3 4 5
SI- Rt. Lt.
R
+ - LBP LP Febere-Patrick Test
PALPATION
C- 1 2 3 4 5 6 7
T- 1 2 3 4 5 6 7 8 9 10 11 12
Muscle Pain Areas:
Forearm
oL60 oLbp. Lp. Sign of the Buttock +
A
S
Well Leg Raise Test + - R
PRONE
N/A LL
R
R
P
M
SUPINE
XII
L
L
Ely’s Test + - R L LS SI HIP FEMORAL FLEXION-CONTRACTURE
Mennell’s Test +
Patient in extreme pain.
-
LS SI R
L
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SPECIALTY TESTS
FOOT
SHOULDER
A
/
N
WRIST
Ant. Foot Draw Sign + - R L Drop Arm (Cozens)
+-RL
Bracelet Test + - R L
A
/
N
+-RL
Phalen’s Test + - R L
+-RL
Tinel’s Test
Metatarsal Test
+ - R L Dawbarn’s Sign
Abduction Stress Test + - R L Yergason’s Test
N/A
+-RL
Adduction Stress Test + - R L Shoulder Compression Test + - R L
Supraspinatur Press Test
E
L
+-RL
KNEE
COMPENSATORY PAIN
Libmans
Ant. Drawer
+ - R L
ELBOW
Post. Drawer
+ - R L
Cozen’s Test
+ - R L
Mill’s Test
+ - R L
Tinel’s Test
Apley’s Test
A
/
N
McMurray’s Test
+ - R L
Adduction Stress
+ - R L
Patellar Tap
+ - R L
OTHER
Burn’s Bench
P
M
A
S
Abduction Stress
A
/
N
L N H
A
/
N
+ -
+ - R L Mannkopf’s
+ -
+ - R L Flip Test
+ -
+ - R L Axial Loading
+ -
MUSCLE STRENGTH 5: normal, 4: good, 3: fair, 2: poor, 1: trace, 0: no contraction
CERVICAL SPINE
LUMBAR SPINE
UPPER EXTREMITIES R
Flexion
Extension
Lat. Flex (R)
(L)
Rotation (R)
(L)
Flexion
Extension
Lat. Flex (R)
(L)
Rotation (R)
(L)
Deltoid
(C5)
Biceps
(C6)
Triceps
(C7)
Wrist Ext. (C6)
Flex. (C7)
Finger Ext.(C7)
Flex. (C8)
Abd. (T1)
A
/
N
N
/A
A
/
N
L
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MUSCLE STRENGTH
LOWER EXTREMITIES
R L
HIP Flexors
(L1,2,3)
Extension (L4,5)
Abductors (L5)
Adductors (L2,3,4)
5
5
5
5
5
5
5
5
KNEE Flexors (L5,S1)
Extensors (L2,3,4)
FOOT Dorsi Flex.(L4,5)
Plantar Flex. (S1)
R
L
R
L
5
5
4
5
5
5
5
5
4
Exertion (L5,S1) 5
GR. TOE Dorsi Flex (L5) 3
Plantar Flex. (S1) 5
5
5
E
L
JOINT ROM:
rt.
lt.
Flexion
1 2 3 4:
/
Extension
1 2 3 4:
/
Abduction
1 2 3 4:
/
Adduction
1 2 3 4:
/
Ext. Rot.
1 2 3 4:
/
Int. Rot.
1 2 3 4:
/
rt.
FOOT Inversion
lt.
rt.
P
M
A
S
1 2 3 4:
/
1 2 3 4:
/
1 2 3 4:
(L4)
lt.
1 2 3 4:
/
1 2 3 4:
/
/
1 2 3 4:
/
1 2 3 4:
/
1 2 3 4:
/
1 2 3 4:
/
1 2 3 4:
/
1 2 3 4:
/
1-4-93
Office
FACILITY
X-RAY DIAGNOSIS Negative for Fx or path; marked disc space
narrowing L5/S1- otherwise unremarkable
X-RAY: DATE
1 2 3 4:
VIEWS
5
5
/
Lumbar; A/L/O
DIAGNOSIS
1.
2.
Rt L5 radiculitis
Rt. L5/5 disc herniation
3.
4.
Legend
R or Rt. ..........right
L or Lt. ..........left
N ....................normal/neutral
C ....................cervical
L ....................lumbar
T ....................thoracic
(+) ............positive
(-) ............negative
LBP ..........low back pain
LP ............leg pain
S/D ............sharp or dull pain
NAF ..........no abnormal findings
RX ............right crossed leg straight leg raise
LX ............left crossed straight leg raise
LOP ..........location of pain
LS ............lumbosacral
SI ..............sacroiliac joint
Sample Form
Instructions
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Print
Table of Contents
REGIONAL EXAM FORM –
CERVICAL/ DORSAL
1
PATIENT NAME
Ht
5’ 4”
BP
126/80
Wt
Rt
Auscultation
Heart
Head/Neck
Observation
Scars
Antalgia
Range of Motion
Active
Passive
Reflexes
Muscle Strength
Sensation
Palpation
Spine
Paraspinal muscles
Trapezius
Levator scapulae
Rhomboideus
Shoulder Rotators
Adrian Myers
130
98.6
#T
Lt
✓
FILE #
0000
DATE
oF P
78
bpm R
SYSTEMS REVIEW
HEENT
Lungs
Abdomen
Genital/Hernia
Rectal
cpm
negative
position VAS
History: Patient has been experiencing headaches on and off for about 10 yrs. Becoming more frequent and painful,
not always responsive to OTC medication. Does not like to take RX. Uses hot tub baths which relieve neck
stiffness and headaches. Past history unremarkable, except for minor auto accident 12 years ago, which did not
require treatment.
(S) headaches local to upper neck and back of head with pain radiating over the head to the front of the forehead.
Feels her “eyes might pop out.”neck is always stiff and many nights has difficulty sleeping.
(O) mildly limited cervical range of motion with mild stiffness all planes. Normal DTR upper, sensation and motor
power WNL, blood pressure normal, neg vertebral artery screen, digital palpation demonstrated considerable deep
cervical muscle spasm, and tenderness in the upper trapezias muscle. Exquisite tenderness was elicited around the
superior/medial scapular angle and multiple muscular trigger points were found in the cervical, upper trap, and
medial scapular muscles. Motion palpation revealed bilateral articular fixations localized to the upper to middle cervical
spine bilateral, more pronounced on the right at the C-2-3 level.
DX: 1. chronic cervicogenic headache, 2. chronic cervicodorsal sprain/strain.
(A-P) X-rays taken: explained films and correlated symptoms with abnormal residual healing of soft tissue. Told
patient we would approach conservatively for 2-4 weeks to determine progress and if no change will suggest
neurological consult, MRI, EEG, vision examination. Patient understood the logic of the approach we were using and
approved of the plan. She was shown videos on chiropractic, given brochure as report of findings outlining the early
DJD evidenced on her films. Was told what the adjustment would be as well as any reactions which she might
experience.Patient agreed. Will use ultrasound to relax cervical and dorsal musculature, hot moist packs and soft
tissue manipulation for the first visit along with trigger point grading. Will use osseous adjustment 2-3 visit.
1/5/93 Adrian felt much better following yesterday’s treatment.Manipulated C-2-3 with diversified cervical
move, used ultrasound, and trigger point.
(Fri.)
1/8/93 had a slight headache but significantly less painful than previous. Neck is less stiff and she is sleeping
better. Diversified cervical move C-2-3 and moist heat applications with trigger point goading.
(Mon.)
1/11/93 had a great weekend, Neck stiffness considerably less, muscles are less spasmed. Patient taking no OTC
medication. Cervical and dorsal manipulation, C-2-3-4 and T-4-5-6, moist heat.
(wk)
E
L
P
M
A
S
Orthopedics
Cervical Compression
Neutral
Lateral flexion
Rotational
Hyperextension
Cervical Distraction
Adson’s
Shoulder Depression
Abbot-Saunders
Costo-clavicular
Soto-Hall
January 4, 0000
1 Form reproduced courtesy of the National College of Chiropractic, Lombard, Illinois
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REGIONAL EXAM FORM –
LUMBAR/PELVIS
1
PATIENT NAME:
HT
BP
5’ 11”
130/82
WT
Rt
SEATED
Reflexes
Bechterew’s
Valsalva
Kemp’s
STANDING
Observation
Scars
Antalgia
Trunk Range Motion
Adams
Supported Adams
SI Motion
Gait
Heel/ Toe Walk
SUPINE
Abdomen
Observation
Auscultation
Percussion
Palpation
Muscle Strength
Sensation
Orthopedics
Straight Leg Raise
Bragard’s
Popliteal Compression
Medical Hip Rotation
Fabere’s
Gaenslen’s
Illiac Compression
Rich Morris
190
FILE #
DATE
oF P
#T
Lt
position VAS
January 4, 0000
bpm R
cpm
negative
1/4/93 Patient woke in severe pain this morning and could not get out of bed without assistance. His lower back had
felt “tight and bruised after he helped another worker lift a truck tire/wheel. He did not report the incident
immediately, felt some distress but continued to work.
(S) Patient points to his lower right lumbo-sacral region and the right leg and lateral calf as the part which hurts.
The pain begins in the gluteal area and extends into the postero-lateral thigh and lateral calf. Low back pain is
described as “dull” “pulling,””deep achiness,” unable to sit, stand, lie, bend for any length of time. Coughing
increases pain and bowels have not moved since yesterday, which he describes as unusual.
(O) lumbar ROM’s limited and painful, flex, extend, rt. lat, flexion, lt. rotation and extension.
DTR, sensation with pinwheel, and gross functional motor power all WNL. Patient exhibits a pronounced antalgic lean
to the left, with visible paraspinal spasm right gluteal and lumbar area. Bechterew’s pos Right Leg. SLR pos
bilaterally 45o with pain. Unable to stand on right leg, unable to heel or toe walk, motion palpation difficult to
perform. X-rays taken Erect AP-Lat-Lumbar, A-P Pelvis, revealed mild DJD L-5S-1 with retrolisthesis and
increased lumbosacral angle L-4, S-1, transitional segment at S-1/lumbarization.
DX: 1. acute right lumbosacral IVD syndrome with attending sciatic neuralgia,
2. possible HNP at L-5, S-1 on right, 3. muscle spasm.
(A-P) contact employer immediately and report injury, indicate that Mr. Morris may be disabled for 3-6 weeks
conservatively, and longer if surgical intervention is necessary. Explained condition to Mr. Morris and his wife, told
them of options of care. Will treat for 2-4 weeks conservatively and then will determine if MRI, or surgical consult
is warranted, depending on response. Will use specific spinal manipulation of L-4-5 S-1 with flexion distraction and ice
application. Gave patient ice pack for home use, limit home activities non-weight bearing. Showed patient and wife,
video, and gave written booklet as report of findings. Patient had no questions and treatment will begin. Told patient if
at any time pain should increase or if he would develop foot drop, bowel or bladder problems, he should call me
immediately.
E
L
P
M
A
S
PRONE
Ely’s
Hibbs
Yeoman’s
Hyperextension
Murphy’s Punch
Palpation
SI Sacrum, Spine
Paraspinal Muscles
Gluteals, Piriformis
Quadratus Lumborum
Rectal
8765
SYSTEMS REVIEW
HEENT
Heart/Lungs
Genital/Hernia
1 Form reproduced courtesy of the National College of Chiropractic, Lombard, Illinois
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LABORATORY REQUEST SLIP
GUIDELINES
• The appropriate use of clinical laboratory procedures in chiropractic practice is for diagnosis,
screening and patient management.
Comment: Clinical laboratory tests are used by the practitioner to (1) aid in the diagnostic
process; (2) screen for early recognition of preventable health problems; and (3) monitor
patient progress and outcomes. It is appropriate to utilize clinical laboratory procedures for
other purposes (e.g., for defensive testing or economic gain).
• It is recommended that the practitioner who uses the services of a clinical laboratory should
be aware of the laboratory’s scope of services, recognition (licensure and accreditation), and
reputation.
• Laboratory procedures may be appropriate when the information available from the history,
clinical examination, and previous evaluation is considered insufficient to address the clinical
questions at hand.
Comment: The decision to order and/or perform a given test or procedure is made on the
assumption that the results will appreciably reduce the uncertainty surrounding a given
clinical question and significantly change the pre-test probability that the disorder is present.
• Documented results of special studies become a…part of the…file. this documentation should
include date of study, facility where performed, name of technician, name of interpreting
practitioner, and relevant findings.
BACKGROUND
The exhaustive attention given Clinical Laboratory considerations makes it particularly
important that doctors be aware of the various tests which may be helpful. This request slip
serves as a reminder of the variety of tests available as well as serving as a simple order form for
desired tests.
PRACTICE SUGGESTIONS
The doctor may find it helpful to take this form to a local printer and have it made into multicopy carbonless packets. Then the doctor can use the original to order the tests and the copy
can immediately go to the file. Upon review of the laboratory results, the reports should be
compared with the tests ordered to assure that all that were originally deemed necessary were
actually performed.
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LABORATORY PROCEDURES WHICH MAY BE USEFUL FOR SPINAL DISORDERS *
Caused/ Dysfunction
Mechanical
Compression fracture
Inflammatory
Infective:
TB of the spine
Other Infectious agents
Non-infective:
Rheumatoid arthritis
Tests
Serum alkaline phosphatase, Total Protein, Albumin,
Serum total calcium, Inorganic PO4
ESR or ECP, CBC
Urine and sputum cultures
ESR or CRP, CBC, Blood culture
Agglutination titers
ESR, CRP, Serum viscosity, Rheumatoid factor
(anti-IgG)
Ankylosing spondylitis
ESR or CRP, CBC, Alkaline phosphatase, HLA-B27
Nutritional Osteoporosis
Alkaline phosphatase, Calcium, Inorganic
PO4, Total protein, Albumin, BUN,
Creatinine, sTSH or FT4
Osteomalacia
CBC, BUN, Creatinine, Calcium, Inorganic PO4,
Alkaline phosphatase, Total protein, Albumin,
Vitamin D assay
Endocrine: Adrenal
Serum electrolytes, Urinary free cortisol
Parathyroid
Calcium, Inorganic PO4, Ionized calcium,
PtH assay, Alkaline phosphatase, Serum Chloride
(C1/PO4 ratio)
Other
Paget’s disease
Alkaline phosphatase, Calcium, Inorganic PO4,
Urinary hydroxyproline
Neoplastic
Multiple myeloma
Total protein, Albumin, CBC, Serum protein
electrophoresis, Urinary protein electrophoresis,
Uric acid, BUN, Creatinine, Immunoelectrophoresis, Urinary light chain typing
Metabolic
* This is only a guide and does not constitute a complete list.
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Alkaline phosphatase, Calcium, Inorganic PO4, Uric
acid, Acid phosphatase, Prostate specific antigen (PSA)
LDH, Serum protein electrophoresis, ESR
or CRP
Primary tumors
Visceral
Referred
Pain
Myocardial Infarction
Same as metastatic tumors
Total CK, CK and LDH isoenzymes
Posterior Peptic Ulcer
CBC, BUN, Stool occult blood test
Acute Pancreatitis
Glucose, Calcium serum and urine amylase, Serum
lipase, Serum trypsin
Chronic Pancreatitis
Glucose, Serum amylase, Serum lipase, Stool fat, Serum
bilirubin, Lundh test meal
Carcinoma of the Pancreas
Glucose, AST, Alkaline phosphatase,
T. bilirubin, GGT, Tumor marker assays, ESR
Cholecystitis
CBC, T. bilirubin, AST, Alkaline phosphatase,
Serum amylase
Pyelonephritis
Urinalysis, Urine culture, Colony count,
BUN and creatinine, CBC, ESR
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LABORATORY REQUEST SLIP
Joseph Wellner
Patient’s Name:
Please do the following:
Diagnosis
ASO Titre
HIV
Uric Acid
C-Reactive Protein
Hepatitis B Antigen
Blood Type & Rh
Monospot
Glucose
R.A. Test
HDL
Hemoglobin/Hematocrit
Bilirubin, Total
Iron/Iron Binding
Platelet
BUN
Potassium
Sed. Rate
Chlorides
PSA (Prostatic Specific Antigen)
Protime
CEA
Sodium
Cholesterol
T3
Creatinine
T4
Digoxin
T7 (includes T3 Uptake/T4)
Hemiglobin A,C
TSH
Coagulation Profile
Prothrombin Time
Partial Thromboplastin Time
Fibrinogen
Clot Retraction
Platelets
Comprehensive Metabolic Panel
Sodium
Potassium
Chloride
Glucose
BUN
Creatinine
Calcium
Protein, Total
Albumin
AST
Alkaline Phosphatase
Bilirubin, Total
X
Thyroid Profile
T3 Uptake
T4
T7
TSH
CBC
E
L
Pregnancy
Urinalysis
Throat Culture
P
M
A
S
Electrolyte Profile
Na
K
Chloride
CO2
X
X
Profiles Available
X
02/11/0000
Date
Hepatitic Function Panel
AST
Total Bilirubin
Direct Bilirubin
Albumin
Alkaline Phosphatase
ALT
Care 2 (Lipid Profile)
Cholesterol
HDL
Triglyceride
LDL
VLDL
Cardiac Panel
SGOT
CPK
CK-MB if necessary)
LDH
Osteoporosis Profile
Ca
P
Alk.Phos.
T. Protein
Albumin
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Urine Culture
Other
Prenatal Profile
CBC
Type & Rh
Antibody Screen
RPR
Rubella Titer
Renal Profile
Ca
Uric Acid
Phosphorus
Creatinine
BUN/Creatinine Ratio
Na
K
Chloride
CO2
Arthritis Profile
ASO
RA
C-Reactive Protein
Uric Acid
SED Rate
CHEM 7 Basic Metabolic Panel
Na
K
CI
CO2
Glucose
BUN
Creatinine
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PREGNANCY WARNING AND CONSENT TO X-RAY
GUIDELINES
The following precautions should be taken…Completion and signature of standard forms by
every pre-menopausal patient prior to radiographic examination on the pelvic region. Forms
must include an express inquiry about the patient’s pregnancy status.
Genetic and somatic damage to the embryo following radiation exposure during the first
trimester of pregnancy is well documented.
BACKGROUND
Malpractice Implications. If a patient gives birth to a less than perfect baby after being Xrayed during pregnancy, she may, right or wrong, blame the defect upon the X-ray.
OBJECTIVES
This completed form will be a critical element in demonstrating that the doctor took all
reasonable precautions to identify a potential pregnancy.
Use of this form documents that the patient was advised of the risks of X-ray during pregnancy
and that the doctor sought information for his independent assessment of the likelihood of
pregnancy.
The specificity of obtaining the date of onset of last menses is intended to show more detailed
analysis than a simple inquiry: “Are you, or may you be, pregnant?”
The patient whose cycle is irregular may consider her recent failure to have a period normal —
when in fact she could be pregnant. Having the date, the doctor can conduct a more exhaustive
discussion with the patient if there is an unusually long interval between menses.
APPLICATION
This form should be used with all post-pubescent, pre-menopausal women who are to receive
X-rays of the pelvic area.
FREQUENCY
Each female patient should fill out this form prior to any radiographic procedure of the pelvic
area.
>>
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PRACTICE SUGGESTIONS
Use of any form to elicit this information is difficult when the patient is unmarried. If a teenaged
girl who has been sexually active is “late” with her menses, she is unlikely to provide accurate
information on a form she fills out while sitting next to her mother.
With minor females, the doctor must arrange an opportunity to discuss the possibility of
pregnancy out of the hearing of parents and, if possible, apart from any third party except the
D.C.’s employees. (The wife of a post-vasectomy husband may not be candid in her spouse’s
hearing if she fears a pregnancy.) Doctors should institute a “check-off ” system on the form to
confirm that the answers were verified in private.
Patients should be required to answer all questions. Simply marking “no” beside “I am
pregnant” and returning the form is unacceptable.
The CA who collects this form should affix a “Do Not X-ray Without Doctor Approval” label
on the patient file of any patient with a “yes” answer to any of the first three questions, or whose
last menstrual period began more than ten days earlier.
>>
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PREGNANCY WARNING AND CONSENT TO X-RAY
PATIENT NAME:
Elizabeth Molen
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Today’s date is:
January 4, 0000
I understand that if I am pregnant and have X-rays taken which expose my lower torso to
radiation, it is possible to injure the fetus.
E
L
I have been advised that the 10 days following onset of a menstrual period are generally
considered to be safe for X-ray exams.
With those factors in mind, I am advising my doctor that:
P
M
Yes
I am pregnant
I could be pregnant
I am late with my menstrual
period
A
S
I am taking oral contraceptives
I have an IUD
No
X
X
X
X
X
I have had a hysterectomy
X
X
I have irregular menstrual
periods
X
I have had a tubal ligation
My last menstrual period began on:
December 28, 0000
An X-ray may be performed on me with my consent.
Witness:
Joseph Molen
Signature
Don’t know
Signature
Elizabeth Molen
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IMAGING REQUEST SLIP
GUIDELINES
The decision on whether or not to use diagnostic imaging studies is made following a carefully
performed history, physical and regional evaluation, and consideration of cost/benefit/radiation
exposure ratios. It is based on…the likelihood that significant information can be obtained from
the study in regards to diagnosis, prognosis and therapy.The decision remains solely the domain
of the examining (primary) practitioner.
BACKGROUND
Doctors exercising their clinical judgement in utilizing sophisticated imaging studies such as
MRI, CT Scans, Doppler Ultra Sound and other tests should properly inform their patients of
the procedure. Preparation in advance will greatly aid the process and provide assurance to the
patient that the doctor is familiar with the testing procedures. Alerting the patient that “if they
are claustrophic” they may require medication to calm them when they are placed into the MRI
scanning tube. Providing the laboratory with a complete request sheet indicating any items
which may pose a problem such as implants, metallic screws, pins, implants and the like will
make the procedure go much more smoothly and provide the laboratory with the necessary
information to facilitate the procedure. Providing a history, examination findings, and brief
commentary will not only enhance the ability of the laboratory technician to perform the test,
but alert the radiologist, neuro-radiologist, or physician of your clinical impression and rationale
of why the testing is being ordered.
PRACTICE SUGGESTIONS
• Doctors who do not maintain independent radiographic capability can use the appropriate
forms to order X-rays, MRI, CT, or Diagnostic ultrasound testing from another facility.
• Doctors performing X-rays “in house” still need to inform the technician, if one is utilized, of
the views desired and may use the same form. Even if the doctor is the individual who takes
the films, the form should be used to memorialize that the actual views taken were those that
were felt to be clinically necessary.
• Using the forms that follow will also avoid the appearance that all patients are subjected to the
same radiographic or diagnostic testing regardless of entering complaints, examination
findings or history. The ordering of tests should be on an individual basis and not a pre-set
“car wreck” series for example.
• The doctor may find it helpful to take these forms to the local printer and have them made
into multi-copy carbonless packets. Then the doctor can order the tests and a copy can
immediately go to the file, while the original goes with the patient to the facility. Upon review
of the films, the views taken should be compared with those ordered to assure that all that were
originally deemed necessary were actually taken.
>>
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IMAGING REQUEST SLIP
CARBONLESS FORMS SUGGESTED
Patient Name:
Elizabeth Molen
Case #
Date: January 4, 0000
1234
PLEASE STOP AT THE OUT-PATIENT WINDOW BEFORE GOING TO THE X-RAY DEPARTMENT
SPINAL STUDIES:
CERVICAL SPINE:
Cervical—AP, lateral, flexion and extension
Cervical—AP, lateral and rt. & lt. obliques
Cervical—AP, lateral, open mouth
Cervical—9 views–Davis series and lateral
flexion views
Cervico-thoracic—AP and lateral 14 x 17
of cervical and upper thoracic
DORSAL SPINE:
Thoracic spine—AP and lateral
Thoracic spine—AP, lateral and “swim view”
Thoraco-lumbar spine—AP and lateral
LUMBAR SPINE:
Lumbar spine—AP and lateral
Lumbar spine—AP, lateral and both obliques
Lumbar spine—AP, lateral, both obliques &
spot view of L-5
PELVIS AND HIPS:
AP Pelvis only
AP and frog pelvis
Sacrum
Sacrum and coccyx
RIB CAGE:
Bilateral rib study (includes Pa chest)
Bilateral rib study (without Pa chest)
Sternum
X
EXTREMITIES:
Ankle—AP, lateral and oblique
Ankle—AP, lateral, oblique and lateral
stress views for ligamentous stability
Clavicle—PA and axial views
Elbow—routine includes AP, lateral
and both obliques
Fingers—includes AP, lateral and
obliques of the involved finger
Foot—AP, lateral and oblique
Foot—lateral weight bearing of Right
Left
Foot—views of the calcaneus only
Forearm—AP and lateral
Hand—PA, oblique and lateral
Humerus—AP and lateral
Knee—AP and lateral
Knee—AP, lateral and tunnel
Knee—AP, lateral and lateral stress
studies for ligamentous instability
Knee—AP standing views of both knees
Shoulder—AP internal and
External rotation views
Shoulder-—AP internal and external and baby arm
Thigh (Femur)—AP and lateral
Tibia and Fibula—AP and lateral
Wrist—PA, lateral and oblique
SKULL VIEWS:
Skull series
Sinus series
Temporomandibular joints
CHEST STUDIES:
Chest—PA Only
Chest—PA and lateral
FULL SPINE:
14 x 36—AP full spine postural film
14 x 36—lateral full spine postural film
UPPER GI
LOWER GI
GALL BLADDER STUDY
E
L
P
M
X
A
S
Patient fell om sidewalk
hitting head and low back. R/O
fracture L4-L5 lumbar
INFORMATION:
SPECIAL STUDIES:
Please give patient special instructions for
study.
Please send copies of film and report
Please send report only
X
Send Report to:
Occasionally there will be an emergency or
scheduled inpatient procedure which may
necessitate your waiting. If this occurs your
patience will be appreciated.
Dr. Richard Roe
Practice of Chiropractic
Roe Chiropractic Office
18 Water Street
Anytown, State 99999
(555) 123-4567
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MRI HISTORY SHEET
GUIDELINES
The decision on whether or not to use diagnostic imaging studies is made following a carefully
performed history, physical and regional evaluation, and consideration of cost/benefit/radiation
exposure ratios. It is based on…the likelihood that significant information can be obtained from
the study in regards to diagnosis, prognosis and therapy.The decision remains solely the domain
of the examining (primary) practitioner.
BACKGROUND
Doctors exercising their clinical judgement in utilizing sophisticated imaging studies such as
MRI, CT Scans, Doppler Ultra Sound and other tests should properly inform their patients of
the procedure. Preparation in advance will greatly aid the process and provide assurance to the
patient that the doctor is familiar with the testing procedures. Alerting the patient that “if they
are claustrophic” they may require medication to calm them when they are placed into the MRI
scanning tube. Providing the laboratory with a complete request sheet indicating any items
which may pose a problem such as implants, metallic screws, pins, implants and the like will
make the procedure go much more smoothly and provide the laboratory with the necessary
information to facilitate the procedure. Providing a history, examination findings, and brief
commentary will not only enhance the ability of the laboratory technician to perform the test,
but alert the radiologist, neuro-radiologist, or physician of your clinical impression and rationale
of why the testing is being ordered.
PRACTICE SUGGESTIONS
• Doctors who do not maintain independent radiographic capability can use the appropriate
forms to order X-rays, MRI, CT, or Diagnostic ultrasound testing from another facility.
• Doctors performing X-rays “in house” still need to inform the technician, if one is utilized, of
the views desired and may use the same form. Even if the doctor is the individual who takes
the films, the form should be used to memorialize that the actual views taken were those that
were felt to be clinically necessary.
• Using the forms that follow will also avoid the appearance that all patients are subjected to the
same radiographic or diagnostic testing regardless of entering complaints, examination
findings or history. The ordering of tests should be on an individual basis and not a pre-set
“car wreck” series for example.
• The doctor may find it helpful to take these forms to the local printer and have them made
into multi-copy carbonless packets. Then the doctor can order the tests and a copy can
immediately go to the file, while the original goes with the patient to the facility. Upon review
of the films, the views taken should be compared with those ordered to assure that all that were
originally deemed necessary were actually taken.
>>
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MRI HISTORY SHEET
2/1/0000
Joe Klotz
1444 Winding Road
Dansville,
STATE
DATE:
NAME:
ADDRESS:
CITY:
TX
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
11462
ZIP
555-444-3121
PHONE:
D.O.B 10/16/40
WT. 208
HT. 5’ 10’
Blue Cross
Dr. Sam Sledge
REF. PHYSICIAN:
INSURANCE
R/O
HNP-C-5-6
MRI
of
cervical
spine
EXAM:
INDICATION
PREVIOUS SURGERY:
HEAD (ANEURYSM CLIPS)
CHEST (PACER)
ABDOMEN/ PELVIS
Hernia, 1995
OTHER
P
M
YES
DATE:
DATE:
DATE:
ARE YOU PREGNANT? NO X YES
HAVE YOU EVER BEEN A WELDER OR SHEET METAL WORKER? NO
HAVE YOU EVER HAD METAL REMOVED FROM YOUR EYES?
NO
A
S
X
E
L
PREVIOUS MRI/ CT/ X-RAY/ NUCLEAR MED OR MYELOGRAM? NO
WHEN?
WHERE?
YES
YES
X
X
DO YOU HAVE ANY OF THE FOLLOWING? PLACE AN “✗” WHERE APPROPRIATE
X
CARDIAC PACEMAKER
AORTIC CLIPS
NEUROSTIMULATOR (Tens units)
HEART VALVE
ELECTRODES
SHUNT
HARRINGTON RODS
PROSTHESIS (Joint, Orbital, Staples)
ROOT CANAL
METALLIC FILINGS (Welding, etc)
PLATES OR MESH
COCHLEAR IMPLANTS
OTHER
X
BRAIN CLIPS
CAROTID CLIPS
INSULIN PUMP
I.U.D.
JOINT REPLACEMENT
WIRE SUTURES
DENTURES
SHRAPNEL
METALLIC IMPLANTS
PINS/ SCREWS/ NAILS
GREENFIELD FILTER
GUN SHOT WOUND
OTHER
I have answered the above questions to the best of my knowledge. I hereby give consent to
perform an MRI (Magnetic Resonance Imaging) study on myself. I understand, that if I am
pregnant, there may be risks to my unborn fetus from this type of study that are, at this time
unknown. All of my questions concerning this examination have been answered.
Signature of Patient:
Witnessed by:
Joe Klotz
Emma Jean Smith
Date:
2/1/0000
Date:
2/1/0000
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REQUEST FOR CEREBROVASCULAR
ULTRASOUND
GUIDELINES
The decision on whether or not to use diagnostic imaging studies is made following a carefully
performed history, physical and regional evaluation, and consideration of cost/benefit/radiation
exposure ratios. It is based on…the likelihood that significant information can be obtained from
the study in regards to diagnosis, prognosis and therapy.The decision remains solely the domain
of the examining (primary) practitioner.
BACKGROUND
Doctors exercising their clinical judgement in utilizing sophisticated imaging studies such as
MRI, CT Scans, Doppler Ultra Sound and other tests should properly inform their patients of
the procedure. Preparation in advance will greatly aid the process and provide assurance to the
patient that the doctor is familiar with the testing procedures. Alerting the patient that “if they
are claustrophic” they may require medication to calm them when they are placed into the MRI
scanning tube. Providing the laboratory with a complete request sheet indicating any items
which may pose a problem such as implants, metallic screws, pins, implants and the like will
make the procedure go much more smoothly and provide the laboratory with the necessary
information to facilitate the procedure. Providing a history, examination findings, and brief
commentary will not only enhance the ability of the laboratory technician to perform the test,
but alert the radiologist, neuro-radiologist, or physician of your clinical impression and rationale
of why the testing is being ordered.
PRACTICE SUGGESTIONS
• Doctors who do not maintain independent radiographic capability can use the appropriate
forms to order X-rays, MRI, CT, or Diagnostic ultrasound testing from another facility.
• Doctors performing X-rays “in house” still need to inform the technician, if one is utilized, of
the views desired and may use the same form. Even if the doctor is the individual who takes
the films, the form should be used to memorialize that the actual views taken were those that
were felt to be clinically necessary.
• Using the forms that follow will also avoid the appearance that all patients are subjected to the
same radiographic or diagnostic testing regardless of entering complaints, examination
findings or history. The ordering of tests should be on an individual basis and not a pre-set
“car wreck” series for example.
• The doctor may find it helpful to take these forms to the local printer and have them made
into multi-copy carbonless packets. Then the doctor can order the tests and a copy can
immediately go to the file, while the original goes with the patient to the facility. Upon review
of the films, the views taken should be compared with those ordered to assure that all that were
originally deemed necessary were actually taken.
>>
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REQUEST FOR CEREBROVASCULAR
ULTRASOUND
Mary Jo Bennet
Name
66 Winding Way
Address
D.O.B
10/18/53
B/P
128/80
Previous Stroke/ TIA
Memory Loss
Headaches
Visual
Paresis
A
S
X
Diabetes
Claudication
Pain
Prior Studies
None
X
Zip
Dizziness
E
L
Lt. Hemisphere
Numbness
X
Hypertension
Tingling
Prior Surgery
None
Medications
B/P Medication
Comments
Symptomatology progressively
44466
Dr. Janet Pope
P
M
X
TN
Physician Phone No.
Rt. Hemisphere
Weakness
2/4/0000
Date
State
Referring Physician
History
Aphasia
Boetemp
City
Dr. Benjamin Peel
Family Physician
46
Age
worsening R/O carotid blockage
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Vertigo
X
Other
555-163-4217
Other
X
X
MI
Syncope
Smoking
X
X
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IMAGING INTERPRETATION
GUIDELINE
• Imaging studies are performed primarily to contribute to a diagnostic impression.
Interpretation of each imaging study should be documented in the patient’s permanent record.
• Unique radiology reports are generated for each study. The use of checklist forms is not
supported.
• Full-spine Radiography. Is established for scoliosis evaluation where indicated by clinical
examination. Promising for evaluation of complex bio-mechanical or postural disorders and the
evaluation of multi-level spinal complaints as a result of biomechanical compensation.
• The necessary components of a formal written radiology report…include patient
identification, location where studies were performed, study dates, types of studies, radiographic
findings, diagnostic impressions, and signature with professional qualifications.
OBJECTIVES
1. To provide demonstrable evidence of clinical findings to confirm the working diagnosis.
2. To facilitate providing meaningful records for consultations, referrals and subsequent
treating doctors.
3. To facilitate providing meaningful records to the patient’s lawyer when litigation is
involved.
4. To allow associates, and temporary doctors to have full information for treating in the
doctor’s absence.
5.To provide improved response to third party requests for data, as well as aiding in replying
to requests from reviewers to provide additional information.
6. To document diagnostic impressions for future use including defense of malpractice
claims and furnishing same to successors and other professionals.
PRACTICE SUGGESTIONS
•
•
•
•
•
Attach to narrative report to patient’s lawyer
Present to patient along with report of findings
Attach to insurance company request for additional data
Consideration should be given to sending films to a specialist in radiology when warranted
Assist in avoiding misdiagnosis
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IMAGING INTERPRETATION
John Smith
PATIENT NAME:
Age
Acute low back pain from lifting. R/O Disc Herniation
32
Sex
Male
Type and Date of Study:
9865
MRI Center of Anytown
Facility Where Studies Performed:
History:
Case #
Doctor:
MRI of Lumbosacral spine
10/20/0000
E
L
(XYZ Radiologist)
P
M
FINDINGS:
The conus medularis is normal in appearance and location at the L-1 Level. There is satisfactory alignment of the
lumbosacral spine with maintenance of the vertebral body and IVD heights. There is a minimal degree of disc
protrusion lateral to the left at the level of L-3-4. No other lumbar disc protrusions are identified. No spinal
stenosis is identified. No significant facet joint disease is identified.
A
S
DIAGNOSTIC IMPRESSIONS
1. MRI of lumbosacral spine demonstrates minimal left lateral disc protrusion at L–3, L-4 level.
(XYZ Radiologist)
Signature
Professional Qualifications:
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REPORT WRITING CHECKLIST
GUIDELINES
Information for reports comes from patient records. Adequate reporting usually requires the
practitioner to review the patient’s history, examination findings, diagnosis, treatment
procedures, progress notes/work chart and other reports that may have been written together
with records from other health care providers that have treated or evaluated the patient.
BACKGROUND
The treating physician’s narrative report can be the patient’s lawyer’s most valuable tool in
seeking to settle an injury claim. The patient claim and the doctor’s utility as an expert witness
are initially contingent upon well written reports.
OBJECTIVE
The following checklist is intended to serve as a reminder of the elements the doctor must
consider when seeking to produce an accurate, comprehensive report. Information for each of
the categories listed is available on forms from this text and correspondence which should be
maintained in the patient file.
PRACTICE SUGGESTIONS
Among the items in the following checklist is a reminder to refer to any “non-compliance”
letters which have been sent to the patient. The doctor can do his patient, the lawyer and
perhaps himself a service by alerting the lawyer to non-compliance before sending a written
report. Once unfavorable information is provided in written form it may be “discoverable” and
can be harmful to the patient’s claim. The lawyer needs to be aware of his client’s arguable
failure to assist in his own recovery…but most would prefer to learn of it through a friendly
telephone call rather than by reading a narrative report.
Having afforded the lawyer that courtesy, however, the doctor cannot thereafter omit such
information from any written report which may be requested. Any report provided by the doctor
must be complete and accurate even if it divulges potentially unhelpful information.
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REPORT WRITING CHECKLIST
[ ] History
[ ] Examination findings
[ ] X-ray interpretation
[ ] Lab results
[ ] Diagnosis
[ ] Treatment procedures
[ ] Progress notes
[ ] Outcomes Assessment Forms
[ ] Correspondence from lawyers
[ ] Depositions
[ ] Activities of Daily Living (Positive)
[ ] Activities of Daily Living (Negative)
[ ] Exercise Monitor
[ ] Hazard Warning
[ ] Exercise follow-up
[ ]
Job description
[ ] Non-compliance letters
[ ]
Prognosis
[ ] Progress reports
[ ] Social history
[ ] Symptom list
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WARNING LABELS
BACKGROUND
X-rays are intended to serve a clinical function.They are of no benefit if they are taken and then
ignored. Too often the busy practitioner will take appropriate films, but then fail to review them
prior to treatment.
Equally harmful may be the situation in which the doctor does review the X-rays, but makes no
note to indicate that he has done so, or to indicate anything remarkable he may have found.
PRACTICE SUGGESTIONS
• The treating doctor should highlight important X-ray findings by affixing an appropriate
“X-ray Findings” label to each film indicating: “fracture,” “scoliosis,” “osteoporosis,” “spurs,”
“disc,” “degeneration,” or “surgical metal.” The staff person assigned the responsibility of filing,
hanging or otherwise storing the films must first examine each one in search of any labels.
• If a label is present, the CA must affix all appropriate “warning” labels to the patient file, travel
card or whatever other paperwork the doctor is certain to refer to when treating. After reviewing
the films for labels, the CA dates and initials the form.
• The second group of warning labels includes additional reminders of patient conditions.
These should also be affixed to the daily records. It is the responsibility of intake personnel to
review patient responses on questionnaires and to affix appropriate labels in a conspicuous
location. The examining/treating doctor, of course, may wish to add other cautions as the result
of his examination and X-ray findings.
• No patient information should be given out unless an authorization no older then ninety days
is on file. Consequently, each patient file should have the expiration date of the authorization
conspicuously posted so that information is not inadvertently given out improperly. The CA
taking an authorization should fill out the expiration date on the appropriate label and place it
on the file.
• Some lawyers will routinely have their clients revoke any prior authorizations when they sign
the lawyer’s form allowing him to obtain information. The staff person responsible for
responding to requests for information should check for revocations and if one is made, the
revocation label should be used.
• Another potential problem can occur when the radiographs which are taken are sub-optimal
or non-diagnostic in quality and the doctor does not retake the film and subsequently charges
for the procedure. Not only is this a potential problem from a clinical standpoint, it can
potentially result in a charge of fraudulent billing.
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I. X-RAY FINDINGS LABELS
(to place on X-ray)
Reviewed
(Date)
(Initials)
FRACTURE
SCOLIOSIS
OSTEOPOROSIS
SURGICAL METAL
SPURS
DISC DEGENERATION
PROTHESIS
CONGENITAL ANOMALY
II. WARNING LABELS
(to place on chart, “travel card,” or patient file folder to ensure that the doctor sees the
warning prior to treatment)
DO NOT ADJUST CERVICAL SPINE
DO NOT ADJUST THORACIC SPINE
DO NOT ADJUST LUMBAR SPINE
DO NOT X-RAY
VASCULAR
DISC
SPURS
ILLUSTRATIVE WARNING LABELS
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DIABETIC
OSTEOPOROTIC
OPEN CHEST SURGICAL PATIENT
HYPERTENSIVE PATIENT
SURGICAL METAL
PACEMAKER IMPLANT
PROSTHESIS
mm ANEURYSM PRESENT
AUTHORIZATION EXPIRES
AUTHORIZATION REVOKED
PREVIOUS RIB FRACTURE
PREVIOUS PELVIS FRACTURE
HIP REPLACEMENT
PREGNANT
APPLY HEAT ONLY WITH CAUTION
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CONSENT TO TREATMENT (MINOR)
GUIDELINES
• The treatment of minors requires the prior consent of a guardian.
• Radiographic examination of a minor requires the consent of a parent or legal guardian.
• Basic information identifying the practitioner or facility should appear on documents used to
establish the doctor-patient relationship. This can be pre-printed…Basic information should
include:
•
•
•
•
•
•
practitioner’s name/specialty
specialty designation (if applicable)
facility name (if different)
legal trade name (if applicable)
street address and mailing address (if different)
telephone number(s)
BACKGROUND
Written consent to treat a minor is always necessary prior to treatment. The age of majority
varies from state to state and may be modified by such factors as marriage and parenthood.
Doctors should check with their state association or legal counsel to assure compliance with
consent requirements in their respective states.
Today’s divorce statistics make it necessary that the doctor inquire as to the parent’s legal right
to select and authorize health care under the terms of the divorce or separation order.
OBJECTIVE
It is unlikely any measure will completely protect the physician if a non-custodial parent
wrongfully presents his child for treatment he does not have the legal right to authorize. Use of
this form manifests the doctor’s thoroughness and good faith.
PRACTICE SUGGESTIONS
Subsequent or repeated consents should not be necessary unless there is a new court order
under which the right to select health care is altered. This form anticipates that possibility by
urging the person granting consent to notify the doctor of such a change.
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CONSENT TO TREATMENT (MINOR)
PATIENT NAME:
Johnny Doe
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
E
L
I hereby request and authorize Dr. RICHARD ROE to perform diagnostic tests and render
chiropractic adjustments and other treatment to MY MINOR SON1: JOHNNY DOE. This
authorization also extends to all other doctors and office staff members and is intended to
include radiographic examination at the doctor’s discretion.
P
M
As of the date, I have the legal right to select and authorize health care services for the minor
child named above.
A
S
(If applicable) Under the terms and conditions of my divorce, separation or other legal
authorization, the consent of a spouse/ former spouse or other parent is not required. If my
authority to so select and authorize this care should be revoked or modified in any way, I
will immediately notify this office.
Date:
January 4, 0000
Jeffery Doe
Signature
Sally Deldman
Witness
Jeffery Doe
Printed Name
Father
Relationship to Patient
1 minor daughter/ward or other.
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INFORMED CONSENT
GUIDELINES
• When there is risk of significant harm from the treatment proposed, this risk must be
disclosed, understood and accepted by the patient. Such informed consent is required for
ethical and legal reasons. The best record of consent is one that is objectively documented (e.g.,
a witnessed written consent or videotape.)
• Basic information identifying the practitioner or facility should appear on documents used to
establish the doctor-patient relationship. This can be pre-printed on forms…Basic information
should include:
•
•
•
•
•
•
practitioner’s name/specialty
specialty designation (if applicable)
facility name (if different)
legal trade name (if applicable)
street address and mailing address (if different)
telephone number(s)
• A literature review of cerebro-vascular accidents will include the following potential
complications:
•
•
•
•
•
•
stroke or stoke-like conditions
Horner’s syndrome
diaphragmatic paralysis
cervical myelopathy
pathological fracture
cervical disc protrusions
•
•
•
•
•
cervical dislocation
costovertebral strains
rib fractures
costochondral separations
compression of the caudia equina
BACKGROUND
Despite the fact that a form may be useful — even essential — in protecting a doctor from a
patient who claims he was not informed of the risks of an adjustment or other treatment, a form
alone is not enough. Informed consent is a process, not just a form. A doctor must discuss the
informed consent elements with the patient, answer any questions and then have the form
signed to memorialize that process.
The essence of informed consent lies in the doctor’s securing the patient’s knowing and
intelligent agreement to undergo the treatment recommended. This indispensable legal
requirement is easily satisfied because patients are usually willing to comply with their doctors’
recommendations. A patient’s actual consent to a certain diagnostic or therapeutic procedure
may often be inferred from his having initially sought the doctor’s advice and treatment.
>>
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OBJECTIVE
This form is designed to “objectively document” that the informed consent process took place.
PRACTICE SUGGESTIONS
• Describe the procedures to be employed. To obtain informed consent, the physician must
outline in some detail what is to be done. This explanation of proposed procedures has
practical advantages besides satisfying legal requirements. A patient who understands the nature
of the treatment is less likely to be surprised by it. Particularly if any sudden change, movement,
or shock attends the treatment, the patient should be alerted to expect it. The well-informed
patient is likely to be more relaxed, comfortable, and cooperative. This type of psychological
preparation at the outset may prevent misunderstandings that can lead to dissatisfaction,
estrangement, and litigation.
• Disclose the risks of treatment. The key words to be emphasized in a discussion of risks
are material and inherent. A doctor has no obligation to disclose or discuss risks that are not
inherent (foreseeable, natural, related to) to the suggested procedure or to discuss other risks
that, inherent or not, are not material (sufficiently likely and significant) under applicable state
law. The rule leaves considerable room for subjective interpretation (and subsequent secondguessing) and its application affords a fruitful area for potential litigation.
• The greatest protection will be afforded by an exhaustive recitation of risks. Doctors failing
to warn patients of the risks mentioned in the Mercy guidelines do so at their peril.Your authors
have sought to include all necessary warnings in the informed consent form.
• The literature review, however, does refer to the conditions discussed as “rare” and “rarely reported
in the literature.” Doctors may certainly exercise their own clinical judgement in choosing to omit,
modify or add to any of the risks contained in the following informed consent form. They should
recognize, however, that each deletion from the informed consent form. They should recognize,
however, that each deletion from the informed consent form dilutes its protective capability.
• The harsh sounding warning necessary to adequately advise of risks may frighten some
patients. A professional demeanor and a properly prepared presentation, however, will greatly
add to the patient’s confidence level as he decides whether to undergo treatment. The doctor’s
attitude, image, reputation and confidence will significantly lessen the patient’s apprehension.
• It is important not only to place the “informed consent” process into its proper perspective,
but to assure that the dialogue takes place in a setting conducive to understanding and
communication between the patient (family)and doctor.
• Some states require a written informed consent verification — or afford additional protection
when written confirmation is employed. Consultation with legal counsel is necessary to insure
legal compliance and optimum use of statutory protections.
• The “comments” section on the last page of the “informed consent form” affords the doctor
the opportunity to individualize the form by memorializing any specific question the patient
may have asked and the response given. This section should be routinely used to note any
particulars which may serve to emphasize the thoroughness of the process and the
reasonableness of the doctor’s conclusion that the patient understood the information provided.
>>
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FREQUENCY
The initial informed consent should be obtained before undertaking diagnostic testing or
treatment. The process need not be repeated unless treatment is altered or a new, not previously
discussed diagnostic test is to be employed.
POTENTIAL DISADVANTAGES
• A patient may elect to forego treatment after learning of potential risks.
• A doctor may become complacent and rely exclusively upon the form to attempt to document
that he fully informed the patient. Failure to customize the informed consent process to
individual patients and to adequately discuss the risks may leave the doctor exposed to
malpractice attack even with a signed consent form.
• The form represents that the doctor uses procedures designed to screen potential
stroke candidates. Doctors who do not use such tests should delete that portion. The
authors advise most strongly, however, that practitioners use and document some
screening protocol.
INFORMED CONSENT
Doctors need to understand that informed consent is a process, which may or may not be
satisfied with a written form. It is the doctor’s responsibility to make sure that the patient is
properly informed, understands, and consents to the treatment to be provided; however, it is
also within the doctor’s discretion as to how the information is communicated and how the
consent is obtained.
Generally the legal concept of informed consent arises from the principle that, absent
extenuating circumstances, a patient has the right to exercise control over his or her body by
making an informed decision concerning whether to consent to a particular course of treatment.
The doctor has the duty to disclose to the patient all material risks involved in the procedure.
The patient, then, can truly make an informed, intelligent decision concerning his or her care.
Even though the principles stated above have been generally well accepted throughout the
country, specific state statues or state case law often further define the necessary elements to
establish informed consent. For example, some states, like Iowa, have a consent law. In Iowa, if
a health care provider satisfies the requirements of the statute, a presumption is raised that
informed consent was given.
Because of the possible peculiarities in any given state laws or statues, doctors of chiropractic
would be best served by contacting an attorney in their state who practices health care related
law and ask that person to advise the doctor regarding their particular practice. In this way, the
doctor will have the benefit of an attorney who should be current on the informed consent
issue in that state. The attorney can advise the doctor whether there are any specific informed
consent laws which might impact that doctor’s practice and whether use of an informed consent
form would be prudent.
>>
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From our experience, when doctors get sued for malpractice, oftentimes an allegation is made
that there was no informed consent given by the patient. Accordingly, it is important for doctors
to obtain informed consent and be certain to document in the records that the process of
informed consent took place. However, the information provided by the doctor and the consent
given by the patient must be specific to both the individual patient and the individual treatment
regimen. A single blanket informed consent form may not accomplish this purpose.
We have included several samples of informed consent forms which meet the criteria of
complying with all relevant information which a patient should know. The doctor should design
a form he is comfortable with and incorporate it into his practice procedure.
>>
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INFORMED CONSENT
PATIENT NAME: Michael Wellington Jr.
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
E
L
The primary treatment used by doctors of chiropractic is the spinal adjustment. I will use
that procedure to treat you.
P
M
• The nature of the chiropractic adjustment.
I will use my hands or a mechanical device upon your body in such a way as to move your
joints.That may cause an audible “pop” or “click,” much as you have experienced when you
“crack” your knuckles.You may feel or sense movement.
A
S
• The material risks inherent in chiropractic adjustment.
As with any health care procedure, there are certain complications which may arise during
a chiropractic adjustment. Those complications include: fractures, disc injuries,
dislocations, and muscle strain, Horner’s syndrome, diaphragmatic paralysis, cervical
myelopathy and costovertebral strains and separations. Some types of manipulation of the
neck have been associated with injuries to the arteries in the neck leading to or contributing
to serious complications including stroke. Some patients will feel some stiffness and
soreness following the first few days of treatment.
• The probability of those risks occurring.
Fractures are rare occurrences and generally result from some underlying weakness of the
bone which we check for during the taking of your history and during examination and Xray. Stroke has been the subject if tremendous disagreement within and without the
profession with one prominent authority1 saying that there is at most a one-in-a-million
chance of such an outcome. Since even that risk should be avoided if possible, we employ
tests in our examination which are designed to identify if you may be susceptible to that
kind of injury. The other complications are also generally described as “rare.”
1 Haldeman, Scott, D.C. M.D.
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• Ancillary treatment.
In addition to chiropractic adjustments, I intend to use the following treatments:
Ultrasound
Hot packs
These treatments involve the following additional significant risks:
None
None
E
L
• The availability and nature of other treatment options.
Other treatment options for your condition include:
P
M
• Self-administered, over-the-counter analgesics and rest
• Medical care with prescription drugs such as anti-inflammatory, muscle relaxants and
pain-killers
• Hospitalization with traction
• Surgery
A
S
• The material risks inherent in such options and the probability of such risks
occurring include:
• Overuse of over-the-counter medications produces undesirable side-effects. If complete
rest is impractical, premature return to work and household chores may aggravate the
condition and extend the recovery time. The probability of such complications arising is
dependent upon the patient’s general health, severity of the patient’s discomfort, his pain
tolerance and self-discipline in not abusing the medicine. Professional literature describes
highly undesirable effects from long term use of over-the-counter medicines.
• Prescription muscle relaxants and pain-killers can produce undesirable side effects and
patient dependence. The risk of such complications arising is dependent upon the patient’s
general health, severity of the patient’s discomfort, his pain tolerance, self-discipline in not
abusing the medicine and proper professional supervision. Such medications generally
entail very significant risks — some with rather high probabilities.
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• Hospitalization in conjunction with other care bears the additional risk of exposure to
communicable disease, iatrogenic (doctor induced) mishap and expense. The probability if
iatrogenic mishap is remote, expense is certain, exposure to communicable disease is likely
with adverse result from such exposure dependent upon variables.
• The risks inherent in surgery include adverse reaction to anesthesia, iatrogenic (doctor
caused) mishap, all those of hospitalization and an extended convalescent period. The
probability of those risks occurring varies to many factors.
• The risks and dangers attendant to remaining untreated.
Remaining untreated allows the formation of adhesions and reduces mobility which sets up
a pain reaction further reducing mobility. Over time this process may complicate treatment
making it more difficult and less effective the longer it is postponed. The probability that
non-treatment will complicate a later rehabilitation is very high.
E
L
P
M
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.
PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW:
I have read [ X ] or have had read to me [ ] the above explanation of the
chiropractic adjustment and related treatment. I have discussed it with Dr.
Richard Roe and have had my questions answered to my satisfaction. By signing
below I state that I have weighed the risks involved in undergoing treatment and
have myself decided that it is in my best interest to undergo the treatment
recommended. Having been informed of the risks, I hereby give my consent to
that treatment.
DATED:
A
S
January 4, 0000
Michael Wellington, Jr.
Printed Name
Michael Wellington, Jr.
Signature
WITNESSES:
Marilyn Sanford
Printed Name
Marilyn Sanford
Signature
Signature of Parent or
Guardian (if a minor)
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*************************************************
CONDITION OF PATIENT AT TIME OF CONSENT PROCESS
Based on my personal observation and direct conversation with the patient, I conclude that
throughout the consent process he was:
[ X ] Oriented as to time and place
[ X ] Coherent and lucid
E
L
[ ] Receiving medication but unimpaired
[ X ] Able to understand the language used
P
M
[ ] Assisted in understanding by use of an interpreter
N/A
(Interpreter’s name:
)
[ ] Assisted in consent process by family members:
N/A
A
S
Name
Relationship
[ ] Assisted in consent process by staff members:
N/A
Name
Patient had the following questions and was supplied with the following answers:
COMMENTS:
Michael asked about the possibility of a stroke, I assured him that the possibility
was very low. I related the fact that being struck by lightening was
approximately the same possibility of risk, one in a million. Michael related that he
was willing to take that risk.
I certify that the above accurately describes the consent process in this case.
January 4, 0000
Date
Marilyn Sanford
Witness
Richard Roe, D.C
Signature of Doctor
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INFORMED CONSENT
GUIDELINES
• When there is risk of significant harm from the treatment proposed, this risk must be
disclosed, understood and accepted by the patient. Such informed consent is required for
ethical and legal reasons. The best record of consent is one that is objectively documented (e.g.,
a witnessed written consent or videotape.)
• Basic information identifying the practitioner or facility should appear on documents used to
establish the doctor-patient relationship. This can be pre-printed on forms…Basic information
should include:
•
•
•
•
•
•
practitioner’s name/specialty
specialty designation (if applicable)
facility name (if different)
legal trade name (if applicable)
street address and mailing address (if different)
telephone number(s)
• A literature review of cerebro-vascular accidents will include the following potential
complications:
•
•
•
•
•
•
stroke or stoke-like conditions
Horner’s syndrome
diaphragmatic paralysis
cervical myelopathy
pathological fracture
cervical disc protrusions
•
•
•
•
•
cervical dislocation
costovertebral strains
rib fractures
costochondral separations
compression of the caudia equina
BACKGROUND
Despite the fact that a form may be useful — even essential — in protecting a doctor from a
patient who claims he was not informed of the risks of an adjustment or other treatment, a form
alone is not enough. Informed consent is a process, not just a form. A doctor must discuss the
informed consent elements with the patient, answer any questions and then have the form
signed to memorialize that process.
The essence of informed consent lies in the doctor’s securing the patient’s knowing and
intelligent agreement to undergo the treatment recommended. This indispensable legal
requirement is easily satisfied because patients are usually willing to comply with their doctors’
recommendations. A patient’s actual consent to a certain diagnostic or therapeutic procedure
may often be inferred from his having initially sought the doctor’s advice and treatment.
>>
<<
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OBJECTIVE
This form is designed to “objectively document” that the informed consent process took place.
PRACTICE SUGGESTIONS
• Describe the procedures to be employed. To obtain informed consent, the physician must
outline in some detail what is to be done. This explanation of proposed procedures has
practical advantages besides satisfying legal requirements. A patient who understands the nature
of the treatment is less likely to be surprised by it. Particularly if any sudden change, movement,
or shock attends the treatment, the patient should be alerted to expect it. The well-informed
patient is likely to be more relaxed, comfortable, and cooperative. This type of psychological
preparation at the outset may prevent misunderstandings that can lead to dissatisfaction,
estrangement, and litigation.
• Disclose the risks of treatment. The key words to be emphasized in a discussion of risks
are material and inherent. A doctor has no obligation to disclose or discuss risks that are not
inherent (foreseeable, natural, related to) to the suggested procedure or to discuss other risks
that, inherent or not, are not material (sufficiently likely and significant) under applicable state
law. The rule leaves considerable room for subjective interpretation (and subsequent secondguessing) and its application affords a fruitful area for potential litigation.
• The greatest protection will be afforded by an exhaustive recitation of risks. Doctors failing
to warn patients of the risks mentioned in the Mercy guidelines do so at their peril.Your authors
have sought to include all necessary warnings in the informed consent form.
• The literature review, however, does refer to the conditions discussed as “rare” and “rarely reported
in the literature.” Doctors may certainly exercise their own clinical judgement in choosing to omit,
modify or add to any of the risks contained in the following informed consent form. They should
recognize, however, that each deletion from the informed consent form. They should recognize,
however, that each deletion from the informed consent form dilutes its protective capability.
• The harsh sounding warning necessary to adequately advise of risks may frighten some
patients. A professional demeanor and a properly prepared presentation, however, will greatly
add to the patient’s confidence level as he decides whether to undergo treatment. The doctor’s
attitude, image, reputation and confidence will significantly lessen the patient’s apprehension.
• It is important not only to place the “informed consent” process into its proper perspective,
but to assure that the dialogue takes place in a setting conducive to understanding and
communication between the patient (family)and doctor.
• Some states require a written informed consent verification — or afford additional protection
when written confirmation is employed. Consultation with legal counsel is necessary to insure
legal compliance and optimum use of statutory protections.
• The “comments” section on the last page of the “informed consent form” affords the doctor
the opportunity to individualize the form by memorializing any specific question the patient
may have asked and the response given. This section should be routinely used to note any
particulars which may serve to emphasize the thoroughness of the process and the
reasonableness of the doctor’s conclusion that the patient understood the information provided.
>>
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FREQUENCY
The initial informed consent should be obtained before undertaking diagnostic testing or
treatment. The process need not be repeated unless treatment is altered or a new, not previously
discussed diagnostic test is to be employed.
POTENTIAL DISADVANTAGES
• A patient may elect to forego treatment after learning of potential risks.
• A doctor may become complacent and rely exclusively upon the form to attempt to document
that he fully informed the patient. Failure to customize the informed consent process to
individual patients and to adequately discuss the risks may leave the doctor exposed to
malpractice attack even with a signed consent form.
• The form represents that the doctor uses procedures designed to screen potential
stroke candidates. Doctors who do not use such tests should delete that portion. The
authors advise most strongly, however, that practitioners use and document some
screening protocol.
INFORMED CONSENT
Doctors need to understand that informed consent is a process, which may or may not be
satisfied with a written form. It is the doctor’s responsibility to make sure that the patient is
properly informed, understands, and consents to the treatment to be provided; however, it is
also within the doctor’s discretion as to how the information is communicated and how the
consent is obtained.
Generally the legal concept of informed consent arises from the principle that, absent
extenuating circumstances, a patient has the right to exercise control over his or her body by
making an informed decision concerning whether to consent to a particular course of treatment.
The doctor has the duty to disclose to the patient all material risks involved in the procedure.
The patient, then, can truly make an informed, intelligent decision concerning his or her care.
Even though the principles stated above have been generally well accepted throughout the
country, specific state statues or state case law often further define the necessary elements to
establish informed consent. For example, some states, like Iowa, have a consent law. In Iowa, if
a health care provider satisfies the requirements of the statute, a presumption is raised that
informed consent was given.
Because of the possible peculiarities in any given state laws or statues, doctors of chiropractic
would be best served by contacting an attorney in their state who practices health care related
law and ask that person to advise the doctor regarding their particular practice. In this way, the
doctor will have the benefit of an attorney who should be current on the informed consent
issue in that state. The attorney can advise the doctor whether there are any specific informed
consent laws which might impact that doctor’s practice and whether use of an informed consent
form would be prudent.
>>
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From our experience, when doctors get sued for malpractice, oftentimes an allegation is made
that there was no informed consent given by the patient. Accordingly, it is important for doctors
to obtain informed consent and be certain to document in the records that the process of
informed consent took place. However, the information provided by the doctor and the consent
given by the patient must be specific to both the individual patient and the individual treatment
regimen. A single blanket informed consent form may not accomplish this purpose.
We have included several samples of informed consent forms which meet the criteria of
complying with all relevant information which a patient should know. The doctor should design
a form he is comfortable with and incorporate it into his practice procedure.
>>
<<
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INFORMED CONSENT TO
CHIROPRACTIC TREATMENT
Medical doctors, chiropractic doctors, osteopaths, and physical therapists who
perform manipulation are required by law to obtain your informed consent before
starting treatment.
East Podunk, IN
Jane Doe
I
, of
do hereby give my consent to
the performance of conservative noninvasive treatment to the joints and soft tissues.
I understand that the procedures may consist of manipulations/adjustments
involving movement of the joints and soft tissues. Physical therapy and exercises may
also be used.
E
L
Although spinal manipulation/adjustment is considered to be one of the safest , most
effective forms of therapy for musculoskeletal problems, I am aware that there are
possible risks and complications associated with these procedures as follows:
P
M
Soreness: I am aware that like exercise it is common to experience muscle soreness
in the first few treatments.
A
S
Dizziness: Temporary symptoms like dizziness and nausea can occur but are
relatively rare.
Fractures/Joint Injury: I further understand that in isolated cases underlying physical
defects, deformities or pathologies like weak bones from osteoporosis may render the
patient susceptible to injury. When osteoporosis, degenerative disk, or other
abnormality is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency in our world, strokes from
chiropractic adjustments are rare. I am aware that nerve or brain damage including
stroke is reported to occur once in one million to once in ten million treatments. Once
in a million is about the same chance as getting hit by lightening. Once in ten million
is about the same chance as a normal dose of aspirin or Tylenol causing death.
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Physical Therapy Burns: Some of the therapies used in this office generate heat and
may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a
temporary increase of pain and possible blistering. This should be reported to the
doctor.
Tests have been performed on me to minimize the risk of any complication from
treatment and I freely assume these risks.
E
L
TREATMENT RESULTS
I also understand that there are beneficial effects associated with these treatment
procedures including decreased pain, improved mobility and function, and reduced
muscle spasm. However, I appreciate there is no certainty that I will achieve these
benefits.
P
M
I realize that the practice of medicine, including chiropractic, is not an exact science
and I acknowledge that no guarantee has been made to me regarding the outcome
of these procedures.
A
S
I agree to the performance of these procedures by my doctor and such other persons
of the doctor’s choosing.
ALTERNATIVE TREATMENTS AVAILABLE
Reasonable alternatives to these procedures have been explained to me including
rest, home applications of therapy, prescription or over-the-counter medications,
exercises and possible surgery.
Medications: Medication can be used to reduce pain or inflammation. I am aware
that long-term use or overuse of medication is always a cause for concern. Drugs may
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mask pathology, produce inadequate or short-term relief, undesirable side-effects,
physical or psychological dependence, and may have to be continued indefinitely.
Some medications may involve serious risks.
Rest/Exercise: It has been explained to me that simple rest is not likely to reverse
pathology, although it may temporarily reduce inflammation and pain. The same is
true of ice, heat, or other home therapy. Prolonged bedrest contributes to weakened
bones and joint stiffness. Exercises are of limited value but are not corrective of
injured nerve and joint tissues.
E
L
Surgery: Surgery may be necessary for joint stability or serious disk rupture.
Surgical risks may include unsuccessful outcome, complications, pain or reaction to
anesthesia, and prolonged recovery.
P
M
Nontreatment: I understand the potential risks of refusing or neglecting care may
include increases pain, scar/adhesion formation, restricted motion, possible nerve
damage, increased inflammation, and worsening pathology.The aforementioned may
complicate treatment making future recovery and rehabilitation more difficult
and lengthy.
A
S
I have read or have had read to me the above explanation of chiropractic
treatment. Any questions I have had regarding these procedures have been
answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT
FORM. I have made my decision voluntarily and freely.
To attest to my consent to these procedures, I hereby affix my signature to this
authorization for treatment.
Jane Doe
Mary Sue Benton
2/1/0000
Signature of patient
Signature of witness
Date and time
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PATIENT STATUS AT TIME OF INFORMED CONSENT PROCESS
Based on my personal observations, medical history and direct conversation with the
patient, I conclude that throughout the consent process the patient was:
[X]
[X]
[ ]
[X]
[ ]
[X ]
[ ]
Of legal age
Oriented x 3
Disoriented as to
Coherent and lucid
On prescription/OTC medication but unimpaired
Proficient in understanding the English language
Assisted in understanding by an interpreter
(Interpreter’s name:
)
[ X ] Resolute in denying the use of alcohol and or recreational
drug use prior to consent
[ ] Unable to give legal consent
[ ] Consent given thru legal guardian
E
L
P
M
A
S
Patient’s questions (if any) and information supplied are as follows:
Patient wanted to know if I had any patient who
experienced a stroke and I said no.
Comments:
I certify that the above accurately describes the above named patient’s status during the
informed consent.
2/1/0000
Date
Betty Jane Smith, DC
Signature of Doctor
We wish to acknowledge the kind permission extended by Charles W. Theisler, D.C., J.D., to include a copy
of his informed consent form as well as a patient status report in this Form and Sample Letter Book.
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NEW PROBLEM/RE-EVALUATION FORM
GUIDELINES
When possible, history questionnaires…and other information personally completed by the
patient should be included in the initial documentation.
BACKGROUND
Many malpractice cases concern failures to diagnose. The patient may insist that he complained
about some symptom which the doctor failed to properly address even though it was a sign of
a serious condition. If the entry complaints were not properly documented, the doctor's
protestations that the patient never voiced the complaint will not be very persuasive.
This form puts the onus on the patient to provide the doctor with all the complaints. A patient
would be hard pressed to successfully argue later that he had complaints in addition to the ones
he listed himself.
APPLICATION
Every new patient should provide this information. It may also be used to monitor progress and
should be re-submitted following re-injury, exacerbation, falls or other complication, upon reexamination and discharge.
PRACTICE SUGGESTIONS
The information should always be provided in the patient's own handwriting — dated and
signed or initialed.
This form requires that the doctor establish a system whereby he assures that the information
gathered will be reviewed and not simply filed away. Delegation of one staff person to be
responsible for filing the forms after the doctor has reviewed and initialed them will
accomplish this.
FREQUENCY
This information should be sought:
1. During the initial examination
2. At 2-3 week intervals until the patient is asymptotic
3. Upon any exacerbation or aggravation of symptoms
4. If the patient has not been seen for more than 6 months.
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NEW PROBLEM/RE-EVALUATION FORM
Sylvester Ulker
Patient Name:
Date of Birth: 1/1/45
January 4, 0000
Date:
Employer's Name:
John Horvest Co.
Address:
Phone No.: 555-123-4567
1415 Main st., Plainstown, GA 44432
What relieves this problem?
What is your main complaint?
leg pain and low back pain
standing and walking
When does it bother you most?
Describe in detail.
fell off hayride during
Halloween Party
When is it most troublesome?
get rid of the pain
standing, sitting or walking
Does it “come and go”?
Indicate any secondary complaint.
P
M
fairly consistent
none
If so, at predictable times?
no
Describe in detail.
When did it begin?
Date
N/A
October 31, 1999
A
S
What caused it?
Fall
Was it work related?
no
Was it related to an auto accident?
no
E
L
What do you expect our care to
accomplish?
Was it related to an injury?
yes
Have you seen any other doctor,
since it began?
no
If so, other doctors' names and
addresses
N/A
When is it most troublesome?
After I am tired
Do you have any other complaints or
conditions?
no
Describe in detail.
N/A
Sylvester Ulker
Printed Name
Sylvester Uker
Signature
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SHOW AREA(S) OF PAIN OR UNUSUAL FEELING
Mark the areas on this body where you feel the described sensations.
Use the appropriate symbols.
Mark areas of radiation.
Include all affected areas.
NUMBNESS
-------------
PINS & NEEDLES
00000
00000
00000
BURNING
XXXXX
XXXXX
XXXXX
ACHING
*****
*****
*****
STABBING
/////
/////
/////
E
L
Please mark on the pain scale from Zero to 10 the pain you feel with this condition. 10 being
the worst pain you have felt with this condition.
P
M
Pain Chart
A
S
right
January 4, 000
On a scale of zero to 10, I rate my
discomfort as follows:
(
0
no pain
left
-X- -X- -X- -X- -X- -X- -X- -
Mid Back Pain
(
0
no pain
)
5
10
severe pain
Low Back and Leg Pain
On a scale of zero to 10, I rate my
discomfort as follows:
(
0
no pain
right
Sylvester Uker
Signature
)
10
severe pain
On a scale of zero to 10, I rate my
discomfort as follows:
*****
*****
*****
left
Date:
Neck-Shoulder-Arm-Pain
)
9
10
severe pain
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DAILY NOTES
GUIDELINES
• A dated record of what occurred on each visit, and any significant changes in the clinical
picture, or assessment, or treatment plan, need to be noted.
• Upon completion of the subjective and objective database, the practitioner formulates a
clinical impression or diagnosis. This clinical impression should be recorded within the file or in
the contemporaneous visit record.
• The written treatment plan may appear on a form dedicated to the clinical work-up, or in the
contemporaneous visit record, and may include:
•
•
•
•
diagnostic/reassessment plan
practitioner's treatment plan (modes and frequency of care)
patient's education and self-care plan
intra- or interdisciplinary referral or consultation
• There are many different adjusting/manipulation/manual techniques. It is important to record
what area was adjusted/manipulated/treated and the procedure used.
BACKGROUND
Recording the segment(s) adjusted, and the technique used on any given day can be a virtual
lifesaver in a malpractice defense. There is at least one case in which a patient alleged a brain
stem injury on a day when the chiropractor claimed he did not perform a cervical adjustment.
In a malpractice suit experts will be asked to give their opinions as to what caused a patient
injury. The fact that the doctor utilized a light touch, non-force technique or performed no
cervical adjustment and notation of the position the patient was in when the manipulation was
given all will be important factors.
The patient's progress is usually the subject of considerable discussion throughout the course of
treatment. Staff members regularly talk with patients and learn, without much difficulty, which
patients are progressing and which are not.
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OBJECTIVES
1. Busy practitioners lament that the volume of paperwork necessary to satisfy risk-managers is
so cumbersome, time-consuming and annoying as to be virtually impossible to consistently
maintain. This form is intended to assist the doctor who cannot or will not generate detailed
written notes by allowing him to quickly record the segments adjusted and the technique utilized.
2. While a jury may still believe a patient’s word over the doctor’s, a ledger such as this one will
corroborate the doctor's testimony and enhance its credibility.
3. The form will also serve as a ready reminder of precisely what treatment the doctor rendered
on previous visits. If the patient says: “I really felt great after my last adjustment,” or “Whatever
you did last time tore me up…I thought I'd never get to sleep,” with this form the doctor doesn’t
have to “guess” what he did.
4. Likewise, if the doctor is ill, becomes disabled, goes on vacation or retires, the substitute
doctor will have a ready “script” of how and where each patient was being adjusted.
PRACTICE SUGGESTIONS
Doctors should encourage staff/patient conversation in the office visit “routine.” Much valuable
information can be obtained informally. Since no one recalls the details or content of such brief
conversations years or even weeks later, some notation is important for both treatment and risk
reduction purposes. Many doctors find the use of so-called “SOAP” notes helpful in
maintaining daily notes.
SOAP is an acronym for:
S - Subjective comments from the patient
O - Objective observation and findings
A - Assessment
P - Plan
The subjective element may be obtained by informal questioning or by the patient's
completion of a “today I feel” form. Doctors should supplement that information by eliciting
reasons the patient feels better or worse and the precise nature of the improvement or worsening
of condition that the patient describes.This is not an area for technical terms. If the patient says,
“My back hurt so bad this morning. I couldn’t even get out of bed,” that is sufficient subjective
analysis.
In support of the subjective entry, the doctor should note any objective corroboration for the
patient's complaints. Test or examination results, demeanor changes in gait, abnormal range of
motion, tenderness or swelling may confirm the patient’s account and should be noted.
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The assessment should reconcile subjective and objective components and notes their
deviation, if any, from what was expected. At this point the doctor should evaluate the need for
additional examination or testing if inadequate progress or some other unexpected result
suggests it.
The plan can range from dismissing the patient to radical alteration of treatment. Other
treatment options should be considered if the current treatment is not proving effective. The
doctor who steadfastly continues treatment, despite unsatisfactory response or lack of patient
improvement, is on dangerous malpractice grounds.
Daily notes do not necessarily have to conform to the SOAP format to comply with good clinical
practice. Notes which are hand written and contain the essential elements of the Subjective,
Objectives, Assessment, and Plan are adequate and satisfactory for the purposes of maintaining
good, defensible clinical records.
Doctors who elect not to follow the SOAP format, however, should develop a method of
standardizing record keeping in each patient's records.
ADDITIONAL BENEFIT
SOAP notes have the additional benefit of furnishing supplementary documentation of the
necessity for continued treatment. With insurance companies increasingly requesting such
documentation, SOAP notes may also improve the doctor's cash flow by facilitating compliance
with insurance company requests for “additional information.”
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DAILY NOTES
PATIENT NAME:
John Smith
1/20/0000
Clinical Impression as of
Treatment Plan as of
1/20/0000
S: LBP localized to right. Leg pain in gluteal extending to postero lateral thigh. Aggravated by moving
coughing, sneezing, sitting.
DATE
O: Limited ROMs all planes, antalgic (see physical exam) fixations of L-5 S-1.
E
L
1/20/00 A: Acute right lumbo-saral IVD with sciatic neuralgia
P: Contact employer, off for 3-4 weeks minimal. Seen daily, ice, ultrasound, soft tissue technic,
specific spinal manipulation. Monitor carefully, to be seen as frequently as necessary for the next
2-3 weeks depending on clinical picture. Will consider MRI if no improvement. Home ice and mild
stretch exercises.
P
M
S:
O:
DATE
A:
P:
S:
O:
DATE
A:
P:
A
S
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DAILY PROGRESS NOTES
DAILY PROGRESS NOTES
• Record the clinical progress of the patient
• Use SOAP or DAP Format
• Need to be contemporaneous
DAILY PROGRESS NOTES — SOAP FORMAT
• Daily SOAP notes should include:
• date
• subjective complaints
• objective findings
• assessment/action taken
• plan
• Must be individualized to the patient
We wish to acknowledge the kind permission extended by Dr. Steven Savoie of Palmer College, to
include copies of his Daily notes, S.O.A.P. notes in this Form and Sample Letter Book.
>>
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DAILY PROGRESS NOTES — DAP FORMAT
• Daily DAP notes should include:
• date
• data (clinical/patient)
• assessment/ action taken
• plan
• Must be individualized to the patient
WHAT ARE CHART NOTES?
• Very brief daily notes on patient progress
• Do not necessarily include subjective and objective findings (data)
• Are used in combination with a detailed comprehensive SOAP note every 12 visits
• Not acceptable to some State Boards
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EXAMPLE 1 SOAP NOTES
On 8-8-96 patient complained of increased pain in the cervical spine. Review of History and
Physical Exam findings revealed no contraindications to CMT. Examination demonstrated
decreased active and segmental range of motion, increased tenderness to palpation and
decreased muscle spasm in the cervical and lumbar spine.
EXAMPLE 1 SOAP NOTES (continued)
Assessment found no improvement with subluxations at C1, C5, T5, L5. Patient was adjusted
at those levels and interferential current with ice was also applied to the cervical spine. Continue
with current treatment plan and follow-up in two days.
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EXAMPLE 1 SOAP NOTES
08-08-96
•
S patient c/o p C-sp, HX + PE neg for contraind. To CMT
•
O AROM, SROM, T2p, MS, C-sp LSROM T-sp + L-sp
•
A No improvement, Dx same, Adj at C1R, C5L, T5L. L5R, IF/ice C-sp
•
P continue TX-P, f/u 2d.
→
→
→
→
→
•
EXAMPLE 2 SOAP NOTES
On 8-10-96 patient complained of decreased pain in the cervical spine, but still complained of
stiffness in the thoracic spine. No radicular pain or sensory change reported. On examination
there was limited range of motion in the cervical spine and limited segmental range of motion
in the thoracic spine with decreased muscle spasm but tenderness to palpation. Assessment
revealed improvement with subluxations at C1, T5 and sacrum. Those segments were adjusted.
Patient will continue on the same treatment plan with follow-up in two days.
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EXAMPLE 2 SOAP NOTES
• 08-10-96
→
• S C-sp, LSROM T-sp stiffness, - radic p, -sensory def.
→
• O LROM, C-sp, LSROM T-sp, MS, T2p C+T-sp, LSROM Sac.
• A improved, Adj C1R, T5L, PI-R Sacrum
• P continue TX-P, f/u 2d.
EXAMPLE 3 SOAP NOTES
On 2-5-96 patient complained of pain in the cervical spine and right upper extremity.
Examination revealed decreased active range of motion in the cervical spine, positive foramina
compression test with radicular pain, positive Valsalva’s test, biceps reflex was plus 1 on the right
with decreased sensation in the C5 dermatome on the right. Limited segmental range of motion
and tenderness to palpation in thoracic and lumbar spine. Assessment indicated regression in
cervical spine, subluxations at T10 and L4 adjusted. Cervical spine not adjusted this visit,
interferential current with ice was applied to the cervical spine to rule-out herniated nucleus
pulposus of the cervical spine. Follow-up in one day.
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EXAMPLE 3 SOAP NOTES
• 02-05-96
• S patient c/o p C-sp + R- UE
→
→
• O AROM c-sp + foram. Comp t., + Valsal. T. biceps + 1R, sensation C5 derm R,
LSROM, T2p T-L-sp
• A Pt regressed, adj T10R, L4L, no adj c-sp IF/ice C-sp
• P order MR C-sp tp R/O HNP C-sp, f/u 1 d.
EXAMPLE 1 DAP NOTES
On 2-8-98 patient entered for routine wellness chiropractic visit. Patient had no clinical
complaints. Evaluation demonstrated reduced segmental function and motion on palpation.
There were taut and tender fibers in the upper cervical spine. Instrumentation showed patient
to be in subluxation pattern. Subluxation found at C1 and adjusted. Patient to continue on
current management plan, follow-up in 1 month.
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EXAMPLE 1 DAP NOTES
02-08-98
•
D well visit, SROM, taut + tender fibers, C-sp, instr + sublux, pattern
•
A Adj C1- ASRP
•
P cont Tx Plan, f/u 1 mo
→
•
DAILY THERAPY NOTES
Documentation necessary
•
Date
•
Modality used
•
Area treated
•
Intensity of therapy (settings)
•
Who performed the therapy
•
Length of time for therapy treatment
•
Clinical effect on patient
•
Skin condition pre + post
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EXAMPLE 1
Daily Therapy Notes
On 8-8-97 in compliance with treatment plan patient underwent interferential current with ice
from lower cervical spine (C5) to upper thoracic spine (T2). Intensity was 10 for ten minutes.
Skin condition pre and post was normal. JMC
EXAMPLE 1
Daily Therapy Notes
• 08-08-96
• IF/ice, C5-T2, Int. 10, 10m., sc/pp/n JMC
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EXAMPLE 2
Daily Therapy Notes
On 8-10-97 in compliance with treatment plan patient underwent ultrasound therapy from the lower
cervical spine (C6) to upper thoracic spine (T1) on the right. Intensity was 2.0 watts per centimeter
squared, pulsed for ten minutes. Skin condition pre and post was normal. JMC
EXAMPLE 2
Daily Therapy Notes
• 08-10-96
• US C6- T1R, pulse 2.5 w/cm2, 10 min., sc/pp/n JMC
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DAILY NOTES — ALTERNATIVE VERSION
Jane Doe
PATIENT NAME:
X-ray listings
Negative for fracture or pathology-subluxation C-5-6, lordosis C-spine
Date 10/4/0000
1C
B.P. 120/86
11T
2C
1T ✔ 2T
4C ✔
3C
✔ 3T
1/4/0000
Clinical Impression as of:
4T
5T
5C ✔
6T
6C ✔
7T
12T
7C
8T
9T
10T
E
L
136 1L
2L
3L
4L
5L
Rt. Ilium
Lt. Ilium
Sacrum
shoulder pain local to front and side of shoulder following
S Right
Technique Diversified
exertion with exercise and swinging golf club
10/3/0000
shoulder limited ROM in all planes. Shoulder held
Next Visit
O Right
protective adducted flexed position.
Acute right supraspinatus/rotator cuff strain of shoulder with
Instructions No heat
A attending
calcific tendinitis
office ultra sound electric stim, ice pack, cross friction mass, cervical adjustments as indicated. Home ice applications, limited use of
P In
arm, sling. See 3x weekly for one week reducing as clinically indicated.
WT.
P
M
♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦
Date
B.P.
11T
WT.
S
O
A
P
1C
2C
3C
A
S
1T ✔ 2T ✔ 3T
12T
1L
2L
3L
4C
4T
4L
✔ 5C ✔ 6C ✔
5T
5L
6T
7C
7T
Rt. Ilium
8T
9T
Lt. Ilium
10T
Sacrum
Technique
Next Visit
Instructions
♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦
Date
B.P.
11T
WT.
1C
1T
2C
3C
✔ 2T ✔ 3T
4C
4T
✔ 5C ✔ 6C ✔
5T
6T
7T
7C
8T
9T
10T
12T
1L
2L
3L
4L
5L
Rt. Ilium
Lt. Ilium
Sacrum
S
Technique
O
Next Visit
A
Instructions
P
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DAILY PROGRESS NOTES
DAILY PROGRESS NOTES
• Record the clinical progress of the patient
• Use SOAP or DAP Format
• Need to be contemporaneous
DAILY PROGRESS NOTES — SOAP FORMAT
• Daily SOAP notes should include:
• date
• subjective complaints
• objective findings
• assessment/action taken
• plan
• Must be individualized to the patient
We wish to acknowledge the kind permission extended by Dr. Steven Savoie of Palmer College, to
include copies of his Daily notes, S.O.A.P. notes in this Form and Sample Letter Book.
>>
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DAILY PROGRESS NOTES — DAP FORMAT
• Daily DAP notes should include:
• date
• data (clinical/patient)
• assessment/ action taken
• plan
• Must be individualized to the patient
WHAT ARE CHART NOTES?
• Very brief daily notes on patient progress
• Do not necessarily include subjective and objective findings (data)
• Are used in combination with a detailed comprehensive SOAP note every 12 visits
• Not acceptable to some State Boards
>>
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EXAMPLE 1 SOAP NOTES
On 8-8-96 patient complained of increased pain in the cervical spine. Review of History and
Physical Exam findings revealed no contraindications to CMT. Examination demonstrated
decreased active and segmental range of motion, increased tenderness to palpation and
decreased muscle spasm in the cervical and lumbar spine.
EXAMPLE 1 SOAP NOTES (continued)
Assessment found no improvement with subluxations at C1, C5, T5, L5. Patient was adjusted
at those levels and interferential current with ice was also applied to the cervical spine. Continue
with current treatment plan and follow-up in two days.
>>
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EXAMPLE 1 SOAP NOTES
08-08-96
•
S patient c/o p C-sp, HX + PE neg for contraind. To CMT
•
O AROM, SROM, T2p, MS, C-sp LSROM T-sp + L-sp
•
A No improvement, Dx same, Adj at C1R, C5L, T5L. L5R, IF/ice C-sp
•
P continue TX-P, f/u 2d.
→
→
→
→
→
•
EXAMPLE 2 SOAP NOTES
On 8-10-96 patient complained of decreased pain in the cervical spine, but still complained of
stiffness in the thoracic spine. No radicular pain or sensory change reported. On examination
there was limited range of motion in the cervical spine and limited segmental range of motion
in the thoracic spine with decreased muscle spasm but tenderness to palpation. Assessment
revealed improvement with subluxations at C1, T5 and sacrum. Those segments were adjusted.
Patient will continue on the same treatment plan with follow-up in two days.
>>
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EXAMPLE 2 SOAP NOTES
• 08-10-96
→
• S C-sp, LSROM T-sp stiffness, - radic p, -sensory def.
→
• O LROM, C-sp, LSROM T-sp, MS, T2p C+T-sp, LSROM Sac.
• A improved, Adj C1R, T5L, PI-R Sacrum
• P continue TX-P, f/u 2d.
EXAMPLE 3 SOAP NOTES
On 2-5-96 patient complained of pain in the cervical spine and right upper extremity.
Examination revealed decreased active range of motion in the cervical spine, positive foramina
compression test with radicular pain, positive Valsalva’s test, biceps reflex was plus 1 on the right
with decreased sensation in the C5 dermatome on the right. Limited segmental range of motion
and tenderness to palpation in thoracic and lumbar spine. Assessment indicated regression in
cervical spine, subluxations at T10 and L4 adjusted. Cervical spine not adjusted this visit,
interferential current with ice was applied to the cervical spine to rule-out herniated nucleus
pulposus of the cervical spine. Follow-up in one day.
>>
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EXAMPLE 3 SOAP NOTES
• 02-05-96
• S patient c/o p C-sp + R- UE
→
→
• O AROM c-sp + foram. Comp t., + Valsal. T. biceps + 1R, sensation C5 derm R,
LSROM, T2p T-L-sp
• A Pt regressed, adj T10R, L4L, no adj c-sp IF/ice C-sp
• P order MR C-sp tp R/O HNP C-sp, f/u 1 d.
EXAMPLE 1 DAP NOTES
On 2-8-98 patient entered for routine wellness chiropractic visit. Patient had no clinical
complaints. Evaluation demonstrated reduced segmental function and motion on palpation.
There were taut and tender fibers in the upper cervical spine. Instrumentation showed patient
to be in subluxation pattern. Subluxation found at C1 and adjusted. Patient to continue on
current management plan, follow-up in 1 month.
>>
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EXAMPLE 1 DAP NOTES
02-08-98
•
D well visit, SROM, taut + tender fibers, C-sp, instr + sublux, pattern
•
A Adj C1- ASRP
•
P cont Tx Plan, f/u 1 mo
→
•
DAILY THERAPY NOTES
Documentation necessary
•
Date
•
Modality used
•
Area treated
•
Intensity of therapy (settings)
•
Who performed the therapy
•
Length of time for therapy treatment
•
Clinical effect on patient
•
Skin condition pre + post
>>
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EXAMPLE 1
Daily Therapy Notes
On 8-8-97 in compliance with treatment plan patient underwent interferential current with ice
from lower cervical spine (C5) to upper thoracic spine (T2). Intensity was 10 for ten minutes.
Skin condition pre and post was normal. JMC
EXAMPLE 1
Daily Therapy Notes
• 08-08-96
• IF/ice, C5-T2, Int. 10, 10m., sc/pp/n JMC
>>
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EXAMPLE 2
Daily Therapy Notes
On 8-10-97 in compliance with treatment plan patient underwent ultrasound therapy from the lower
cervical spine (C6) to upper thoracic spine (T1) on the right. Intensity was 2.0 watts per centimeter
squared, pulsed for ten minutes. Skin condition pre and post was normal. JMC
EXAMPLE 2
Daily Therapy Notes
• 08-10-96
• US C6- T1R, pulse 2.5 w/cm2, 10 min., sc/pp/n JMC
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DAILY NOTES
PATIENT NAME:
Pain in neck unable to turn head
Subjective:
Objective: Limited ROM 10 o RT Rotation
Muscle Spasm
❏ Cervical
❏ Thoracic
✗
Cervical ROM severely limited
Assess:
❏ Same
❏ Some Improvement
❏ Much Better
ice, collar, muscle stretch technic
Plan:
Treatment today consisted of manipulation:
(Div/Cox/
Cervical 1 2 3 4 5 6 7
Thoracic 1 2 3 4
Lumbar 1 2 3 4 5
Ilium L R
Sacrum
Physiotherapeutic Modalities administered:
❏ EMS
❏ Trigger Point Therapy/Other
❏ Hot/Cold
Restrictions: ❏ limited work
❏ lifting
❏ no work
Recommendations: ❏Cervical / Lumbar Exercises
❏ Ice
X
X
X
2/15/0000
Date:
Sam Shelly
X
❏ Lumbar
Lumbar ROM
)
5 6 7 8 9 10 11
Short Leg
❏ U.S.
❏ Interf
lbs.
Pack
A
S
Subjective:
Objective:
Muscle Spasm
❏ Cervical
❏ Thoracic
Cervical ROM
Assess:
❏ Same
❏ Some Improvement
❏ Much Better
Plan:
Treatment today consisted of manipulation:
(Div/Cox/
Cervical 1 2 3 4 5 6 7
Thoracic 1 2 3 4
Lumbar 1 2 3 4 5
Ilium L R
Sacrum
Physiotherapeutic Modalities administered:
❏ EMS
❏ Trigger Point Therapy/Other
❏ Hot/Cold
Restrictions: ❏ limited work
❏ lifting
❏ no work
Recommendations: ❏Cervical / Lumbar Exercises
❏ Ice
12
E
L
X
❏ Traction
❏ sitting, bending, standing
❏ Hot Compress
❏ Other
P
M
Subjective:
Objective:
Muscle Spasm
❏ Cervical
❏ Thoracic
Cervical ROM
Assess:
❏ Same
❏ Some Improvement
❏ Much Better
Plan:
Treatment today consisted of manipulation:
(Div/Cox/
Cervical 1 2 3 4 5 6 7
Thoracic 1 2 3 4
Lumbar 1 2 3 4 5
Ilium L R
Sacrum
Physiotherapeutic Modalities administered:
❏ EMS
❏ Trigger Point Therapy/Other
❏ Hot/Cold
Restrictions: ❏ limited work
❏ lifting
❏ no work
Recommendations: ❏Cervical / Lumbar Exercises
❏ Ice
X❏ New Condition
❏ Worse
Date:
❏ Lumbar
Lumbar ROM
❏ Worse
❏ New Condition
)
5 6 7 8 9 10 11
Short Leg
❏ U.S.
❏ Interf
lbs.
Pack
12
❏ Traction
❏ sitting, bending, standing
❏ Hot Compress
❏ Other
Date:
❏ Lumbar
Lumbar ROM
❏ Worse
)
5 6 7 8 9 10 11
Short Leg
❏ U.S.
❏ Interf
lbs.
Pack
❏ New Condition
12
❏ Traction
❏ sitting, bending, standing
❏ Hot Compress
❏ Other
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TELEPHONE LOG
BACKGROUND
A doctor’s staff should maintain a record of all telephone conversations other than those
scheduling appointments or concerning insurance and payments.
The form can refresh the doctor’s recollection and by virtue of its format recording other calls
on the same day pertaining to the other matters — it is less susceptible to suspicion of
fabrication than a single note in a patient file would be.
OBJECTIVES
1. These forms are designed to allow the doctor to check quickly, to determine if any calls
require his personal attention.
2. To document the instructions given, patient complaints and office to response defend against
malpractice attack.
PRACTICE SUGGESTIONS
The “Caller,” “Phone #” and “Patient Message” columns on the following form are selfexplanatory
The most important column is “Check Dr.” (check with doctor). Staff members should never
offer clinical advice or use their own judgment on whether to “bother” the doctor with patient
complaints or inquiries. If the patient seemed agitated, professional advice is required or the
operator senses any other unresolved problem, this column should be clearly marked so the
doctor is alerted and can make his own assessment of the need to take follow-up action.
FREQUENCY
The form should be used for every call, which has potential clinical importance.
POTENTIAL DISADVANTAGES
If the “check with doctor” column is checked or the doctor is indicated as the party needing to
return the call, there must be some notation in the “Follow- up” column as to the actions taken.
If the doctor takes no action, it will appear that he failed to act despite warnings. If the doctor
does respond, he should record that fact. If he elects not to personally respond, he should note
to whom he delegated that responsibility.
This type of form may invite staff members to make judgmental observations: “Grouch,”
“Complainer,” etc. The forms should be monitored and staff instructed not to succumb to the
temptation to make unflattering or “humorous” notations.
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TELEPHONE LOG
DATE
Caller
January 4,0000
Phone
#
Patient
Message
CA
Message
Call
Back?
Check
Doctor
Wants to discuss
recent referral
of Jane Smith
Dr. Jones
555-1234
Mary Smith
555-3286
Lower back
better
Susan May
555-4219
wants to know
about headache
wants Dr. to
call her
yes
John Daves
555-1367
wants to know
about test
wants Dr. to
call him
yes
yes
A
S
P
M
E
L
Follow
Up
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ASSESSMENT AND OUTCOMES INSTRUMENTS
GUIDELINES
Various assessment and outcome instruments can contribute to clinical management and
become part of the case record. Many of these instruments are used in a repeated or serial
fashion, which makes it essential for the record to identify the date(s) of completion and
name(s) of scoring practitioner/technician. Measurement instruments currently in use include:
•
•
•
•
•
•
•
visual analog scale
pain diagrams
pain questionnaires (e.g. McGill)
pain disability instruments (e.g. Oswestry, Neck Disability Index)
health status indices (e.g. SF-36, Sickness Impact Profile)
patient satisfaction indices
other outcome measures.
BACKGROUND
Patient outcome and patient satisfaction instruments are widely used and there are a wide
variety of acceptable alternatives from which the doctor may choose. Rather than trying to
illustrate the various “Oswertry” and related forms, or re-inventing the wheel, we have outlined
a comprehensive list of references on the subject to assist the doctor in selecting an appropriate
instrument to address his objectives.
The following is a partial list of references to better acquaint you with the literature relative to
outcome measures. These outcome measures are becoming increasingly more important in the
care, management, and assessment of the effectiveness of treatment.
An excellent and practical way to begin incorporating outcomes assessment instruments into
your practice is to order this patient questionnaire package from The Chiropractic Report. Mr.
David Chapman-Smith has compiled an excellent package of materials, which is currently available.
Back and Neck Questionnaires — How to get started?
Survey Forms/Instruments
Back Pain — Oswestry, and Roland Morris Questionnaires
Neck Pain — Neck Disability Index
Pain Assessment — Visual Analog Scale, Numerical Rating Scale
Instructions — Instructions on how to use and administer the forms
Research Backing — Research paper supporting validity
Write to: The Chiropractic Report, 3080 Yonge Street, Suite 3002
Box 39, Toronto, Ontario (CANADA) M4N 3NI
Fax (416) 484-9665 Phone (416) 484-9601
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REFERENCES
INTRODUCTION
Ellwood P.M., “Outcomes Management: A Technology of Patient Experience.” New England
Journal of Medicine, 1988; 318:1549-1556.
Eppstein A.M., “The Outcomes Movement — Will it Get Us Where We Want to Go?”
New England Journal of Medicine, 1990; 324(4): 266-270.
EVALUATION OF OUTCOME MEASURES
Bombardier C.,Tugwell P., “Methodological Considerations in Functional Assessment.” Journal
of Rheumatology, 1987; (Suppl. 15) 14:6-10.
Kirchner B., Guyatt G., “A Methodologic Framework for Assessing Health Indices.” Journal of
Chronic Disease, 1985; 38:27-36.
SYMPTOMS
Vernon H.T., Applying Research-based Assessments of Pain and Loss of Function to the Issue of
Developing Standard of Care in Chiropractic. Chiro Tech, 1990; 2(3); 121-126.
SIGNS
LeBouf C. The Sensitivity of Seven Leumbo-pelvic Orthopedic Tests and the Armfossa Test. JMPT 13
(3):138, 1990
Liebenson C., Phillips R. The Reliability of Range of Motion Measurements for Human Spine
Flexion: A Review. Chiro Tech 1 (3):69, 1989
Fischer A.R., “Application of Pressure Algometry in Manual Medicine.” J. Manual Medicine
(1990) 5:145-150.
Hsieh J., Phillips R., Reliability of Manual Muscle Testing with A Computerized Dynamometer.
JMPT 13 (2):72, 1990.
Delong, Marilyn Fuller, Medical Acronyms & Abbreviations. 1985.
Evans, Ronald C., Illustrated Essentials in Orthopedic Physical Assessment. 1994
Ferri, Fred F., Practical Guide to the Care of the Medical Patient. 3rd Ed., 1995
Fischbach, Frances, A Manual of Laboratory & Diagnostic Tests. 4th Ed., 1992
Gatterman, Meridel I., Chiropractic Management of Spine Related Disorders. 1990.
Plauger, Gregory, Textbook of Clinical Chiropractic: a specific biomechanical approach. 1993
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Souza, Thomas A., Differential Diagnosis for the Chiropractor. 1997.
Wyatt, Lawrence H., Handbook of Clinical Chiropractic. 1992
TYPE-SPECIFIC FUNCTIONAL STATUS
Fairbanks J., Davies J., Couper J., O'Brien J., The Oswestry Low Back Pain Disability
Questionnaire. Physiotherapy 66:271,1980.
Roland M., Morris R., Study of Natural History of Back Pain, “Part 1: Development of Reliable
and Sensitive Measure of Disability in Low Back Pain.” Spine 8; 141, 1983
Vernon H., Mior S., The Neck Disability Index: A Study of Reliability and Validity. JMPT 14 (7):
409,1991
Ransford A.O., Cairns D., Mooney V., The Pain Drawing as an Aid to the Psychologic Evaluation
of Patients with Low Back Pain. Spine 1:127, 1976.
GENERAL WELL-BEING
SF-36D
Interstudy
4715 Christmas Lake Road, Excelsior, MN 55331-0458
Tel: (612) 474-1176.
Dartmouth COOP Project
Dartmouth Medical School, Hanover, NH 03756
Tel: (603) 645-8974.
PATIENT SATISFACTION
Cherkin D., Patient Satisfaction as an Outcome Measure. Chiro Tech 2(3):138, 1990
Deyo R., Diehl A., Patient Satisfaction with Medical Care for Low Back Pain. Spine 11:28, 1986.
GENERAL REFERENCES ON OUTCOME MEASURES IN CLINICAL PRACTICE
McDowell I., Newell C., Measuring Health: A Guide to Rating Scales and Questionnaires. New
York, Oxford Press, 1987.
Stewart A.L.,Ware J.E. (eds.), Measuring Functioning and Well Being:The Medical Outcomes Study
Approach. Durham, Duke University Press. 1992
Wilkin D., Hallan L., Dogget M., Measures of Need and Outcomes for Primary Health Care. New
York, Oxford University Press, 1992.
Wonca Classification Committee. Functional Status Measurement in Primary Care. New York,
Springer-Verlag, 1990.
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PROGRESS REPORT
GUIDELINES
• Functional Outcomes Assessment (by Questionnaire): functional outcome assessments
of everyday tasks are very suitable for evaluating treatment of dysfunctions of the
neuromusculoskeletal system. Many questionnaires could be used.
• Patient Perception Outcomes Assessment. Pain: Pain measurement is generally a
relevant, valid, reliable, responsive, and safe outcome assessment. Practicality may vary
depending on the specific procedure used.
• Patient Satisfaction Measures: Patient satisfaction measures are an important marker of
quality and are useful in clinical practice. Satisfaction is best assessed using standard
questionnaires measuring a number of dimensions. Scales may be found in the scientific
literature.
BACKGROUND
Patients will sometimes forget how much benefit and pain relief they have received since
beginning treatment. Particularly if the professional relationship deteriorates and there is a fee
dispute, patients are prone to claim that: “The treatment never did any good and I shouldn’t
have to pay for it!” This form may be of immeasurable benefit in dispelling such inaccurate or
fabricated recollection.
Even when the relationship is intact, occasional reminders of the progress obtained provide
good, positive reinforcement for the patient.
Outcome assessment information is essential in evaluating the need for modification of the
treatment plan.
APPLICATION
• Progress forms should be used with every patient at the termination of the acute phase and
periodically thereafter.
• The use of outcome assessments will assist in documenting the necessary requirements to
satisfy proof of patient improvement.
POTENTIAL DISADVANTAGES
The difficult patient will view this form as an opportunity to complain endlessly. The doctor
can not solicit this information and them ignore it. The patient whose complaints are not
resolved is the one who may consider litigation. The doctor must review the information and
consider treatment modification, referral and/or consultation. Perhaps most importantly, the
doctor should reassure the patient and discuss with him the information provided in response
to the questionnaire. This, of course, is essential if the patient has indicated “dissatisfaction”
with progress.
Identification of such patients may be the greatest benefit of the regular use of this form.
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PROGRESS REPORT
Patient Name:
Myrtle Daddonie
Please help us evaluate your response to treatment by answering all questions:
1. What are your present complaints?
Severe low back pain
2. Has anything worsened since you began care?
E
L
Pain has gone into leg
3. Have you had any accident or injury since you began care?
P
M
No
No
4. Has your pain been reduced?
Where?
A
S
How much?
On a scale from zero to 10, I rate my discomfort as follows:
ORIGINALLY
)
0
NOW
(
10
X
no pain
severe pain
5. Has your mobility improved?
X(
)
0
10
no pain
severe pain
No
6. Are you satisfied with your progress? (Circle one)
YES
NO
Comment:
Signature
Myrtle Daddonie
Date
January 4,0000
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PROGRESS REPORT ALTERNATIVE FORM
GUIDELINES
This form is also an “outcome assessment” device. As such, it serves many of the same purposes
set forth in the preceding form.
OBJECTIVE
This form provides a good running record of the patient's response to treatment. It documents
how much better he feel so that if he should later deny improvement, that allegation is refuted
by his own hand. It encourages a favorable mind-set and does not suggest negative response.
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PROGRESS REPORT
Ursula Minoti
Patient Name:
TODAY I FEEL:
About the same
Somewhat improved
Much improved
No more complaints
Other
X
E
L
Please mark on the pain scale from zero to 10 the pain you feel with this condition. 10 being
the worst pain you have felt with this condition.
P
M
Pain Chart
On a scale of zero to 10, I rate my
discomfort as follows:
(
0
no pain
X
A
S
right
Neck-Shoulder-Arm-Pain
Mid Back Pain
On a scale of zero to 10, I rate my
discomfort as follows:
(
0
no pain
On a scale of zero to 10, I rate my
discomfort as follows:
0
no pain
left
January 4, 0000
)
10
severe pain
Low Back and Leg Pain
left
(
Date:
)
10
severe pain
right
Ursula Minoti
Signature
)
10
severe pain
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PATIENT SATISFACTION SURVEY
GUIDELINES
• Patient satisfaction is an important perception having not only to do with the actual effectiveness,
but also the setting and the process of receiving care.
• Patient Satisfaction Measures: Patient satisfaction measures are an important marker of
quality and are useful to clinical practice. Satisfaction is best assessed using standard
questionnaires measuring a number of dimensions.
BACKGROUND
Office surveys are an excellent way to gauge patient satisfaction.
OBJECTIVES
1. The primary objectives of a patient survey is to identify areas of both weakness and strength
in the practice.
2. Sending surveys to all patients — past and present — also serves as a “subtle” advertisement.
Doctors will find that surveys prompt former patients to resume care.
PRACTICE SUGGESTIONS
• The doctor should acknowledge helpful suggestions and legitimate complaints, promise to
take appropriate action and then do so.
• These forms should be retained in a patient’s file to disprove any claim he might later make
that he was dissatisfied with his care.
POTENTIAL DISADVANTAGES
Any patient survey will backfire if the doctor is not prepared to use the information gathered. If
patients perceive that the doctor is not listening to them, they will soon find another doctor. In
today’s competitive climate, patient loyalty is sometimes spread very thin. While many patients
will never complain to the doctor, they may simply switch providers when an excuse to do so
presents itself. A new practitioner, a solicitation in the mail, or a telephone inquiry all have the
potential to entice a patient who is generally dissatisfied with care to seek services elsewhere.
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PATIENT SATISFACTION SURVEY
Dear Patient:
Please help us provide better service to our patients by sharing your opinion as to how we’re
doing.You may sign the form or return it anonymously. Thank you.
PLEASE RATE THE FOLLOWING ON A SCALE OF 1-10
With 10 being the best:
6
Ease of making appointments
10
Ease of finding the office
10
Convenience of office location
9
9
5
6
9
9
5
5
10
Attitude of staff
E
L
P
M
Helpfulness of staff
Bright, pleasant waiting area
Punctuality
Appearance of staff
A
S
Courtesy of staff
Fair fees
Help with insurance
Adequacy of parking
IF YOU HAVE TELEPHONED THE OFFICE
Circle one
Did you have trouble getting through?
Yes
No
Were you kept on hold for too long?
Yes
No
If the office was closed, were you satisfied
with the information given by the answering
service or message?
Yes
No
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PROCESSING & FORMS
Was the staff helpful in filling out your
paperwork?
Yes
No
Were you embarrassed at any of the
questions or comments made?
Yes
No
Were your questions answered?
Yes
No
E
L
Did you have any problem with your
forms?
Yes
No
Did you see the doctor near your
appointment time?
Yes
No
If not, were you given a satisfactory
explanation?
Yes
No
Did the doctor explain his findings
in a way that you could
understand?
Yes
No
Did the doctor spend enough time
with you?
Yes
No
Did the doctor explain treatment
adequately before beginning it?
Yes
No
Did you have an opportunity to have
your questions and concerns
addressed?
Yes
No
Insurance
If yes, please explain
P
M
DOCTOR'S CARE
A
S
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HOW DID YOU LEARN ABOUT US (Check all that apply)
X
Newspaper
Friend
Relative
Co-worker
Radio
Television
Yellow Pages
Referral from Dr.
Other
E
L
SUGGESTIONS
If you could change one thing about this office what would it be?
P
M
Reduce fees
If you could keep one thing about this office from ever changing, what would it be?
Staff
A
S
OTHER SUGGESTIONS
THANK YOU
OPTIONAL INFORMATION
Name
Street
City, State and Zip
Telephone Number
Please return in the enclosed self-addressed stamped envelope.
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DIFFICULTY IN PERFORMING
ACTIVITIES OF DAILY LIVING
GUIDELINES
Functional outcome assessments of everyday tasks are very suitable for evaluating treatment of
dysfunctions of the neuromusculoskeletal system. Many questionnaires could be used.
BACKGROUND
Doctors need to learn if their patients are engaging in any activities which may interfere with
their response to treatment. Obtaining this information allows the D.C. to recommend that the
activity be discontinued altogether or to suggest ways to reduce the risk of harm from
continuing the activity.
OBJECTIVES
1. Avoiding re-injury. Reading through the form will make the patient aware of some of his
daily activities, which may be aggravating his condition. That awareness should make him more
careful during the healing process.
2. Helping the patient testify. Patients with claims against others — auto accidents, workers’
compensation or other tort situations, will often be called upon years after the acute phase of
their injuries to recount for a jury or hearing officer what effect their condition has on their daily
lives. A witness may not recall in detail how drastically his everyday routine was altered by the
trauma. Having this form to refresh his recollection before trial should assist the patient in
testifying effectively.
3. Helping the doctor write reports and testify. The form will also be useful for report
writing and testifying. The patient’s lawyer is almost certain to ask the D.C. to describe the
impact that the injuries had on his patient’s everyday life. He will include that information in
the “settlement package” he sends to the insurance adjuster or defense lawyer. Easy to
understand manifestations of injury and impairment will bolster the claim and possibly assist in
generating a settlement. If no settlement is achieved, the doctor will be asked, at trial, to
describe to a jury what impact the patient’s condition had on his life. Without adequate
documentation, few witnesses have sufficient recall to testify either accurately or effectively.
4. Avoiding malpractice. Many patients whose conditions are exacerbated by some activity
outside of the doctor's office look for someone to blame other than themselves. If the doctor has
not taken the time to inquire about the activities, which cause difficulty, he will appear
neglectful. Conversely, using this form will memorialize the thoroughness of the doctor’s care.
Asking for any difficulties not listed, precludes the patient’s arguments that: “He never asked
never whether my weekend job as a bouncer in a mud-wrestling bar caused me problems.”
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PRACTICE SUGGESTION
Attach the completed form to the narrative report sent to the patient’s lawyer in a personal
injury or workers’ compensation case.
FREQUENCY OF USE
Trauma: At the initial visit
Weekly thereafter until patient is no longer acute
Monthly thereafter
Upon discharge/or having reached MMI/MCI
Chronic: At the initial visit
Every 4-6 weeks until patient is significantly improved
Quarterly thereafter
Upon discharge/or having reached MMI/MCI
“Maintenance” patient: Annual assessment.
Which used in conjunction with the patient progress form (pages 189-195) this information
should allow the doctor to make accurate periodic re-evaluations of each patient’s condition.
POTENTIAL DISADVANTAGES
If a patient checks an activity and no one ever questions him about it, he will be left wondering
what good it does to provide information which is never used. He will also wonder what would
have happened to him if he had checked something really important and nobody had paid any
attention to it. In short, he will lose confidence in the doctor if the information supplies is not
acted upon appropriately.
If the patient is later injured while performing one of the activities, he will assume he should
have received some king of warning. Such doubts may encourage him to visit a lawyer to ask
about a lawsuit!
Inaction in response to an activity the patient “notes” can give a malpractice attorney the
opportunity to suggest to the jury that the doctor obviously knew the activity was potentially
harmful because it was right on his own form! Failing to follow up on a positive response is
potentially worse than never having asked about it at all.
This form and many others share the potential to make matters worse if the doctor does not
make proper use of the information which they are designed to elicit.
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DIFFICULTY IN PERFORMING
ACTIVITIES OF DAILY LIVING
PATIENT NAME:
Kristen Weller
Check each of the activities which you have difficulty performing and/or can perform only with
pain. (There is no particular priority in the order presented.)
HOUSEWORK
✓ Doing laundry
✓ Making beds
✓ Vacuuming
✓ Washing dishes
✓ Ironing
✓ Carrying groceries
✓ Caring for pets
✓ Cooking
✓ Other lifting children
YARD WORK
✓ Mowing lawn
Shoveling Snow
✓ Raking leaves
✓ Gardening
PERSONAL GROOMING
✓ Combing hair
Shaving
In/out bathtub
Brushing teeth
Other:
TRAVEL
Riding (Passenger)
Minutes per day
Type vehicle
Auto
Train
Bus
Truck
Airplane
A
S
GENERAL
✓ Walking
Standing
✓ Running
✓ Sitting
✓ Lifting children
Bending
Climbing stairs
Reading
Laying in bed
Chewing
Swimming
Sports: List
E
L
P
M
✓ Driving
120 minutes
✓ Getting in and out of
✓
auto
Playing piano
Using
typewriter/computer
Kneeling
Sexual intercourse
Exercising
Sleeping
Using telephone
Sitting in recliner
OTHER: Please list any other difficulties you are experiencing with activities you have engaged
in since your condition arose:
Signed
Unable to use my exercise rowing machine; unable to lift or bathe my daughter.
Kristen Weller
January 4,0000
Date
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SELF- HELP ACTIVITIES
GUIDELINES
Ethical Considerations…[require the doctor to] maintain the patient's autonomy by sharing
knowledge, providing self-help measures, and avoiding physician dependency.
Important elements of the history may include…attempts at self-care.
BACKGROUND
A doctor needs to know about patient activities which facilitate treatment just as much as those
which impede it. This information allows him to instruct the patient on how to maximize the
benefit of such activities and perhaps to suggest other.
OBJECTIVES
• Encouraging “self-help.” Reading through the form will suggest soothing, “self-help”
activities which the patient might not otherwise consider. It will also assist in remembering to
alert each patient to the many helpful activities which may afford additional relief.
• Assisting in the patient's claim. Patients with claims against others — auto accidents,
workers’ compensation or other tort situations — are required to “mitigate” their damages. This
means the patient is required to do everything reasonable to assist in his own recovery and
thereby minimize his loss. This form will document the steps taken, in addition to office care,
to speed the patient's recovery. That the patient was unable to achieve full recovery even with
faithful devotion of 30 minutes a day to exercising, for example, can create a vivid image of a
jury to focus upon in assessing the “value” of the patient's injury.
• Avoiding Malpractice. A doctor who has not even inquired about the types of activities,
which relieve his patient's symptoms, may appear slipshod. Conversely, use of the form will
memorialize a comprehensive treatment plan.
PRACTICE SUGGESTION
Attach the completed form to the narrative report sent to the patient’s lawyer in a personal
injury or workers' compensation case.
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FREQUENCY OF USE
Trauma: At the initial visit
Weekly thereafter until patient is no longer acute
Monthly thereafter
Upon discharge/or having reached MMI/MCI
Chronic: At the initial visit
Every 4-6 weeks until patient is significantly improved
Quarterly thereafter
Upon discharge/or having reached MMI/MCI
“Maintenance” patient: Annual assessment.
POTENTIAL DISADVANTAGES
If the patient checks activities which help him and the doctor never mentions them, the patient
will wonder why he wasted his time completing the form. This kind of seemingly minor patient
relations blunder — coupled with others — can erode the patient’s confidence in the doctors. If
the D.C. elects to seek input from patients, he must acknowledge it and take appropriate action
or explain why no action is necessary.
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SELF-HELP ACTIVITIES
PATIENTS NAME:
Samuel Jacobsen
Check each of the activities, which make you more comfortable and/or more mobile.
✓
Sleeping
Hot water bottle
Heating pad
Liniment
Swimming
Sauna
Whirlpool
Sitting
Over-the-counter medicine
Home traction
Home exercise equipment
List types:
✓
✓
Lying Down
Hot baths
Ice pack
Exercising
Stretching
Steam room
Walking
Sitting in recliner
Prescription drugs
E
L
✓
P
M
OTHER: Please list any other activities, which make you, feel better or allow you to
massage of my low back area
move easier:
A
S
Please state the amount of time you devote daily to each.
4-5 hrs.
1 hour
January 4, 0000
Date
Sleeping
Hot water bottle
Heating pad
Liniment
Swimming
Sauna
Whirlpool
Sitting
Over-the-counter medicine
Home traction
Home exercise equipment
8-10 hours
3 x day 10 minutes
1 hour
Lying Down
Hot baths
Ice pack
Exercising
Stretching
Steam room
Walking
Sitting in recliner
Massage
Samuel Jacobsen
Signature
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INSURANCE INFORMATION
GUIDELINES
• Heath care coverage information is important for the business function of a heath care facility,
and such records are a part of the health care record. However, the information obtained and
the format used are at the discretion of the practitioner.
•
•
•
•
current incident result of accident or injury
insurance company or responsible party (auto/workers’ comp/heath/other)
group and policy numbers effective date
spouse's insurance company and policy information.
• Administrative records are primarily those relating to the non-clinical side of practice, but
there is some overlap into the doctor-patient relationship. Examples of administrative records
may include insurance forms and billing, collection and patient billing, routine correspondence,
a record filing system that makes for accurate retrieval of patient data. These records must be
maintained in a legible and retrievable format.
• While financial data is important for the business function of a health care facility, and such
records are indeed part of the health care record, the information obtained and the method of
acquiring such information is at the discretion of the practitioner. Any alteration of standard
fees charged necessities documentation (e.g. in cases of financial hardship).
BACKGROUND
Simply stated: This is what gets the doctor paid in many cases. Omissions here will disrupt
future cash flow.
PRACTICE SUGGESTIONS
The “financial” CA should always examine the patient's insurance card to verify numbers,
expiration, exclusions and deductibles. Making a photocopy of the card may prove helpful.
When the insurer is a new or different company, the CA will usually find a “customer service”
phone number on the card which can be used to verify coverage and secure claim forms.
Most information should be filled in by the patient or verified by the patient's signature.
Mistakes can happen, but the doctor will want to take all reasonable measure to assure that the
patient verifies the “insured number” he uses for his submissions. If there is a mistake, it will not
be the doctor’s.
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INSURANCE ASSIGNMENT, INFORMATION
RELEASE AND PAYMENT INFORMATION
John L. Spalding
Patient Name:
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
ASSIGNMENT OF INSURANCE BENEFITS
E
L
I authorize and direct that payment be made directly to:
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
P
M
For any and all insurance benefits or reimbursement for services rendered by HIM which
amounts would otherwise be payable to me under any insurance or pre-paid health care
plan.
A
S
January 4,0000
Date
John L. Spalding
Patient Signature
RELEASE OF INFORMATION. I authorize the release of any information
concerning my health and health care services to my insurance companies, pre-paid
health plan of Medicare.
January 4,0000
Date
John L. Spalding
Patient Signature
PAYMENT AGREEMENT. I understand that there is no guarantee that my insurance
companies or pre-paid health plan will cover or pay for all of my charges. Notwithstanding
denial, reduction of benefits or failure to pay for any reason, I understand that I am
responsible for all remaining charges.
January 4,0000
Date
John L. Spalding
Patient Signature
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ASSIGNMENT, LIEN & AUTHORIZATION TO
RELEASE MEDICAL RECORDS & INFORMATION
BACKGROUND
Heath care providers expect to be paid for their services. In some instances a practitioner may
forego immediate payment based upon reasonable assurances that he will be paid after
settlement of a personal injury cause or receipt of some other form of third party payment.
One device widely used by providers to attempt to assure payment is the assignment and/or lien
form. The patient signs this form during his first visit to promise the doctor that he will be paid
when the case is settled or some other third party payment is received.
ADVANTAGES
This form purports to protect the doctor in many ways; (1) by instructing the insurance
company making payments or the attorney who receives it to pay the doctor directly; (2) by
assigning to the doctor all rights that the patient might have to the payment from third parties,
including the right to file suit to secure that payment; (3) by granting a lien to the doctor against
all third parties for the proceeds; and (4) by permitting the doctor to release the patient’s records
TO ANYONE if necessary to obtain payments. The agreement is irrevocable according to its
terms.
DISADVANTAGES
• Not all states recognize the validity of this form for all of the purposes mentioned above. A
doctor should provide a copy of this form to local counsel for review to determine if it meets
the requirements of that state’s lien statute.
• The provisions of this form may be extremely difficult to enforce in those states that do not
grant such statutory protection to the provider. Many states have held that the insurance
company or attorney is not bound by the form's terms since it was not signed by the third party.
The document is also extremely harsh. For instance, it grants the doctor the right to release
records to the insurance company defending the person responsible for the accident. Certainly
no attorney representing a patient would allow his client to sign such a release. It is also
“irrevocable”; a term which a court may find “against public policy” if a doctor tried to enforce
its terms against a patient who later sought to revoke the agreement.
While patients are accustomed to signing most documents placed in front of them at the time
of their first visit, many patients who read this agreement will take offense at its blunt terms.
Even if a patient signs it without comment, the form may “strain” the doctor-patient
relationship from the outset, and the doctor may be puzzled by the patient's “negative attitude”.
Certainly, the doctor deserves to be paid. The doctor may, however, wish to consider other
payment devices, which are less onerous, such as the letter of protection discussed in this text.
See page 409-410 “Letter of Protection.”
Any doctor proposing to use this form should do with discretion and only after consulting local
counsel.
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ASSIGNMENT, LIEN & AUTHORIZATION TO
RELEASE MEDICAL RECORDS & INFORMATION
Patients Name
J.D.
John Doe
Patient's Initials
For good and valuable consideration received, I JOHN DOE, being the undersigned, authorize
and direct you, DAIRYFARM INSURANCE COMPANY AND JOHN Q. GREEN, ESG, to
pay directly to DR. RICHARD ROE any sums as may be due and owing this chiropractic office
for services rendered me, both by reason of accident, or illness and/or by reason of any other
bills that are due this chiropractic office, and to withhold such sums from any disability benefits,
medical payment benefits, no-fault benefits, health and/or accident benefits, workers’
compensation benefits, or any other insurance benefits or reimbursement whatsoever for which
you may be obligated to reimburse me, or from any settlement, judgement or verdict on my
behalf as may be necessary to adequately protect said chiropractic office.
E
L
In further consideration of the above-indicated treatment, I hereby give a lien to said office
against any and all insurance benefits named herein, and any and all proceeds of any
settlements, judgement, or verdict, which may be owed me as a result of the injuries or illness
for which I have been treated by said office. This contract to act as an assignment of my rights
and benefits to the extent of the office's charges for services provided herein.
P
M
I, the undersigned, further hereby authorize and direct my attorney, JOHN Q. GREEN,
when settlement or judgement is reached, to pay in full the chiropractic bills rendered for all
treatment and services as a result of the injuries or illness for which I have been treated by said
office and any other amounts which I may owe said office at that time.
A
S
In further consideration of the treatment rendered herein, I do hereby authorize the chiropractic
office to furnish you, the above-indicated party, a full report of my examination, diagnosis,
treatment, prognosis, chiropractic bills and any other relevant information pertaining to my
treatment.
I UNDERSTAND THAT BY SIGNING THIS DOCUMENT I AM AUTHORIZING
RELEASE OF REPORTS AND INFORMATION TO THE ABOUT-INDICATED
PARTY, WHICH COULD INCLUDE THE RESPONSIBLE PARTY'S INSURANCE
COMPANY.
Furthermore, I authorize the chiropractic office to release any information pertinent to my case
to any insurance company, adjuster or attorney to facilitate collection under this assignment,
lien and medical authorization.
In the event any insurance company is obligated to make payments to me upon the charges
made by this office for the service rendered and refuses to make such payments, I hereby assign
and transfer to this office any and all causes of action, claims, whether in law or equity,
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that I might have or that might exist in my favor against such company, and authorize this
office to prosecute said cause of action either in my name or in the office's name and further
authorize this chiropractic office to compromise, settle or other wise resolve any claim or
cause of action in its sole discretion herein as it relates to amounts owed this doctor.
I understand that I am directly and fully responsible to said office for all medical bills
submitted by them for services rendered me and this agreement is made solely for said
office's additional protection. I further understand that such payments is not contingent on
any settlement, judgment or verdict by which I may eventually recover said fees. Said
medical payments are due on demand by the office. I further understand and agree that
said assignment, lien and authorization do not constitute any consideration for the office to
await payment and it may demand payments from me immediately upon rendering services
at its option.
E
L
This agreement is irrevocable and is binding upon the heirs, executors and legal
representatives of the undersigned. Wherefore, the undersigned has hereunto set his hand
this
4th
day of
January
, 0000.
P
M
John Doe
Patient
ATTORNEY ACKNOWLEDGEMENT OF ASSIGNMENT, LIEN, AND
AUTHORIZATION AND RELEASE OF MEDICAL RECORDS AND
INFORMATION.
A
S
John Q. Green
I,
, attorney for the above-indicated
patient hereby acknowledge receipt of the above assignment and lien
and agree to protect said chiropractic office pursuant to aboveindicated terms.
Date:
January 4, 0000
Attorney:
John Q. Green
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FINANCIAL HARDSHIP PAYMENT AGREEMENT
GUIDELINES
• Any alteration of standard fees charged necessitates documentation (e.g. in cases of financial
hardship).
• Any facility utilizing two or more fee schedules for [its] services is engaging in unethical and
potentially illegal activity. Services should be billed at the same rate whether payment is direct
or by a third party.
BACKGROUND
A doctor is not free to randomly adjust fees according to a patient’s ability to pay, the presence
or absence of insurance or the patient's past history of paying cash at the time of service. Using
a “dual fee schedule” under which a person without insurance is automatically — without
regard to his ability to pay — charged less than one with insurance may subject a doctor to
insurance investigation, criminal charges and disciplinary board action.
Zealous anti-fraud enforcement has spawned charges of mail-fraud and federal RICO violations
against doctors when they mail claim forms across state lines. Facing those powerful
governmental weapons is not for the faint heated, no matter how well intentioned.
PRACTICE SUGGESTIONS
Doctors do have the freedom, however, to make their services available to the needy. This
requires a good-faith evaluation of the patient’s resources and ability to pay. While the doctor
need not take a detailed financial statement, he must ask sufficiently detailed questions to
establish that the patient cannot afford care. If he cannot, it is permissible to negotiate a
payment schedule based upon ability to pay.
Such an agreement must be individualized according to ability to pay; it is not intended to
serve as a simple, automatic fee reduction to anyone without insurance.
This form has the additional advantage of requiring minimum monthly payments without the
expense of regular billings.
POTENTIAL DISADVANTAGES
One source of administrative headache and potential, inadvertent violation of law is the charging
of interest on accounts being paid by installments. For small accounts, the additional
bookkeeping required to assess finance charges will likely not be worth the effort. If such an
assessment is made, however, it must comply with the “truth in lending” requirements,
including disclosure of annual percentage rate and all those fine print explanations seen in
connection with credit cards.
Since the whole idea of this form is to make services available for those who otherwise could not
afford care, the easiest course is certainly for the doctor to forego interest.
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FINANCIAL HARDSHIP PAYMENT AGREEMENT
PATIENT NAME:
Bruce Mayer
I hereby certify that I have been informed of the usual fees of Dr. RICHARD ROE
for the examination, testing and treatment HE has recommended that I undergo. I am
unable to pay those fees at this time without substantial financial hardship. I have no
expectation of being able to recover those expenses from any third party.
To enable me to obtain HIS services, Dr. ROE and I have agreed to a special
payment arrangement under which I will make a down payment of TWENTY percent of
the regular charge for each service at the time it is rendered. I will pay the balance of
accrued charges at the rate of $00.00 per month until paid in full.
E
L
It is my responsibility to make these payments without any need for periodic bills or other
reminders of payments due.
In consideration of the courtesy of deferred payment hereby extended to me, I expressly
waive the benefit of any applicable statute of limitations on the collection of my account. I
covenant and agree not to plead the same.
P
M
January 4,0000
Date
A
S
Wendy O’Hara
Witness Signature
Wendy O’Hara
Print Name
Bruce Mayer
Patient Signature
Bruce Mayer
Print Name
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CONSENT TO PARTICIPATE IN RESEARCH
GUIDELINES
When a practitioner engages in research, the ethical basis of the doctor-patient relationship
changes to an investigator-subject interaction. The new relationship must meet a new set of
criteria different from clinical practice.
If a patient is requested to participate in a research study or project the request must be
accompanied by informed consent that meets the minimum requirements for the protection of
human subjects as established by competent authorities (e.g. NIH/NSF or state/provincial law).
BACKGROUND
With the burgeoning interest in, and requirement for studies validating chiropractic, case studies
and field research will doubtless increase. If the doctor decides to conduct research, the patient
is not only entitled to know that, he must consent before he is made a part of it.
This form should only be used as part of a legitimate research project, preferably in association
with an educational institution or other research organization.
PRACTICE SUGGESTIONS
The doctor must advise of any risks which the research may entail for the patient.The “Consent
to Participate in Research” form provides adequate space to list any possible complications and
appropriate clarification to the patient. Presumably routine research and data gathering would
expose the patient to no greater risk(s) than that entailed by treatment(s) employed in the
normal course of care.
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CONSENT TO PARTICIPATE IN RESEARCH
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Dr. RICHARD ROE has explained to me the research project HE is participating in which
is exploring THE EFFECTS OF SPINAL MANIPULATION ON SINUSITIS. I hereby
consent to participate in that project and for any data and other information which may
be gathered to be utilized in whatever manner Dr. ROE deems appropriate, so long as I am
not identified.
E
L
I understand this research may entail the following risks for me of injury, complication(s)
or adverse reaction:
P
M
None
A
S
January 4, 0000
Date
I am
36
years of age
Sally Winer
Signature
Sally Winer
Print Name
Betty Golder
Witness
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PUBLICATION/PHOTO/VIDEO CONSENT
GUIDELINES
• All records from which a patient may be identified (e. g. photographs, videotapes, audio tapes)
should only be created once consent has been obtained. Such consents should identify
the purposes of the record and the circumstances under which it will be released.
a. records for clinical management.
b. records for all other purposes (e.g., research, training, distribution).
• Basic information identifying the practitioner or facility should appear on documents used
to establish the doctor-patient relationship. This can be pre-printed on forms… Basic
information should include:
•
•
•
•
•
•
practitioner's name/specialty
specialty designation (if applicable)
facility name (if different)
legal trade name (if applicable)
street address and mailing address (if different)
telephone number(s)
BACKGROUND
D.C.s have used photographs for some time in Moire Contour Analysis. Growing in popularity
is the practice of videotaping examinations — particularly with patients presenting with injuries
resulting from trauma which will likely be litigated. When these materials are used for internal
“clinical” purposes only, obtaining proper consent is strongly suggested. If, to the contrary they
are going to be used for any other purpose, the consent is deemed necessary.
POTENTIAL DISADVANTAGES
Doctors should be certain to abide by the wishes of patients who decline to sign this
authorization. They will be more aggrieved if, having been asked, their wishes are subsequently
disregarded.
Any mention of commercial purposes may offend some patients who would not otherwise object
to this concept. Deletion of the language in parentheses in the last paragraph will remove that
objection when no commercial use is intended.
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PUBLICATION/PHOTO/VIDEO CONSENT
Patient Name: Beatrice Longworth
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
I consent to the production of photographs, videotapes, and audiotapes during my
examination and treatment under the following conditions:
E
L
• They may be produced only with the consent of Dr. RICHARD ROE at such times and
in such manner as HE may dictate.
• They shall be taken only by Dr. ROE or other technician approved by HIM.
P
M
• They will by used as a part of my medical records, but if in the judgment of Dr. ROE
they will benefit research, training or science, they and other information relating to my case
may be used in any way HE deems fit and proper in the interest of chiropractic education,
research and knowledge. If used for any of these purposes, I shall not be identified by name
in any way.
A
S
• They may be retouched or other wise edited in whatever manner Dr. ROE considers
desirable.
• I waive any claim or right I may have to payment or royalties arising from any showing or
other use of these materials (regardless of whether such use is for commercial or educational
purposes and) regardless of whether admission or other fee is charged.
January 4, 0000
Date
Beatrice Lingworth
Susan Beechworth
Witness Signature
Susan Beechworth
Print Name
Signature
Beatrice Lingworth
Print Name
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AUTHORIZATION TO ADMIT OBSERVERS
GUIDELINES
Persons not participating in the treatment of the patient should not be permitted it watch
examinations or procedures without authorization from the patient.
BACKGROUND
The doctor may have occasion to have a CA, applicant for associateship, chiropractic student or
other person witness an examination or treatment. Failure to obtain the patient's consent is
inconsistent with patient confidentiality and can generate considerable resentment.
OBJECTIVE
Including this form among the intake paperwork eliminates the trouble of seeking approval
when a specific need arises…which will usually be with little advance notice and under
circumstances that would make obtaining the consent then inconvenient or easily overlooked.
DISADVANTAGES
Doctors should be certain to abide by the wishes of patients who decline to sign this
authorization. They will be more aggrieved if, having been asked, their wishes are subsequently
disregarded.
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AUTHORIZATION TO ADMIT OBSERVERS
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
I authorize Dr. RICHARD ROE to admit observers while I am undergoing examinations
or treatment procedures as HE may deem appropriate, including but not limited to, treating
and non-treating doctors and office personnel.
E
L
P
M
January 4, 0000
Date
I am
57
Patricia Bates
years of age
A
S
Witness Signature
Patricia Bates
Print Name
Willard O’Brien
Signature
Willard O’Brien
Print Name
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AUTHORIZATION TO USE PATIENT NAME
IN NEWSLETTER/ON BULLETIN BOARD
BACKGROUND
Many doctors routinely send out announcements of patient birthdays and post “thank-you”
notices listing the names of those who have referred new patients. Technically, such activities
violate patients’ rights to confidentiality and privacy unless the doctor has obtained their
permission to “publish” their names.
While few patients are likely to ever make a serious protest about such a breach, some may be
sufficiently annoyed that the doctor-patient relationship will deteriorate.
OBJECTIVES
Use of this form not only avoids possible breach of confidentiality, it reinforces the appearance
of professionalism even to those patients who would have not objected to such use of their
names without any authorization. Patients appreciate being asked.
DISADVANTAGES
Doctors should be certain to abide by the wishes of patients who decline to sign this
authorization. They will be more aggrieved if, having been asked, their wishes are subsequently
disregarded.
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AUTHORIZATION TO USE PATIENT NAME IN
NEWSLETTER/ON BULLETIN BOARD
PATENT NAME
Elizabeth Mayfield
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
E
L
Dear Dr.:
I give you permission to use my name in your patient newsletter and on any office bulletin
or other notice boards for purposes of announcing births, birthdays, weddings, graduations
or acknowledging my referrals.
P
M
January 4, 0000
Date
Elizabeth Mayfield
Signature
A
S
Elizabeth Mayfield
PATIENT NAME:
Print Name
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RELEASE OF ALL CLAIMS
Contact Malpractice Carrier Before Use
BACKGROUND
A patient who has a complaint about the quality of his care or who alleges that the doctor or a
staff member has caused him injury may demand: “I want my money back.”
If the amount involved is relatively small, the doctor may wish to consider making some kind of
accommodation such as a full or partial refund.
A release is a contract, just like any other contract. If the patient is willing to “sell” any claim he
may have for an amount that the doctor is willing to pay (refund) a binding contract may
be formed.
OBJECTIVES
1. To defuse a potentially volatile situation before the patient’s annoyance can fester and
generate a malpractice suit.
2. To bind the patient to an agreement preventing him from later suing or demanding
additional compensation.
PRACTICE SUGGESTIONS
• Prior to making a refund or other payments, the doctor should contact his malpractice
carrier.
• The doctor should be forthright and candid in assuring that the patient understands what he
is doing. This document is not intended to be used to mislead any patient, but rather to give
binding effect to a good-faith agreement between doctor and disgruntled patient.
• An agreement to forgive fees not yet paid may be sufficient to support this contract. Doctors
should consult their local attorneys to assure compliance with applicable law.
POTENTIAL DISADVANTAGES
WARNING: CHECK WITH YOUR PROFESSIONAL LIABILITY
INSURANCE COMPANY BEFORE EACH INTENDED USE OF
THIS FORM!
• The policy language of the major chiropractic malpractice insurance companies restricts the
doctor's freedom to settle claims by offering anything of value to a patient. Failing to comply
with the wishes of the carrier and its contractual requirements may jeopardize coverage should
the settlement offer be rejected and the patient bring suit.
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• This form will not protect an “independent contractor/associate”; he will need his own,
separate agreement.
• Any use of this form should be reviewed by a local attorney to assure full compliance with any
local requirements.
• Some states monitor settlement of “malpractice” claims and multiple settlements may result
in disciplinary action. A doctor should settle no claim or dispute without consulting his attorney
and insurer to identify any potential adverse effect from entering into a settlement.
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RELEASE OF ALL CLAIMS
Patient Name
John Doe
FOR AND IN CONSIDERATION of the payment of SOME AMOUNT OF (00.00)
Dollars, the receipt of which is hereby acknowledged, I, JOHN DOE, being of lawful age,
do hereby acquit and forever discharge RICHARD ROE, D.C., his associate, RICHARD
JUNIOR, D.C. and the ROE CHIROPRACTIC CLINIC, P.C., their heirs, executors,
employees, agents, principals, directors, associates, successors and assigns, from any and all
liability now accrued or hereafter to accrue on account of any and all claims or causes of
action which I know have or may hereafter have for personal injuries, loss of services,
medical expenses, economic or pecuniary damage, and all other losses or damages of any
and every kind or nature whatsoever, now known or unknown or that may hereafter develop,
arising out of any acts or omissions pertaining to my diagnosis and treatment and any
rendering or failure to render professional advice or service, by RICHARD ROE, D.C.,
RICHARD JUNIOR, D.C. and the ROE CHIROPRACTIC CLINIC, P.C. and its
employees.
E
L
P
M
IT IS FURTHER AGREED AND UNDERSTOOD that this release and settlement is a
compromise of a disputed claim and that the payment is not to be construed as an
admission of liability on the part of the party or parties hereby released.
A
S
I further state that I have carefully read the foregoing release and I know the contents
thereof and have signed the same as my own free act and have not been influenced in
making this release and settlement by any representation of the party or parties released.
Executed at ANYTOWN, STATE, this 15TH day of AUGUST, 0000
CAUTION: READ BEFORE SIGNING BELOW
Ann Black
John Doe
Witness Signature
Signature of patient
Ann Black
Print Name
John Doe
Print Name
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CHILD ABUSE/NEGLECT REPORT
BACKGROUND
Today's doctors assume many obligations never considered by the pioneers of the profession.
One such modern requirement is to report suspected child abuse and neglect. That such
atrocities are of epidemic proportion is confirmed by statistics generated by the National Center
for the Prevention of Child Abuse and Neglect which in 1988 estimated that more than a million
children are abused annually and that 4,000 die each year as a result.
Legislative mandates to report child abuse typically target health care providers since their work
positions them to observe evidence of abuse. Doctors of chiropractic and other designated
professionals are therefore “mandated reporters” under the child protective law of most states.
Doctors of Chiropractic have neither choice nor discretion when it comes to filing a report. If
the situation fits within the statutory framework, the doctor is required to report his
suspicions and/or observations.
In addition to child abuse, another symptom of today’s societal problems is the proliferation of
(or increased awareness of) abuse and neglect of the aged. That this problem has reached
significant proportions is shown by the heightened legislative attention it is receiving. Elderly
abuse statutes in many states now mandate reporting virtually identical to that required by child
abuse laws.
OBJECTIVES
1. To comply with mandatory reporting requirements, violation of which can subject the doctor
to fine and imprisonment.
2. To avoid potential malpractice exposure. The child who is subjected to continued abuse,
which arguably could have been avoided if a report had been made and the perpetrator brought
to task, may sue the doctor for damages sustained after a report should have been made.
PRACTICE SUGGESTIONS
Close review of state law is necessary to understand when a report must be filed. Some laws do
not require that the victim even be a patient, only that the doctor have “reason to suspect” abuse
or neglect from “contacts” made in his professional capacity. Under such broad criteria, the
children or parents of patients, staff, deliverymen, repairmen and clinic maintenance personnel
might be the proper subject of report.
The doctor filing an abuse report should remind staff members that the entire process, including
the incident witnessed, remains confidential even thought a report may properly be filed. Any
comment other than in the report may violate the patient’s rights to confidentiality and privacy.
Each state’s statute will identify one or more appropriate agencies to which the doctor should
address his report.This may be the Department of Social Services, Department of Welfare, local
police or other agency.
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In the event of litigation by an aggrieved parent, a report which cites the statutory requirements
for filing, reinforces the doctor’s claim that he filed the report because it was his legal
responsibility to do so. The form may aid in convincing the jury that the doctor acted without
malice, thought he was performing his civic duty and therefor was entitled to immunity under
the statute.
The time frame specified in the sample form tracks the California statutory requirement and
should be replaced with whatever time period is required in the practitioner’s state.
The doctor should mail the report certified receipt requested and retain the receipt with a cope
of the letter in the patient's permanent record.
In may not be possible to list all the reportable items of information. It may be sufficient to
summarize: “Patient admitted physical abuse.”
FREQUENCY
There is no discretion — reports must be made each and every time the doctor has reasonable
cause to suspect abuse or neglect.
POTENTIAL DISADVANTAGES
An innocent parent who is subjected to the humiliation, expense and familial upheaval incident
to an erroneous child abuse complaint may be so outraged as to strike out at whomever he
suspects may have initiated the investigation.
Doctors are insulated from civil liability by immunity statutes, which protect them if their
suspicions were reasonable, even if they are ultimately proven inaccurate. Those immunity
statutes, however, universally include exceptions for situations in which the report is filed
“maliciously” or with reckless disregard for the truth. A skillful lawyer will certainly include
allegations of malice when he files suit against a doctor. Even the doctor who is successful in
defending such claims will devote considerable time, energy and money to mounting a defense.
Still, it is far preferable to argue that the doctor erred on the side of caution in seeking to protect
a child than to attempt to justify failing to report if subsequent abuse causes an injury.
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CHILD ABUSE/NEGLECT REPORT
Confidential
To: Child Protective Agency of Palm Tree County, California
Re: Suspected abuse/neglect of:
PAUL JONES
(name)
18 WEST SPRUCE
(address)
IMAGINARY CITY, CALIFORNIA
(city & state)
6 YEARS
(approximate age)
E
L
CALIFORNIA CODES ANNOTATED §11166 (PENAL CODE) requires me to report
suspected child abuse. In compliance with the requirements of that law, I immediately
reported my suspicions concerning the above named child, by telephone AUGUST 1, 0000.
I spoke with Mr. Rob Smith of your agency at approximately 2:30 p.m.
P
M
In further compliance with law, I am submitting this written report with in 36 hours of
receiving the information concerning the incident described below, which aroused my
suspicions.
A
S
Where Observed:
MY OFFICE AT 605 SOUTH MAIN ST., ANNA, CALIFORNIA.
Whom Observed:
PAUL JONES AND HIS MOTHER, MARY JONES
Nature of Acts or Injuries Arousing Suspicion:
PAUL HAD NUMEROUS FACIAL BRUISES. I GOT HIM ALONE AND ASKED
HIM WHAT HAD HAPPENED AND HE TOLD ME THAT “MAMMA GOT MAD
AND HIT ME.” I ASKED HIM WHAT SHE HIT HIM WITH AND HE SAID: “HER
FIST — A LOT OF TIMES IN THE FACE AND STOMACH.” HE SAID IT
HAPPENS: “ALL THE TIME.”
Suspected Perpetrator of Abuse or Neglect:
PAUL'S MOTHER, MARY JONES
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Other Relevant Information:
PAUL IS A SMART, ARTICULATE LITTLE BOY; I CAREFULLY QUESTIONED
HIM, AND HAVE NO REASON TO DISBELIEVE HIM.
August 1,
, 0000:
E
L
Richard Roc,
Signature
Richard Roe, D.C.
Print Name
P
M
18 Water St., Anytown , Ca 99999
Address
A
S
555-123-4567
Telephone Number
CERTIFIED, RETURN RECEIPT REQUESTED
D.C.
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AUTHORIZATION TO RELEASE PATIENT
INFORMATION & MEDICAL RECORDS
GUIDELINES
With the consent of a competent patient or guardian, records may and in most situations must,
be provided to third parties. The patient consent should not be more that 90 days old. The
original record should never be released.
OBJECTIVE
This form, properly executed, will protect the doctor against patient claims that he divulged
confidential information without proper authority.
PRACTICE SUGGESTIONS
• If the doctor is seeking patient records from an earlier provider from whom he has had no
cooperation in the past, inclusion of the state's statutory requirement for the release of records
may elicit prompt compliance which may avoid unnecessary duplication of diagnostic and
related services.
• The doctor should exercise care when releasing information to assure that the release is not
outdated and has not been withdrawn.
APPLICATION
The doctor should require that a patient sign this form or provide a similar one, properly
executed, prior to releasing any patient information to a third party or requesting that a third
party release such information to him.
FREQUENCY
• Some lawyers will have their clients sign an authorization, which revokes any prior
authorizations. Each authorization received should be carefully reviewed to learn whether it
contains such a revocation. If so, a warning label should be placed on the patient file to avoid
inadvertent improper disclosure to others.
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AUTHORIZATION TO RELEASE PATIENT
INFORMATION & MEDICAL RECORDS
TO:
Dr. Jeff Goldman
3333 Hamilton Blvd.
Westerfield, FL 03347
I hereby request and authorize you, your employees and agents to furnish to the person(s)
listed below or anyone designated in writing by him/her/them, all records and reports,
including X-rays and photostatic copies, abstracts or excerpts of all records and any other
information he/she/they may request relating to any examination, treatment or opinion
concerning any condition that I may have had in the past, now have, or may have in the future.
Please forward the reports and information requested to:
P
M
Dr. Richard Roe
Name
18 Water St.
Street Address
A
S
Anytown, State 99999
City, State, and zip code
E
L
Sherry Weidman
Signature
Sherry Weidman
Print Name
44 St. James Road
Street
Westerfield, FL 03347
City, State and Zip Code
Date:
January 4, 0000
I am
37
years of age.
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HAZARD WARNING
GUIDELINE
Patient education should include instruction on bending, lifting, pushing and pulling, entry and
exit from vehicles, sitting, yard work, recreation, personal care and sexual activity.
BACKGROUND
Doctors must warn their patients of everyday activities, which may aggravate their conditions.
This will optimize response to treatment and reduce the doctor’s potential liability if the patient
incurs further injury performing some activity he was cautioned against. If there are activities,
which are reasonably likely to exacerbate a patient's conditions, the doctor must take reasonable
action to alert the patient to the risks.
The doctor must also warn the patient of limitations, which his physical condition may impose
on his everyday activities. For example, if a person is unable to turn his head normally, it is
reasonable to expect that he would be unable to fully look to his rear and deal with “blind spots”
while operating a motor vehicle. Even though those limitations may seem obvious, the doctor
has a duty to bring them to the patient's attention.
If the patient or another person suffers injury in a collision that may have been avoided if the
doctor had issued appropriate warnings, the doctor may be held responsible.
OBJECTIVES
This form is intended to serve as:
1. A reminder to the doctor to warn the patient of potential harmful hazardous activities.
2. A written reminder to the patient of the activities he should avoid.
3. Corroboration that warnings were given should a malpractice claim arise.
4. A reminder to the patient concerning activities he may not be aware would be harmful or
injurious to his condition.
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HAZARD WARNING
PATIENT NAME:
Jacob Stoneman
DATE:
January 16, 0000
(Checked Items Apply)
X
❑
Among the conditions we discovered during your examination(s) is a limitation of the
range of motion in your neck and back. This means that your are unable to bend, twist and
turn normally. This limitation may interfere with many of your normal daily activities.
X
❑
If we have prescribed a cervical collar or other supporting device for you, it may limit
your range of motion and reduce your field of vision.
❑
If you suffer from a disc problem or condition, which results in sciatic (leg) pain, it may
prevent you from putting sufficient pressure on your car brakes to safely come to an
emergency stop.
E
L
Activities as indicated below may entail a substantial possibility of injury or
aggravation of your condition.
In your case, we recommend that you temporarily discontinue the following activities as
checked.
P
M
X
Driving: This warning is issued for your own safety, as well as that of your
passengers, other drivers and pedestrians.Your diminished ability to brake, turn, respond to
noises, look behind you or otherwise to quickly and fully observe and respond to potential
hazards and obstacles may create a dangerous situation.
X
X
A
S
Operating Machinery if turning, bending or twisting are involved.
Participating in Sports: Basketball, bowling, football, skiing, jogging, aerobics, golf
and tennis are all ill advised. Please inquire about other sports which you wish to pursue.
Sexual Activity
Childcare: Carrying children, (especially on your hip) or lifting children, (especially
in and out of crib) is not advised,
X
Bending, lifting, pushing and pulling
Entering and exiting vehicles
Sitting for prolonged periods of time
X
X
Yard work/gardening
Personal Care (bathing, tying shoes, shaving, showering, hair drying or other
activity which causes pain upon movement.)
Other
246
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EXERCISE PROFICIENCY TEST
GUIDELINES
• Mobility and Stretching Exercise: Active mobility maintenance and stretching…
are…encouraged in chiropractic practice. Training, counseling and advice in stretching and
mobility exercises are common.
• Strengthening, Conditioning and Rehabilitation: Conditioning exercise is helpful for
both healing and prevention of many mechanical back and neck problems. Conditioning and
spinal stabilization programs are becoming more common for chiropractic management of lowback conditions.
• The doctor needs to share “self-help” measures with patients.
• The usual exercise training plan begins with direct supervision, three to five times per week,
of assigned exercise tasks intermixed with rest periods.
BACKGROUND
Too often doctors will supply patients with a photocopied set of exercises to perform at home
without providing adequate instruction or monitoring to assure that they are done correctly.
Performed improperly, exercise not only offers no benefit, it may exacerbate the patient’s
condition or cause a new injury.
Some patients are very literal-minded and will continue to do the exercises even throughout the
onset of additional pain, rationalizing: “Well, the doctor told me to do them. I'm sure he knows
what he's doing.” Use of this form alerts the doctor to potential patient injury.
Should the patient suffer an exercise injury and bring a suit, the form can be used to document
thoroughness in recommending the exercise program…and use of appropriate measures to
assure that the patient implemented it properly and safely.
PRACTICE SUGGESTIONS
• This form should be used as a cover sheet for any printed exercises instructions, illustrations
or other written materials given the patient.
• When recommending an exercise, the doctor enters its description in the “exercises
recommended” column. He or staff must then teach the patient how to properly perform each
exercise and then monitor his attempts at each one until they are all done properly and safely.
A staff member can enter the date of the satisfactory “test” in the “date” column. The doctor
should periodically monitor the patient's technique and enter the date of the “re-test” in the
“Re-evaluation” column.
• Office staff should never give an exercise packet to a patient unless this cover sheet has been
filled out and removed.That procedure assures that no materials are taken out of the office until
the patient has received appropriate instruction in proper technique.
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POTENTIAL DISADVANTAGES
A problem arises if the doctor fails to properly evaluate the patient’s condition and thereby
negligently recommends exercises which are contraindicated. If knee exercises are prescribed for
a patient with an already torn meniscus, for example, and the exercises make the injury worse,
the written materials may be used effectively against the doctor if a malpractice suit results.
Physicians must take care to assure that only appropriate exercises are recommended.
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EXERCISE PROFICIENCY TEST
PATIENT NAME:
Marlene Hennessy
WARNING: DO NOT ATTEMPT TO DO THESE
EXERCISES IF THIS COVER SHEET IS
ATTACHED: SEE THE DOCTOR FOR
INSTRUCTION IN PROPER TECHNIQUE
BEFORE ATTEMPTING ANY OF THESE
EXERCISES. SERIOUS PERSONAL INJURY
MAY RESULT FROM IMPROPER PERFORMING
OF THESE EXERCISES.
EXERCISES
RECOMMENDED
Single knee to chest
DATE PERFORMANCE
APPROVED
A
S
Hamstring Stretch
Bridging
P
M
E
L
DATES
RE-EVALUATION
1/4/0000
1/18/0000
1/4/0000
1/18/0000
1/4/0000
1/18/0000
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HOME CARE AND EXERCISE REPORT
GUIDELINES
• Mobility and Stretching Exercise: Active mobility maintenance and stretching are
encouraged in chiropractic practice. Training, counseling, and advice in stretching and mobility
exercises are common.
• Stretching, Conditioning, and Rehabilitation: Conditioning exercise is helpful for both
healing and prevention of many mechanical back and neck problems. Conditioning and spinal
stabilization programs are becoming more common for chiropractic management of low-back
conditions.
• The doctor needs to share “self-help” measures with patients.
• The usual exercise training plan begins with direct supervision, three to five times per week, of
assigned exercise tasks intermixed with rest periods.
BACKGROUND
Documentation of self-help measures can be very helpful in malpractice, workers' compensation
and personal injury cases. Encouraging self-help demonstrates the doctor’s interest in
preventing physician dependence and seeking patient relief in non-income generating ways.
Too often, doctors will give patients a photocopied set of at-home exercises without monitoring
whether or not they are ever actually done. If they are sufficiently important to the patient’s
recovery or general health to recommend in the first place, compliance should be monitored.
Patients may also perform exercises improperly or suffer problems otherwise associated with the
activities.
OBJECTIVES
1. Use of this form alerts the doctor to potential injury. Some patients are very literal-minded
and will continue to do the exercises despite experiencing additional pain: Since doctor
prescribed it, they think, perhaps the pain is “normal.”
2. Use of this form may identify such a patient before he exacerbates his condition and decides
to sue his doctor.
3. Should a suit develop, the form can be used to document the safeguards built into the
exercise program. If there are no remarks in the pain report, an adverse award against the doctor
is less likely.
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POTENTIAL DISADVANTAGES
As with many forms and procedures, this form is only helpful if used properly. It can be very
damaging if completed by the patient only to be ignored by the doctor. If the patient reports
pain, for example, that pain is likely very important to him. The doctor must address that
problem.
Talking with the patient, eliminating the offending exercise, reducing the number of repetitions
or alternating days in which that particular exercise is done will likely assuage the patients
concerns. Such appropriate action will also emphasize the doctor’s high responsiveness to
patient input and further enhance a positive doctor-patient relationship.
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HOME CARE AND EXERCISE REPORT
PATIENT NAME:
Marlene Hennessy
Your faithful performance of the exercises and other self-help activities we recommended
for your use at home is important to your recovery. We have found that patients are more
diligent about performing these tasks if we ask them to maintain records as “report cards.”
Therefore we ask that you fill in the following chart and turn it in to us every other week.
Note: If any pain results, discontinue these exercises and report this to the doctor.
Exercises Recommended:
1.
2
3.
Single knee to chest
.Hamstring stretch
Bridging
Others:
P
M
4.
5.
DATES
PERFORMED
E
L
See illustrations of
exercises provided
EXERCISE
ACTIVITY #
A
S
PAIN
DURING
PAIN
AFTER
OTHER
DIFFICULTY
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PHYSICAL EXAMINATIONS: PRE-EMPLOYMENT
BACKGROUND
Courts have differed on whether a doctor performing a pre-employment physical for an
employer owes a duty of care to the person being examined. If a person is not cautioned about
the limitations of the screening exam, a jury may find that he was reasonable in electing to “put
off ” his regular physical since the examining doctor for this new job didn’t find anything wrong.
That risk will be lessened by the regular use of this form.
OBJECTIVES
This form is intended to stress the limitations of the examination and make it obvious that it
would be unreasonable for a person to claim that he was justified in foregoing other examination
in reliance upon the results of this examination. This process will serve the dual purpose of
encouraging the examinee to seek other diagnostic services if needed and to limit the doctor’s
malpractice risk.
APPLICATIONS
The doctor should use this form whenever he conducts employment examinations. (See page.
261 “IME Examinations,” page. 265 “School Physicals.”)
PRACTICE SUGGESTIONS
• Whenever possible, the prospective employer should have this form on hand and require job
applicants to fill it out when they apply for the job. The completed form can then be forwarded
to the doctor with the request that he conduct the examination. If the employer requires that
this form be signed during the job application process, many of the prospective employee’s
questions about the scope and the nature of the examination will be answered before he gets to
the doctor’s office.
• The doctor should not render services or advice to persons for whom he is only hired to
perform pre-employment examinations. If the D.C. exceeds the parameters of that exam, he
may create a doctor-patient relationship with the person being examined.
• The doctor should report to the patient, by letter, any serious conditions or warning signs of
potentially serious conditions he may discover. He should include advice that the examinee
consult the physician of his choice immediately. To say nothing or to mention concerns only to
the employer may be legal — even technically ethical — but it will not play well to a jury if the
doctor is sued.
• The doctor should stay current. Today’s literature, for example, is filled with challenges to
claims that conditions such as “spondylolisthesis” pre-dispose a worker to lost-time injury. Years
ago that condition was thought critical in a work capacity evaluation. Continued inferences of
employment incapacity based upon outdated or inappropriate information could result in an
unsuccessful job applicant seeking redress from the examiner who emphasizes it.
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• The doctor should report his findings, but leave the employer to make his own decisions on
the examinee’s employability.
• There is substantial controversy regarding the utility of X-ray in predicting work injuries.
Doctors who engage in this type of practice should be familiar with the literature.
POTENTIAL DISADVANTAGES
• Use of the form will undoubtedly raise questions in examinees’ minds and result in the doctor
and staff having to spend some additional time with each one. That time will be much better
spent avoiding misunderstandings from the beginning, however, than trying to defend one’s
position after the examinee complains of a condition the doctor failed to diagnose.
• There are risks inherent in doing employment physicals in addition to those arising from a
failure to diagnose. If, for example, the doctor renders an unfavorable report which prevents the
applicants from being hired, the doctor may be called upon to support the validity of his
opinion. A disgruntled applicant may bring a claim alleging that the doctor’s examination was
conducted improperly or his conclusion unsubstantiated, thereby unfairly costing the applicant
the job.
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PRE-EMPLOYMENT PHYSICAL EXAMINATION: NO
DOCTOR-PATIENT RELATIONSHIP CREATED
PERSON EXAMINED: Chaunchy Powell
This will acknowledge that I have been advised of the following:
1. That neither my prospective employer nor DR. RICHARD ROE, who will be
performing my pre-employment physical, intend that this examination will establish a
doctor-patient relationship between me and Dr. Roe. I do not intend that either. HE is not
my doctor, but rather is the company’s consultant.
E
L
2. That this examination is not, and should not be treated as a substitute for a complete
physical.
3. That this examination is done at the request of and paid for by the prospective
employer solely to determine if I am healthy enough for its purposes.
P
M
4. That my relationship with Dr. ROE is limited to this one-time screening examination
and he does not intend to, nor do I except that he will, treat me or otherwise render
professional services or advice.
A
S
I understand and agree to these limitations.
DO NOT SIGN THIS FORM WITHOUT READING
AND UNDERSTANDING IT!
DATE:
January 4, 0000
Chauncy Powell
Signature:
Chauncy Powell
Print Name:
WITNESS:
Karen J. Samuels
Signature:
Karen J. Samuels
Print Name:
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PHYSICAL EXAMINATION: INSURANCE IME
BACKGROUND
Courts have differed on whether a doctor performing a physical examination for an insurance
company owes a duty of care to the person being examined. If a person is not cautioned about
the limitations of the screening exam, a jury may find that he was reasonable in electing to “put
off “ his regular physical since the examining doctor for this new job didn’t find anything wrong.
That risk will be lessened by the regular use of this form.
OBJECTIVES
This form is to stress the limitations of the examination and make it obvious that it would be
unreasonable for a person to claim that he was justified in foregoing other examination in
reliance upon the results of this examination. This process will serve the dual purpose of
encouraging the examinee to seek other diagnostic services if needed and to limit the doctor’s
malpractice risk.
APPLICATIONS
The doctor should use this form whenever he conducts employment examinations. (See page.
257 “IME Examinations,” page. 265 “School Physicals.”)
PRACTICE SUGGESTIONS
• The doctor should not render services or advice to persons for whom he is only employed
to perform an independent medical examination. If he exceeds the parameters of that exam, he
may create a doctor-patient relationship with all its attendant duties and potential liability.
• The doctor should report to the patient, by letter, any serious conditions or warning signs of
potentially serious conditions he may discover. He should include advice that the examinee
consult the physician of this choice immediately. To say nothing or to mention concerns only
to the employer may be legal — even technically ethical — but it will not play well to a jury if
there is a suit.
• The doctor should check with his malpractice insurance carrier to be certain that he is
covered when performing IME’s. Most carriers will provide coverage when there is a “handson” examination. Doctors should verify coverage with their malpractice carrier before
performing IMEs or “paper reviews”. Doctors performing “paper reviews” without seeing the
patient are less likely to be covered.
• The doctor should not make disparaging remarks about the quality of the care being
provided by the treating doctor. Suits alleging defamation or tortious interference with a
contractual relationship can be expensive even if successfully defended.
• Other than to prevent possible patient injury, the doctor should not recommend that
treatment be discontinued. He should provide clinical information based upon his examination
and let the company draw its own conclusions.
POTENTIAL DISADVANTAGE
The person being examined may and can refuse to sign this form. He may be required to
submit to the examination under the terms of this insurance policy or upon court order, but he
does not have to concede anything about the examining doctor’s potential liability.
261
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PHYSICAL EXAMINATIONS: INSURANCE IME NO
DOCTOR-PATIENT RELATIONSHIP ESTABLISHED
PERSON EXAMINED:
Mary Lou Smalling
This will acknowledge that I have been advised of the following:
1. That neither my prospective employer nor DR. RICHARD ROE, who will be
performing my independent medical examination, intends that this examination will
establish a doctor-patient relationship between me and Dr. Roe. I do not intend that either.
HE is not my doctor, but rather is the insurance company’s consultant.
E
L
2. That this examination is not, and should not be treated as a substitute for a complete
physical.
P
M
3. That this examination is done at the request of and paid for by the insurance company
solely to determine whether additional health care services are necessary as a result of my
insured injury.
4. That my relationship with Dr. ROE is limited to this one-time screening examination
and HE does not intend to, nor do I except that HE will, treat me or otherwise render
professional services or advice.
A
S
I understand and agree to these limitations.
DO NOT SIGN THIS FORM WITHOUT READING
AND UNDERSTANDING IT!
DATE:
January 4, 0000
Mary Lou Smalling
Signature
Mary Lou Smalling
Print Name:
WITNESS:
Janice Ortiz
Signature
Janice Ortiz
Print Name:
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IME REPORT BY PATIENT
OF INDEPENDENT EXAMINATION
BACKGROUND
How often have you experienced a patient who was sent for an IME, spent less than 5 minutes
with the doctor and a 10-page report was generated?
OBJECTIVES
This form is intended for you to give to you patients when they have an IME scheduled in order
to memorialize the encounter and to provide a basis if necessary to challenge the IME if not
appropriately conducted.
APPLICATION
Give the patient the form and then tell him to complete the form immediately following the
IME.
SUGGESTIONS
This form is not to suggest that every IME is improper nor is it to suggest than an IME is
intentionally calculated to reduce care. However, it is not beyond reason to imply that there are
those who do not conduct IME evaluations properly and they should be challenged when
appropriate.
The form on page 264 should be used when a patient is subjected to an IME and the results of
the IME are inconsistent with the time spent by the examiner to warrant the report generated.
262
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IME REPORT BY PATIENT OF
INDEPENDENT EXAMINATION
Report of Independent Examination
Date of Independent Examination:
Patient Name:
Scheduled Time of Exam:
Time You Arrived for Exam:
Time Examination Actually Began:
Name of Physician Performing Independent Examination:
Did anyone other than the physician ask you any questions or perform any tests?
❑ Yes
❑ No
Actual time the physician started the examination:
Actual time the physician finished the examination:
Do you remember anything specific the physician said or did?
Did the physician review any X-rays or records in your presence?
❑ Yes
❑ No
Did the physician discuss your current chiropractic treatment?
❑ Yes
❑ No
If yes, what did the physician say regarding your current chiropractic treatment?
What time did you leave the physician’s office?
Patient’s Signature
AM/PM
Date
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PHYSICAL EXAMINATION: ATHLETICS NO
DOCTOR-PATIENT RELATIONSHIP CREATED
BACKGROUND
If a parent is not cautioned about the limitation of a sports screening exam, a jury may find it
reasonable that he “put off ” his child’s regular physical if the examining the doctor didn’t find
anything wrong. That risk will be lessened by the regular use of this form.
OBJECTIVES
This form is intended to stress the limitation of the examination and make it obvious that it
would be unreasonable for a person to claim that he was justified in foregoing other
examinations in reliance upon the results of this examination. This process will serve the dual
purposes of encouraging the examinee to seek other diagnostic services if needed and to limit
the doctor’s malpractice risk.
APPLICATION
This form should be used whenever a doctor conducts screening examinations for minors
wishing to participate in sports. See page 257 "Pre-Employment Examination," page 261 "IME
Examination."
PRACTICE SUGGESTIONS
• The doctor should not render services or advice to persons for whom he is only employed or
is volunteering to perform athletic screening examinations. If he exceeds the parameters of such
exams, he may create a doctor-patient relationship with all its attendant obligations and
responsibilities.
• The doctor should report to the parent, by letter, any serious conditions or warnings signs of
potentially serious conditions he may discover. He should include advice that the parents
consult the physicians of their choice immediately. To say nothing or to mention concerns only
to the school may be legal — even technically ethical — but it will not play well before a jury if
the child suffers some injury that it appears the doctor could have prevented.
• The doctor must require that the school provide parental consent forms for each student he
is to examine.
POTENTIAL DISADVANTAGE
Use of the form will undoubtedly raise questions in parents’ minds and result in the doctor and
staff having to spend some additional time with each one. The time will be much better spent,
avoiding misunderstanding from the beginning, rather than after a child suffers from some
condition the doctor failed to diagnose.
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PHYSICAL EXAMINATION: ATHLETICS NO
DOCTOR-PATIENT RELATIONSHIP CREATED
Person Examined:
Jane Reswold
This will acknowledge that I have been advised of the following:
1. That neither my child’s school nor Dr. RICHARD ROE, who will be performing my
child’s sports physical, intend that this examination will establish a doctor-patient
relationship, between my child, JANE RESWOLD and said doctor. I do not intend that
either. Dr. ROE is not my child’s doctor. HE is a consultant to the ANYWHERE
COUNTY School District.
E
L
2. That this examination is not, and should not be treated as a substitute for a complete
physical.
P
M
3. That this examination is performed solely to advise the school district if my child is
generally healthy enough to participate in athletics.
4.That my child’s relationship with Dr. ROE is limited to this one-time screening examination
and HE does not intend to, nor do I expect that HE will, treat my child or otherwise render
professional services or advice.
A
S
I understand and agree to these limitations.
DO NOT SIGN THIS FORM
WITHOUT READING AND UNDERSTANDING IT!
DATE:
January 4, 0000
Jane Reswold
Print Name of Athlete
Sahara Jane Reswold
Signature of Parent or
Legal Guardian
WITNESS:
Betty Saferio
Signature:
Betty Saferio
Print Name:
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INTERVIEW CHECKLIST
SUBSTITUTE OR ASSOCIATE DOCTOR
BACKGROUND
Some liability risks are obvious: failure to diagnose cancer, fracturing a patient’s rib, therapy
burns. Others, while not as commonplace, still present substantial risk. Among these are
“negligent hiring” claims.
When hiring an associate or temporary substitute doctor “locum tenens” (for vacation or during
a disability), the doctor must exercise reasonable care in assuring that the substitute is
competent.
PRACTICE SUGGESTIONS
Some malpractice carriers will provide coverage for a substitute doctor for up to thirty
consecutive days. This coverage is not automatic; the insured must contact his company and
make arrangements to activate this coverage.
MANAGED CARE REQUIREMENTS
Managed care has imposed significant changes to the processes whereby doctors may
“substitute” or “temporarily fill in” for another doctor. Requirements such as being a
participating doctors in a managed care plan may preclude “locum tenens” from billing for
services rendered. Doctors who are locum tenens and doctors who are seeking to hire locum
tenens should check with their managed care networks for specific information.
On page 271 is a sample of a managed care back-up Coverage Agreement which may serve to
aid the doctor to understand the requirements which may be imposed by managed care
organizations.
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APPLICANT:
BACKGROUND INTERVIEW
[ ] Why are you providing temporary services rather than full-time?
[ ] What are schools did you attend?
[ ] What degrees and when received?
[ ] What techniques are you qualified to use?
[ ] Have you had any special training in them?
[ ] Describe
[ ] Do you have malpractice insurance?
[ ] Liability limits?
[ ] Name of Carrier?
[ ] Policy #
[ ] Have you had disciplinary action taken against you in any state?
[ ] Are you the subject of an investigation?
[ ] Have you ever had a disciplinary complaint filed against you?
[ ] In what state are you licensed?
[ ] Have you been sued or had a malpractice claim against you?
[ ] How many hours of continuing education have you had
[ ] In the last year?
[ ] In the last 5 years?
[ ] List of prior employers
[ ] List of references
CLINICAL DEMONSTRATION
Observe Applicant:
[ ] Take history
[ ] Conduct examination
[ ] Review and interpret X-rays
INTERVIEW CHECKLIST SUBSTITUTE OR ASSOCIATE DOCTOR
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[ ] Operate Equipment
[ ] Tables
[ ] Therapy
[ ] X-ray
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[ ] Paraspinal EMG
[ ] Muscle Testing
[ ] Perform Adjustment
[ ] Cervical
[ ] Thoracic
[ ] Lumbar
PRE-HIRING STEPS
[ ] Obtain certificate showing insurance in force
[ ] Furnish office protocol or description of duties
[ ] Notify your professional liability carrier
[ ] Verify licensure of applicant
[ ] Obtain release to and contact references
[ ] Contact prior employers
[ ] Share are least one day in office with applicant
[ ] Receive an adjustment from applicant
[ ] Obtain a release to permit verification of disciplinary and criminal record
[ ] Conduct confidential interview of trusted, knowledgeable patients who doctor has
treated in his “one day” in the office
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BACK-UP COVERAGE AGREEMENT ABC
MANAGED CARE NETWORK
THIS AGREEMENT is made this
15th
John Doe, D.C.
Janice Henderson, D.C.
January
day of
by and between
,
0000
(“physician”)and
(Back up Physician).
BACKGROUND
A. Physician has an entered into an agreement (the “Participating Physician Agreement”)
with ABC Heath care, In (“ABC”) and pursuant to the terms thereof has agreed that
when Physician is unavailable to provide Covered Services to Enrollees due to vacation,
leave, illness, disability or other emergency, Physician will refer Enrollees (i) to the nearest
Physician participating in the ABC network or (ii) if a Physician participating in the ABC
network is not available within a reasonable distance and such arrangement is permitted
by the plan under which the Enrollees is covered, to a Physician with whom Physician has
entered into a Back-up Coverage Agreement in accordance with the terms hereof.
Capitalized but unidentified terms shall have the meaning provided for in the Participating
Physician Agreement.
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B. Physician wishes to arrange for treatment of the Enrollees by a licensed chiropractor or
other appropriately licensed professional (Back-up Physician) during those times Physician
is not available due to vacation, leave, illness, disability, or other emergency. Physician
desires to contract with Back-up Physician to provide Covered Services to the Enrollees
referred to the Back-up Physician by Physician when Physician is unavailable to provide
such care, and Back-up Physician desires to serve in such capacity.
A
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In consideration of the covenants herein contained, and for other good and valuable
consideration received, the parties do hereby agree as follows:
1.00 Obligations of Back-up Chiropractor. Back-up Physician hereby agrees to perform
for Enrollees referred to Back-up Physician by Physician, chiropractic services that are
reasonable and necessary based on documented clinical need and that are within the scope
of services allowed by applicable law and are generally provided by Back-up Physician.
1.01 Back-up Physician shall satisfy the Credentialialing/Recredentialing Criteria unless
expressly waived by ABC in writing. In addition and at all times, Back-up Physician shall
satisfy the following requirements:
a. Maintain an unrestricted license in accordance with the licensing provisions of the laws
of the applicable jurisdiction in which he/she is licensed to provide chiropractic
services; and
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b. Maintain in force, until the applicable statute of limitations has expired, a
policy of professional liability insurance in a minimum amount of $1,000,000 per
claim, and $3,000,000 in the aggregate, covering chiropractic related services provided
by Back-up Physician.
2.00 Term and Termination of Agreement. This Agreement shall continue in force for
a period of four (4) weeks per calendar year or up to eight (8) weeks per calendar year if
due to Physician illness or disability. Physician shall notify ABC when this Agreement is in
effect. Either party may terminate this agreement without cause at any time upon fifteen
(15) days prior written notice to the other party. Physician or ABC on behalf of Physician
may terminate this arrangement immediately upon written notice to Back-up Physician for:
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a. Failure to comply or to maintain compliance with the Credentialing/
Recredentialing Criteria;
b. Failure to maintain professional liability insurance in accordance with the terms
hereof; or
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c. Failure to comply with the policies and procedures of the Provider Manual.
3.00 General Provisions
A
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3.01 Obligations of Back-up Physician. Back-up Physician understands that he/she
does not by virtue of this arrangement become a participating provider in the Physician
network maintained by ABC and that there is no guarantee that any Enrollees will be
referred to Back-up Physician for Covered Services during any period Physician is not
available to provide care.
3.02 Back-up Physicians understands that this agreement incorporates by reference the
Participating Physician Agreement, and Back-up Physician agrees to be bound by its terms
except to the extent expressly waived by ABC in writing. Back-up Physician shall at all
times perform his/her duties and functions in strict conformance with currently approved
practices in his/her field of chiropractic and in a competent and professional manner.
3.03 Back-up Physician shall maintain, with respect to each Enrollee, medical records in
such form and content as required by applicable law and/or as may be reasonably necessary
for the provision of chiropractic services covered by this Agreement, and as otherwise
necessary to carry out the terms of this Agreement. Physicians shall maintain the
confidentiality of such records in accordance with applicable law. Physician and ABC shall
have that right to review and duplicate such records upon reasonable notice during regular
business hours; provided, however, such records shall be maintained on a confidential basis.
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3.04 Physician and Back-up Physician shall not by virtue of this Agreement be deemed
partners or joint venturers. It is further expressly understood that Physicians and Back-up
Physician shall both be acting as independent contractors and neither party shall be
considered to be an employee of the other. It is further expressly agreed that except with
respect to the obligations specifically set forth in this Agreement, Physician shall neither
have nor exercise any control over the professional judgment or methods used by the Backup Physician in the performance of services hereunder.
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3.05 No assignment of the rights, duties or obligations of this Agreement shall be made by
Back-up Physician.
IN WITNESS WHEREOF, the parties have executed this Agreement the year and date
first above written.
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PHYSICIAN
BACK-UP PHYSICIAN
John Doe, D.C.
Physicians Signature
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John Doe, D.C.
Physician’s Name (Print)
Janice Henderson, D.C.
Back-up Physicians Signature
Janice Henderson, D.C.
Back-up Physician’s Name ( Print)
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EMPLOYMENT INTERVIEW GUIDELINES
BACK GROUND
Interviewing applicants for staff openings is hardly the simple task that it once was. Doctors can no
longer simply chat amicably, and ask whatever questions they wish and offer the position to whichever
applicant “feels” right.
Today’s many anti-discrimination acts: age, race, sex, national origin and disability, make an interview a
virtual minefield. Even employers who have no conscious intent to discriminate and who certainly don’t
wish to do anything unlawful may innocently ask prohibited questions.
OBJECTIVES
These guidelines are intended to alert doctors to particularly sensitive areas of inquiry which could
cause considerable difficulty if not handled properly.
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EMPLOYMENT INTERVIEW GUIDELINES
Address
You MAY ask:
How long have you been a resident of this state or city?
Age
You MAY ask:
Are you at least 18 years of age? If not, state you age.
You MAY NOT ask:
How old are you?
What is your birth date?
Do you receive social security payments?
Aids
You MAY ask:
Do you have AIDS?
Birthplace
You MAY NOT ask:
Where were you born?
Where were your parents born?
Where was your spouse born?
Character
You MAY NOT ask:
Have you ever been arrested?
Have you ever used illegal drugs or controlled substances?
You MAY ask:
Have you ever been convicted of a crime?
If so, when, where, and what was the disposition?
Are you actively using any illegal drugs or controlled substances?
Citizenship
You MAY ask:
Are you a Untied States citizen?
Do you intend to become a United States citizen?
Do you have the legal right to remain permanently in the United States?
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You MAY NOT ask:
Of what county are you a citizen?
Are you a naturalized or native-born citizen?
When did you acquire citizenship?
Is your spouse a naturalized or native-born citizen?
Are your parents naturalized or native-born citizens?
When did your parents or spouse acquire citizenship?
Disability
You MAY ask:
Do you feel you are fully able to perform the job for which you have applied?
Are you familiar with all the requirements of this job?
You MAY NOT ask:
Do you have a disability?
Have you ever been treated for any of the following diseases?
Have you ever filed a workers’ compensation claim?
Education
You MAY ask:
What academic, vocational or professional education have your received?
What public and private schools have you attended?
Experience
You MAY ask:
What work experience have you had?
Language
You MAY ask:
What foreign languages do you read, write or speak fluently?
You MAY NOT ask:
How did you learn to read, write, or speak a foreign language?
Marital Status
You MAY NOT ask:
Are you married?
Where does your spouse work?
How old are your children?
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Military
You MAY ask:
Have you ever served in the Armed Forces?
Would your military experience have any application to the position for which you have applied?
You MAY NOT ask:
What was your discharge status?
What was your rank?
Name
You MAY ask:
Have you ever used any other name which I would need to check to obtain a full
background investigation?
You MAY NOT ask:
Why is your name a hyphenated name?
What was your original name?
National Origin
You MAY NOT ask:
What is your ancestry, national origin, or nationality?
What nationally are your parents and spouse?
Notify in Emergency
You MAY ask:
Who should we notify in case of an accident or emergency?
Organizations
You MAY ask:
Are you a member of any organization or club? (Exclude organizations where the name
or character indicates race, creed, color, or national origin of members.)
You MAY NOT ask:
To what clubs, societies, and lodges do you belong?
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Photograph
You MAY NOT ask:
For a photograph at any time before hiring.
Race or Color:
You MAY NOT ask:
What is your race or the race of your parents or other family members?
References
You MAY ask:
Who suggested that you apply for the position here?
May we contact your references, past employers and schools?
Relatives
You MAY NOT ask:
Information about the applicant’s children or other relatives not employed by you.
Religion or Creed:
You MAY ask:
Are you able to work during our normal days and hours of operation?
You MAY NOT ask:
What is your religious denomination, affiliation, church, or synagogue?
What religious holidays do you observe?
Sex
You MAY NOT ask:
Are you pregnant?
Do you plan to have (more) children?
Who will care for your children during work hours?
What is your sexual orientation?
What is you sexual preference?
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EMPLOYEE CONFIDENTIALITY STATEMENT
GUIDELINES
• The practitioner is responsible for staff actions regarding record keeping. Any employee
involved in the preparation, organization, or filing of records should fully understand
professional and legal requirements, including the rules of confidentiality.
• The rule of confidentiality requires that all information about a patient be kept confidential.
BACKGROUND
New employees, particularly those with no previous work experience in positions requiring
maintenance of confidentiality must be cautioned about the sensitive nature of health
information. The doctor must be sure they understand how crippling it can be to a practice if
word gets out that employees gossip about what goes in the office.
OBJECTIVES
1. Use of this form will reinforce the doctor’s oral admonitions that staff maintain the sanctity
of confidential patient information. The formality of a written agreement will likely make more
of an impression that a casual: “You understand, of course, that you can’t tell anyone anything
about a patient, don’t you?”
2. It will also memorialize the instructions given and support the propriety of discharging an
employee who breaches a patient’s confidences.
APPLICATION
The form should be signed by each new employee as part of his orientation.
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EMPLOYEE CONFIDENTIALITY STATEMENT
EMPLOYEE NAME:
Sandy Holsom
The Rule of confidentiality requires that all information about a patient gathered
within the doctor-patient relationship be kept confidential unless its release is
authorized by the patient or is compelled by law. The rule is an ethical
responsibility as well as a legal one. Assurance of confidentiality is necessary if
individuals are to be open and forthright with their doctor. Patients rightly expect
that information about their health will remain private and secure from public
scrutiny. All doctor-patient communications are privileged and confidential.
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I understand that in the performance of my duties as an employee of Roe Chiropractic
Office, I will obtain patient information which is confidential. I acknowledge having been
instructed that I must not divulge such information to anyone including my own family.
I have been instructed that my violation of a patient’s right to confidentiality may result in
punitive action including discharge from employment.
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January 4, 0000
Date:
Sandy Holsom
Signature of Employee
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Sandy Holsom
Print Name
This will certify that I was present at the orientation regarding patient confidentiality for the
above signed employee and that the confidentiality instructions listed above were given.
January 4, 0000
Date
Margaret Raintree
Witness Signature
Margaret Raintree
Print Name
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DETERMINING INDEPENDENT
CONTRACTOR VERSES EMPLOYEE STATUS
BACKGROUND
Many chiropractors erroneously believe they have avoided the duties and responsibilities of an
employer when they call those who work for them: “independent contractors.” Among their
objectives is limiting their personal liability for employee malpractice. Many also use this device
to reduce costs by eliminating the need to pay matching FICA and to withhold taxes on an
associate's salary. Failure, however, to create a genuine and unassailable independent contractor
relationship can frustrate all of the doctor's purposes and easily prove more costly than not
having attempted the effort.
If the employee/independent contractor does not pay his own taxes and the IRS decides that he
was really an employee, the employer doctor can be held liable not only for penalties for failing
to properly withhold, but also for the full amount of the unpaid tax which he should have
withheld. While the doctor may have recourse against the associate doctor, that will afford little
comfort if that doctor has moved or is without assets.
The following is a tax-related checklist, but the law in most states incorporates many of the same
factors in analyzing employment relationships for other purposes. The presence of several
“employee” criteria will have implications for the employer's malpractice and insurance
concerns as well. An employer is liable for his employees' negligence.
Finally, if the employer has a pension or profit sharing plan, failing to contribute for and allow
participation by a so-called independent contractor who is later ruled to be an employee leaves
the employer open to the associate’s claim for those benefits — to be awarded retroactively.
Even when doctors intend to create an independent contractor relationship, the typical
established doctor/young associate relationship falls instead into the category of employer/
employee.
PRACTICE SUGGESTIONS
The doctor who decides to establish an independent contractor relationship should use the
checklist to evaluate the true nature of the arrangement. If an agreement is purchased from a
consultant, or other advisor, it is still prudent for the doctor to make his own comparison with
the checklist.
There is no iron-clad formula for how many of these elements must be satisfied to show that the
contractor really is “independent.” The more of these factors that indicate an employee status,
however, the less likely it is that the doctor will be able to defend his independent contractor
treatment of workers.
This is an area fraught with hazard — the prudent doctor will take no action without
advice from competent business, legal, and tax advisors.
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DETERMINING INDEPENDENT CONTRACTOR
VERSUS EMPLOYEE STATUS
Indicate opposite each criterion whether it would classify the associate as an employee or
independent contractor.
Contractor
Employee
1.Instructions – a worker who is required to comply
with another person’s instructions about the manner
and method in which work is to be done ordinarily is an
employee.
2.Training – requiring a worker to attend meetings,
work with a more experienced worker or otherwise
perform in a particular manner or method indicates
employee status.
X
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3.Reliance – the more a business depends on the
worker’s services the higher the likelihood that he is an
employee.
4.Services rendered personally – if services must be
rendered by a specific individual, employee status is
indicated.
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5.Hiring, supervising and paying assistants – if services
can be delegated or subcontracted at the worker’s
election, with that worker paying for such help, then
contractor status is indicated.
X
X
X
X
6.Continuing relationship – a continuing relationship,
even one which is recurring at irregular intervals,
indicates employee status.
7.Set hours of work – the establishment of set hours of
work by the person for whom the work is performed
shows control (i.e., employee status).
8.Full time required – if a worker is required to devote
substantially full time to the business and there is an
implicit or explicit restriction from doing other gainful
work, employee status is indicated.
9.Doing work on employer’s premises – if work is
performed on the premises of the person for whom the
services are performed, this suggests control over the
worker, especially if such work could be performed
elsewhere.
X
X
X
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Contractor
X
10. Order or sequence set – if the worker must perform
services in the order set by the person for whom the services
are performed, this indicates employee status.
X
11. Oral or written reports – a requirement that the worker
submit regular reports to the person for whom services are
performed indicates employee status.
X
12.Payment method – an employee usually is paid by the hour
week or month, while the contractor is paid by the job.
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13. Payment of business expenses – the payment of the
worker’s business and traveling expenses by the person for
whom services are performed indicates employee status.
14. Furnishing of tools and materials – the furnishing of
significant tools, materials or other equipment by the worker
indicates contractor status.
X
X
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15. Significant investment – the worker’s lack of investment
in facilities indicates dependence on the person for whom
services are performed (i.e., employee status).
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16. Realization of profit and loss – a worker who can realize
profit or suffer a loss as a result of his services generally is a
contractor; a worker who cannot is an employee.
17. Working for more than one firm at a time – if a worker
performs more than insignificant services for a number of
persons at the same time, contractor status is indicated.
X
X
X
X
18. Making services available to the general public – a
contractor generally makes his services available to the
general public while an employee does not.
19. Right to discharge – the right to discharge a worker
indicates employee status; an independent contractor’s
termination depends upon the terms of his contract.
20. Right to quit – if a worker has the right to end the
working relationship at any time, it indicates employee status;
an independent contractor is contractually bound to
complete an assignment.
X
X
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SAFETY BELT EXAMINATION
BACKGROUND
Many states now have mandatory “seat belt” laws with fines for noncompliance. Perhaps more
financially important, some states are recognizing a “seat belt defense” in automobile liability
cases. The theory is that a plaintiff contributes to the severity of his own injury by not wearing
a safety belt and his damages should be reduced accordingly.
OBJECTIVE
This form is intended to comply with the statutory requirements, allowing doctors to issue
patient waivers from mandatory seat belt laws.
PRACTICE SUGGESTIONS
Precise language in state laws will vary. The example given applies the language found in the
Ohio statute. The doctor should use the language from the statue in his own state.
POTENTIAL DISADVANTAGES
A patient who suffers injury in an automobile accident in which he was not wearing a safety belt
may allege that he was more seriously injured because the doctor told him not to wear the belt.
For that reason, some states grant immunity to a doctor who signs a statement unless he does
no recklessly.
Doctors must avoid the temptation to issue exemptions simply because a patient, friend, or
relative reports: “I hate wearing those things — how about giving me a letter saying I shouldn’t,
Doc?” Only in very rare cases should a doctor issue an exemption.
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SAFETY BELT EXEMPTION
Patient Name:
Myrtle Baker
Date: January 15, 0000
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
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Due to the following physical impairment, this patient’s use of an occupant restraining
device would be impossible or impractical.
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Physical Impairment:
Severe scoliosis of her thoracic and lumbar spine which has resulted in the distortion of the
upper thorax.
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292
Richard Roe, D.C.
Dr. Richard Roe
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DISABILITY CERTIFICATE
BACKGROUND
Doctors will often be called upon to report to employers on the work capability of injured employees.
This form allows for a quick “check” of the patient status with room provided for the doctor to
individualize any work limitations when the patient is allowed to return to “light” duty.
POTENTIAL DISADVANTAGE
The potential for re-injury of a patient who returns to work too soon dictates care in the use of this
form.
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DISABILITY CERTIFICATE
DATE: AUGUST 15, 0000
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Patient: JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
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To Whom it May Concern:
Your employee named above is under my care. Effective this date I have advised HIM to
discontinue work for medical reasons. This restriction will remain in effect until further notice.
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Richard Roe, D.C
Dr. RICHARD ROE
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DISABILITY CERTIFICATE
DATE: AUGUST 30, 0000
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Patient: JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
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To Whom it May Concern:
This is to certify that the above named patient has been under my care since:
August 15, 0000. I advised HIM on that date to discontinue working until further notice.
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As of this date HE is:
( ) Still unable to work
( ) Sufficiently recovered to resume a normal workload
( x ) Sufficiently recovered to return to work with the following limitations:
1. NO LIFTING OVER 25 POUNDS
2. NO PROLONGED BENDING OR KNEELING
3. REST PERIODS AS NEEDED
Richard Roe, D.C
Dr. RICHARD ROE
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PHYSICAL EDUCATION EXCUSE
BACKGROUND
Doctors may find that the physical condition of a student/patient makes his participation in
physical education classes unwise. This form allows the doctor to “check” the student’s status
and allows room for limiting activities which are particularly hazardous.
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PHYSICAL EDUCATION EXCUSE
DATE: AUGUST 15, 0000
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
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Patient: JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
To Whom it May Concern:
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This is to certify that the above named student is currently under my care. Effective this date I
have advised HIS PARENTS that for medical reasons, HE should not participate in physical
education classes.
This restriction will remain in effect until further notice.
A
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Richard Roe, D.C
Dr. RICHARD ROE
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PHYSICAL EDUCATION EXCUSE
DATE: AUGUST 30, 0000
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
Patient: JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
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To Whom it May Concern:
This is to certify that the above named student has been under my care since:
August 15, 0000. I advised HIM on that date to discontinue physical education classes until
further notice.
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As of this date HE is:
( ) Still unable to participate
( ) Sufficiently recovered to resume normal classes
(x ) Sufficiently recovered to return to class with the following limitations:
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1. NO TUMBLING OR OTHER GYMNASTICS
2. NO FOOTBALL OR OTHER CONTACT SPORTS
3. REST PERIODS AS NEEDED
Richard Roe, D.C
Dr. RICHARD ROE
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WORK/SCHOOL EXCUSE DOCTOR’S
APPOINTMENT
BACKGROUND
Many patients will need a written excuse for time missed from school or work while keeping
doctor appointments. This simple form is for that purpose.
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WORK/SCHOOL EXCUSE
DOCTOR’S APPOINTMENT
DATE: AUGUST 15, 0000
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
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Patient: JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
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To Whom it May Concern:
This is to certify that the above named worker/student kept an 11:30 appointment in my office
today. Please excuse his/her absence during that that time allowing reasonable travel time to and
from the above address.
A
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Richard Roe, D.C
Dr. RICHARD ROE
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CREDIT CARD PAYMENT FORM
BACKGROUND
During these times of increasing insurance deductible and co-payment requirements and
general economic hard times, patients often find it difficult to satisfy their portion of a doctor’s
bill. Many health-care providers have begun accepting credit card payment.
OBJECTIVES
1. To avoid the time and expense of repetitive billing.
2. To avoid having patients neglect needed care because of embarrassment over an outstanding bill.
3. To stabilize cash-flow and secure payment at the “time of service” whenever possible.
PRACTICE SUGGESTION
This form is intended to be inserted into patient bills. The doctor may elect to include it only
in bills which have delinquent balances.
POTENTIAL DISADVANTAGE
There is a charge for the service. The doctor pays the card company a percentage of the amount
collected in return for the benefits of the arrangement. When interest rates are low, the doctor
may lose more to the card fee than he would by accepting payment over 90 days.
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CREDIT CARD PAYMENT FORM
For Visa or MasterCard Accounts
As a convenience, we will be pleased to transfer your present balance to your Visa or MasterCard
account. This will enable you to spread out your payments, making them smaller and more
manageable.To take advantage of this arrangement, complete the form below, sign it and return
it to us with your statement.
NAME:
Andrew Balsom
ADDRESS:
BALANCE: $
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1000 Century Blvd., Finsate
NJ
CITY
PHONE:
VISA
X
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3638604993217842
CARDHOLDER’S SIGNATURE:
Andrew Balsom
PRINT CARDHOLDER’S NAME:
A
S
00000
STATE
000-000-0000
ACCOUNT NUMBER:
318.00
Andrew Balsom
ZIP
MASTERCARD
EXP. DATE
10/0000
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MEDICARE EXPLANATION FORM
BACKGROUND
Medicare has changed its regulations as they relate to the Medicare Program and more
specifically to the need for x-ray, effective January 1, 2000.
The current Medicare language statute in force states:
Coverage of chiropractic services is limited to treatment by means of manual manipulation of the
spine. A chiropractor is a physician only for purposes of subsections (s) (1) and (s) (2) (A) of the
Medicare “definitions”, which refer to physician services and supplies furnished incident to physician
services. 3/ Excluded from this reimbursement authority is subsection (s) (3) of the
definitional section, which relates to diagnostic X-rays.
1/42 U.S.C. §1320a-7a
2/42 U.S.C. §1320a-7b
3/42 U.S.C. §1395 x-r (5)
The regulation reflects this statutory distinction in terms of covered services for chiropractors
and provides.
“Manual Manipulation” – Coverage of chiropractic services is specifically limited to treatment by
means of manual manipulation, i.e., by use of hands only. No other diagnostic or therapeutic service
furnished by a chiropractor or on his order is covered. (Of course this prohibition does not affect the
coverage of x-rays furnished by other practitioners under the program. Accordingly, an x-ray
demonstrating the existence of subluxation of the spine would be a ‘diagnostic x-ray test’ covered under
section 1861 (s) (3) if taken and interpreted by a ‘physician’ who for this purpose would be a doctor of
medicine or osteopathy.)” 4/
4/ Medicare Part B Carriers Manual, Rev. 1076 § 2251.1
Essentially under the former Medicare Statute reimbursable services were limited to treatment
consisting of manual manipulation of the spine to correct a subluxation demonstrated by x-rays
to exist. The “subluxation” means an incomplete dislocation, off-centering, misalignment,
fixation, or abdominal spacing of the vertebrae anatomically which must be demonstrable on
any x-ray film to individuals trained in the reading of x-rays. A chiropractic may interpret his or
her x-rays to the same extent as any other physician defined in this section.
For the purpose of explanation it should be noted that services and items that are classified as
non-covered are those that are excluded from the Medicare Program, i.e. Medicare never pays
for these services/items. The physician or supplier may bill the patient for these services/ items
(applies to both assigned and non-assigned claims.
Services and/or items that are considered an integral part of another service or those to which
rebundling provisions apply, are not allowed separate billing to the patient.
305
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New Utilization Guidelines for Medicare Coverage of Chiropractic services.
These new regulations will be enacted and effective January 1, 2000.
The Balanced Budget Act of 1997 (BBA) included changes to the coverage of chiropractic
services under the Medicare program; specifically, § 4513 of the BBA eliminates the need for
an x-ray demonstrating the existence of a subluxation for Medicare coverage and directs the
Secretary of the Department of Health and Human Services (HHS) to develop and implement
utilization guidelines in cases in which a subluxation has not been determined by x-ray to exist.
The Health Care Financing Administration (HCFA) will be developing these guidelines with
assistance from chiropractic organizations and staff from within the department.
It should be noted that as of this writing no definitive regulations have been approved by
Medicare. Therefore, the following information is only for information purposes and it is
strongly suggested that each doctor contact his or her Medicare Regional Offices, or their State
or National Association for specific information regarding the new requirements under the
Balanced Budget Act of 1997, as they specifically relate to the x-ray requirement.
It should be noted that charges for services and items that are denied due to medical necessity
criteria not being met are not allowed to be billed to the patient unless the patient has signed
an advance notification statement. This written notice must be furnished to the patient prior to the
rendering of the service; it must state that the patient understands Medicare will probably deny the
service/item due to his/her medical condition or diagnosis, and he/she agrees to assume responsibility for
the payment. (Medicare Report 1992)
Page 308 lists the regional offices of Medicare. The accompanying forms (pages 309-310-311)
were correct as of December 31, 1999. A shaded portion and line through some areas of the
form illustrate areas that may be changed under the new utilization regulations. For
additional information log on to the Medicare website at:
http://www.medicare.gov.
Potential Medicare Documentation Requirements
New requirements replacing the x-ray criteria may be utilized in lieu of x-ray to determine a
subluxation. The subluxation may be identified by findings derived from:
P.A.R.T.
1. Pain and Tenderness
2. Asymmetry and Misalignment
3. Range of Motion abnormalities
4. Tissue, Tone, Texture, Temperature abnormality assessment tests.
A consensus panel of the ACA developed criteria to describe the P.A.R.T., which have been
recommended to HCFA by the ACA for utilization of chiropractic services under the new
Medicare BBA.
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The manual manipulation must be directed to the spine for the purpose of correcting a
subluxation identified by P.A.R.T. (if approved.) Using the acronym P.A.R.T. four diagnostic
categories describe subluxation:
• “P” - Pain/Tenderness. The perception of pain and tenderness is evaluated in terms of
location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest
primarily by a painful response. Pain and tenderness findings may be identified through
one or more of the following: observation, percussion, palpation, provocation, etc.
Furthermore, pain intensity may be assessed using one or more of the following: Visual
Analog Scales, algometers, pain questionnaires, etc.
• “A” - Asymmetry/Misalignment. Asymmetry/misalignment may be identified on a sectional
or segmental level through one or more of the following: observation (posture and gait
analysis), static palpation for misalignment or vertebral segments, diagnostic imaging, etc.
• “R” - Range-of-Motion Abnormality. Changes in active, passive, and accessory joint
movements may result in an increase or a decrease of sectional segmental mobility.
Range-of-motion abnormalities may be identified through one or more of the following:
motion palpation, observation, stress diagnostic imaging, range-of-motion measurement(s), etc.
• “T” - Tissue, Tone, Texture, Temperature Abnormality. Changes in the characteristics of
contiguous or associated soft tissues, including skin, fascia, muscle and ligament, may be
identified through one or more of the following procedures: observation, palpation,
instrumentation, tests for length and strength, etc.
To demonstrate a subluxation, two of the four “P.A.R.T.” criteria are required, one of which
must be an “A” or an “R.”
Throughout the country there are states which have implemented differing parameters and
guidelines for the implementation of Medicare claims. Some states have utilized 12 visits as
the maximum number of visits permitted by the carrier. Other carriers have implemented
a considerably more liberal implementation of chiropractic visits before any request for
additional documentation is required. The difficulty in making a determination for the
entire country is compounded by the non-uniform standard applied for toward the national
Medicare benefit. In the form on page 309 you will note 12 used as the visit cap applied to
Medicare. This may vary from state and thus you must determine this based upon your
specific Medicare district regulations, and the guidelines imposed by the Medicare carrier.
While no assurance are made that the above information will ultimately be the new requirement
under Medicare 2000, adherence to the four-part diagnostic categories describing subluxation
will provide an excellent basis to begin the process.
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Health Care Financing Administration (HCFA) Regional Offices: Call for information
about local seminars and health fairs or your new Medicare health plan changes or to report a
complaint directly to HCFA.
If you live in. . .
The Regional office is:
The phone number is:
Boston
1-617-565-1232
New York
1-212-264-3657
Philadelphia
1-215-596-1335
Atlanta
1-404-331-2044
Chicago
1-312-353-7180
Arkansas, Louisiana, New Mexico
Oklahoma, Texas
Dallas
1-214-767-6401
Iowa, Kansas, Missouri, Nebraska
Kansas City
1-816-426-2866
Denver
1-303-844-4024
San Francisco
1-415-744-3602
Seattle
1-206-615-2354
Connecticut, Maine,
Massachusetts, New Hampshire,
Rhode Island, Vermont
New York, New Jersey,
Puerto Rico, Virgin Islands
Delaware, District of Columbia,
Maryland, Pennsylvania,
Virginia, West Virginia
Alabama, Florida, Georgia,
Kentucky, Mississippi, North
Carolina, South Carolina, Tennessee
Illinois, Indiana, Michigan,
Minnesota, Ohio, Wisconsin
Colorado, Montana, North Dakota,
South Dakota, Utah, Wyoming
Arizona, California, Guam,
Hawaii, Nevada
Alaska, Idaho, Oregon, Washington
TTY For the Hearing and Speech Impaired: 1-800-820-1202
Last Updated December 22, 1997
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MEDICARE EXPLANATION FORM
PATIENT NAME Jessie Walunda
AS OF SEPTEMBER 1 1990, MEDICARE HAS MANDATED THAT ALL DOCTORS
SEND MEDICARE FORMS DIRECTLY TO THE MEDICARE OFFICE. OUR OFFICE
WILL CONTINUE TO PROCESS YOUR FORMS ON A MONTHLY BASIS, BUT
ACCORDING TO THE NEW LAW WE MUST SEND THEM DIRECTLY TO MEDICARE
Medicare does cover chiropractic care, but it has limitations.
1. Medicare does not cover the cost of X-Rays if performed in a chiropractor’s office.
2. In most cases, Medicare covers percentage of chiropractic manipulation of the spine,
but does not cover therapy, supports, supplements, x-rays, examination or other services
offered in a chiropractic office.
E
L
3. Medicare or your Medicare carrier usually allows a limited number of office visits for
spinal manipulation per year. The number of visits can be determined by the type and
severity of the condition. The patient is responsible for the charges on any visits
exceeding any Medicare limits.
P
M
4. Medicare or the Medicare carrier covering your case may also rule that the type of
treatment, in their opinion was “medically unnecessary.” You as a patient, need to
understand that the chiropractic office or the provider has no control over the decision
made by the Medicare carrier. In fact, the chiropractic office or provider does not learn of
the denial of your claim until several treatments have already been rendered. If this should
happen, and we feel additional care is needed, we will discuss your case with you on an
individual basis to help resolve this matter.
A
S
PLEASE READ AND SIGN BELOW
I UNDERSTAND THE LIMITATIONS DESCRIBED AND FULLY REALIZE THAT I COULD BE
DENIED REIMBURSEMENT BY MEDICARE FOR ANY REASON LISTED ABOVE. I ALSO
UNDERSTAND THAT WHEN SPINAL MANIPULATIONS IS COVERED, IT MIGHT BE COVERED
FOR ONLY TWELVE VISITS PER YEAR AND ANY OTHER TREATMENT PAYMENT WILL BE MY
PERSONAL RESPONSIBILITY.
I ALSO UNDERSTAND THAT AS OF SEPTEMBER 1, 1990, MEDICARE MANDATES THAT ALL
DOCTORS SEND THE MEDICARE FORMS DIRECTLY TO THE MEDICARE OFFICE. I HEREBY
AUTHORIZE THE RELEASE OF ANY INFORMATION ACQUIRED IN THE COURSE OF MY CASE
HISTORY, EXAMINATION OR TREATMENT TO THE MEDICAL OFFICE,ANY DOCTOR,
INSURANCE COMPANY OR ATTORNEY. MY SIGNATURE WILL ALSO SERVE AS MY
“SIGNATURE ON FILE”AND VERIFY THAT ANY INFORMATION I HAVE GIVEN IS CORRECT TO
THE BEST OF MY KNOWLEDGE.
Jessie Walunda
Medicare Number (Soc. Sec. #) 403-06-0000
January 4, 0000
Date:
PATIENT’S SIGNATURE
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MEDICARE EXPLANATION FORM
SINCE JANUARY 1, 1991, OUR OFFICE HAS, AND WILL CONTINUER TO ACCEPT
ASSIGNMENT FOR ALL SERVICES “COVERED” BY MEDICARE. PLEASE
READ CAREFULLY FOR SERVICES NOT COVERED BY MEDICARE.
PATIENT’S NAME: Wanda Willoughy
Soc Sec # 143-00-9000
Medicare does cover chiropractic care, but has certain requirements and limitations.
1. Medicare does not cover the cost of X-Rays if performed in a chiropractor’s office.
2. In most cases, Medicare covers percentage of chiropractic manipulation of the spine,
but does not cover therapy, supports, supplements, x-rays, examination or other services
offered in a chiropractic office.
E
L
3. Medicare or your Medicare carrier usually allows a limited number of office visits for
spinal manipulation per year. The number of visits can be determined by the type and
severity of the condition. The patient is responsible for the charges on any visits
exceeding any Medicare limits.
P
M
4. Medicare or the Medicare carrier covering your case may also rule that the type of
treatment, in their opinion was “medically unnecessary.” You as a patient, need to
understand that the chiropractic office or the provider has no control over the decision
made by the Medicare carrier. In fact, the chiropractic office or provider does not learn of
the denial of your claim until several treatments have already been rendered. If this should
happen, and we feel additional care is needed, we will discuss your case with you on an
individual basis to help resolve this matter.
NOTE:
A
S
I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY SERVICES OR
SUPPLIES NOT COVERED UNDER THE MEDICARE PROGRAM SUCH AS:
1. My annual deductible.
2. The coinsurance of 20% if not covered by secondary Ins.
3. Therapy or non-covered services.
4. Office Visits (spinal manipulation) denied by Medicare.
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BENEFICIARY AGREEMENT
I have been notified by my chiropractor that he believes that, in my case, Medicare is likely to
deny payment for the services and reasons identified above. If Medicare denies payment, I agree
to be personally and fully responsible for payment.
PATIENT’S SIGNATURE:
Wanda Willoughy
Date
E
L
5/1/0000
I ALSO UNDERSTAND THAT AS OF SEPTEMBER 1, 1990, MEDICARE MANDATES
THAT ALL DOCTORS SEND THE MEDICARE FORMS DIRECTLY TO THE
MEDICARE OFFICE AND HEREBY AUTHORIZE CHIROPRACTIC OFFICES TO
RELEASE ANY INFORMATION ACQUIRED IN THE COURSE OF MY CASE
HISTORY, EXAMINATION, OR TREATMENT TO THE MEDICARE OFFICE, ANY
DOCTOR, INSURANCE COMPANY OR ATTORNEY. MY SIGNATURE WILL ALSO
SERVE AS MY “SIGNATURE ON FILE” AND VERIFY THAT ANY INFORMATION I
HAVE GIVEN TO CHIROPRACTIC OFFICES IS CORRECT TO THE BEST OF MY
KNOWLEDGE.
P
M
A
S
MY SIGNATURE ALSO AUTHORIZES ALL BENEFITS TO BE PAID TO
CHIROPRACTIC OFFICES.
PATIENT’S SIGNATURE:
Wanda Willoughy
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RETIREMENT CHECKLIST
BACKGROUND
The doctor concluding his career should attend to a variety of personal and professional tasks.
Malpractice insurance, patient notification, records transfer and related practice considerations
may readily come to mind. There are, however, many personal matters warranting periodic
review which will also require analysis.
OBJECTIVE
This checklist is intended to stimulate retirement planning and execution.
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[ ]
Malpractice Insurance “Tail” Coverage
[ ]
Notice in Newspaper
[ ]
Notice Posted in Office
[ ]
Arrangements for Transfer of Patient Records
[ ]
Notice Letter to Patients
[ ]
Notice Letter to Colleagues and Referral Sources
[ ]
Referrals to Other Providers
[ ]
Staff Gifts
[ ]
Notice of Discontinuance of Leases
[ ] Office Building
[ ] Therapy Equipment
[ ] Tables
[ ] Copier
[ ] Fax
[ ]
Utilities Disconnection
[ ] Electric
[ ] Gas
[ ] Water and Sewer
[ ] Telephone
[ ]
Storage for Records not Transferred
[ ]
Accounts Receivable
[ ] Final Letters
[ ] Transfer/Collection
[ ]
Estate Planning
[ ] Wills
[ ] Insurance
[ ] Bequests to College
[ ]
Retirement Budget
[ ] Social Security
[ ] IRA
[ ] Keogh
[ ] Pension/Profit Sharing
[ ]
Miscellaneous
[ ] Living Wills
[ ] Durable Power of Attorney
[ ] Gifts to Children
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RETIREMENT CHECKLIST
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EQUIPMENT REPLACEMENT LOG
BACKGROUND
Doctors tend to devote the majority of their time and energy to clinical details in the office and
often overlook “housekeeping” chores. Failure to attend to details of professional appearance
can cost the doctor patients, permit potentially hazardous equipment failure and invite
treatment-interrupting “downtime.”
Worn, torn or soiled adjusting table upholstery or other signs of aging equipment can affect the
patient’s confidence in the doctor, thereby interfering with treatment results, engendering
suspicion and ultimately perhaps contributing to a malpractice claim.
PRACTICE SUGGESTIONS
Rather than waiting for an equipment failure or increasing maintenance demands to suggest the
need for equipment replacement, the doctor should plan to replace equipment when it is
purchased.
Regular reference to the log will remind the doctor of upcoming expenses and promote better
planning. It will also serve as a convenient reference for tax depreciation purposes.
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EQUIPMENT REPLACEMENT LOG
EQUIPMENT
Leander Flexion/Distraction
Williams Adjusting Table
I.B.M. Computer
DATE PLACED
IN SERVICE
EXPECTED
USEFUL LIFE
Feb. 1, 0000
June 15, 0000
Jan. 4, 0000
10-12 years
10-12 years
3-4 years
REPLACEMENT
DATE
Feb2 1, 0001
June 25, 0004
Jan. 24, 0004
E
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A
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FAX TRANSMISSION COVER SHEET
BACKGROUND
The explosion of modern day technology has affected not only the clinical component of
chiropractic practice but has had comparable impact on its business aspects. Many D.C.s now
have obtained facsimile machines for professional use.
With increasing use of “faxes” will inevitably come new problems, most of which deal with
patient confidentiality. The more sophisticated machines may have many telephone numbers
programmed into them so that all that is necessary to send a document is the pressing of one
button. If the doctor is asked to fax records to a patient’s attorney and the operator pushes the
wrong button, thereby sending the information to the wrong party, the patient’s information has
been wrongfully divulged.
The simplest way to avoid this problem, of course, is to rely on standard mailing and delivery
procedures and not resort to fax transmissions at all. Rarely is the need for information in the
chiropractic practice so critical as to warrant fax use.
OBJECTIVES
1. This form is intended to give notice to the fax recipient of the sensitive nature of the
information in the effort to prevent unnecessary reading of the materials if there is an error.
2. This attempt to maintain confidentiality by acknowledging the possibility of error should reduce
the unfavorable impression which will be made upon the party receiving the documents in error.
3. Should the patient somehow learn of the error and sue the doctor or file an ethics complaint,
this form should help show that every reasonable effort was made to protect confidentiality even
in the event of possible error.
PRACTICE SUGGESTION
Doctors who receive fax transmissions using thermal paper should photocopy them onto regular
paper prior to filing. Thermal paper will deteriorate and become illegible surprisingly quickly
quickly. Perhaps worse, the acid on thermal paper can migrate to other documents and destroy
them as well.
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FAX TRANSMISSION COVER SHEET
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
E
L
FACSIMILE COVER SHEET
TO:
Harry Jawbs, M.D.
FROM:
Richard Roe, D.C
DATE:
February 3, 0000
SUBJECT:
Examination results of John Doe
PAGE 1 OF
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COMMENTS:
◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆
Please notify us immediately at (000)000-0000 if this facsimile is not received properly.
◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆
OPERATOR:
Mary Brown, CA
◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆
the information contained in this facsimile message is doctor-patient privileged and confidential
information intended only for the use for the individual or entity named above. Any reader of
this message who is not the intended recipient is hereby notified that any dissemination,
distribution, or copy of the communication is strictly prohibited. If you have received this
communication in error, you are asked to not read the pages which follow. Please immediately
notify us by collect telephone call of the error and destroy the original message. Thank you.
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EMPLOYEE CONFIDENTIALITY
STATEMENT
I understand and agree that in the performance of my duties as an employee of
Doe Chiropractic Office , I will obtain patient information which is confidential. I acknowledge
having been instructed that I must not divulge any such information to anyone including my
own family, without the express written consent of the patient.
E
L
I have been instructed that any breach of a patient’s right to confidentiality may result in
punitive action including discharge from employment.
1/4/0000
P
M
Date
Billy Jo Merrifield
Signature of Employee
A
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CORRESPONDENCE
BACKGROUND
A doctor’s correspondence may, at one time or another, be seen and assessed by:
•
•
•
•
•
patients
attorneys
other providers
juries
legislators
•
•
•
•
•
insurance company representatives
workers’ compensation representatives
self insuring employers and administrators
disciplinary/licensing boards
staff
Those readers will often base an initial impression of a doctor and his practice upon the
appearance of the correspondence. While the content of a letter should be the most important
factor, the first impression will be largely influenced by the quality and appearance of the
stationery and preparation.
PRACTICE SUGGESTIONS
Letterhead and envelopes should bear no mottoes or pithy sayings. Few, if any, other
professionals use such attention-seeking artifices. They may be appropriate for political or
association mailings, but not for formal business correspondence. Ideally the letterhead and
envelopes should be professionally designed to project a dignified image.
Antiquated, manual typewriters which space unevenly and leave tell-tale smudges and a filledin letter “e” suggest that the writer’s business practices have not moved into the modern era. A
reader may wonder whether a doctor generating such correspondence maintains a clinical
practice just as out-of-date. Rushing out to buy a computer without assessing the appropriate
equipment is not a fool-proof technology leap either. A dot-matrix computer printer will
certainly let readers know that the doctor has computerized, but at the cost of good, crisp, easily
readable letters.
Correspondence must contain no spelling or grammatical errors. Readers who catch such
failings may conclude that a doctor who generates such errors is either poorly educated or too
busy or disinterested to maintain high standards in his practice.
Some D.C.s use the improper signature or salutation style: “Dr. Jim Jones, D.C.”
The signature could be “Dr. Jim Jones” or “Jim Jones, D.C.” but Dr. and D.C. should not be used together.
Letters should bear the typist’s identification in standard business style: the author’s initials in
capital letters followed a by “backslash” and the typist’s initials in lower case letters. A letter
dictated by Dr. Richard Roe and typed by Sue Sorrells, for example, should have the designation
RR/ss at the bottom left margin.
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Much of the utility of a business letter is lost if it is not dated. If the date of the letter, mailing or
receipt is highly important, it should be sent”Certified, Return-Receipt Requested.”
APPLICATION
These sample letters are not designed for photocopying.They must be re-typed, programmed into
a word processor, or printed commercially on the doctor’s letterhead to project a crisp, clean and
professional appearance.
The samples have illustrative entries in BOLD, UPPERCASE ITALICS as displayed in this
sentence. These entries must be deleted and appropriate information substituted when the letters
are re-typed on the doctor’s letterhead.
Care must be taken to assure that all deletions are made — the doctor will appear rather foolish
if his letters refer to the office of Dr. Richard Roe.
Excellent reference article in Topics in Clinical Chiropractic, 2000; 7(4); 25-34 © Aspen Publishers. Inc.
entitled Communicating Chiropractic with Integrity.
EXPLANATORY TEXT
This book not only offers you the ability to produce camera-ready forms by photocopying a clean
form directly from this book, now you can go directly to the “starting into practice website”
startingintopractice.com and download the forms you need directly from the website in a
Microsoft Word® document format. The book also explains WHY the form may be useful for your
practice, HOW to use the forms properly, WHAT the potential disadvantage may be and HOW
to avoid those disadvantages so the selection of forms and letters will be most effective.
We have found that doctors often continue to use obsolete forms, ask inappropriate questions and
continue using systems or procedures with little justification other than: “That’s what I’ve always
done” or “That’s what was in the packet of forms I bought.”
An understanding of the proper use of a form is as important as the form itself. The doctor who
is asked during a trial to explain the purpose of a form or portion of a form must have a reasonable
explanation or the credibility of his/her entire testimony will suffer.
We have sought to explain the thought process behind the ideas shared in the following pages.
USE P.R.N
These forms and letters are intended to give the doctor the opportunity to adopt those forms and
letters which are appropriate for immediate use, modify others and discard those which may not
be relevant to the doctor’s practice style.
We hope you will find them valuable, but we recognize that every practice is unique. Each form
and letter can be modified at the discretion of the doctor. The ability to obtain them ia a Word
document format has made this process easier.
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LETTER TO PATIENT WHEN INSURANCE
COMPANY REJECTS CLAIM
BACKGROUND
Few things are more infuriating to a doctor than having a patient receive a letter from his
insurance company stating that it is denying payment for treatment it claims was not “medically
necessary.” Sometimes an insurance “consultant” reduces “medically necessary” treatment to a
certain number of visits and then advises the insurance company to pay only for that number.
These denial letters may even state that the carrier will defend that patient in any legal action if
the doctor attempts to collect fees in excess of a specified amount.
OBJECTIVES
1. Such a letter is embarrassing to the doctor and can easily persuade the patient to discontinue
care. Using the sample letter provided, the doctor may lessen the impact of the insurance
company denial letter.
2. If the patient still needs care, it is critical that he be so advised. Simply because an insurance
company has denied payment does not mean that a doctor can avoid liability for malpractice if
continued care is needed and he fails to recommend it.
3. The D.C.’s intake form and discussions with the patient should have emphasized that a denial
of insurance payments was a possibility and that the patient is ultimately responsible for
payment regardless of the actions of the insurance company. This letter serves as a reminder of
that earlier agreement.
PRACTICE SUGGESTIONS
• This letter must be modified in response to the specific terms of the insurance carrier’s
denial. For instance, the carrier may only agree to pay a certain amount and deny payment in
excess of that amount based upon a “consultant’s review.”
• Most insurance companies have an appeal process that the patient can follow to obtain a
second review of the case. The patient’s insurance agent can assist him in pursuing that appeal
and also may be able to persuade the company to pay the claim.The patient should be recruited
to assist in combating the insurance company. It is, after all, his problem.
• Some states have regulated paper reviews by requiring reviewer registration and compliance
with certain standards. The doctor should ask a local attorney or the patient’s attorney to
determine if the insurance carrier has complied with local law. An out-of-state carrier may be
unaware of a state law governing chiropractic reviews and re-evaluate the claim if an attorney
gives the carrier a “gentle” reminder.
>>
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LETTER TO PATIENT WHEN INSURANCE
COMPANY REJECTS CLAIM
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
Dear MR. DOE:
E
L
I have received notice from your insurance company that it will not pay a portion of your
claim, stating that our services were “not medically necessary.” Apparently your case was
reviewed by a firm which did not examine you or consult with us. It only reviewed a portion
of you records.
This is very discouraging to me as I am sure it is you. We have found that insurance
companies sometimes hire “consultants” who reduce health claims without a complete
review of the case. While I cannot say with certainty that this happened in you case, I
nevertheless encourage you to appeal to your insurance company for reconsideration.
P
M
Please contact your insurance agent for assistance in pursuing this appeal. I will do my
utmost to provide any information your carrier may require and will attempt to help you get
this decision altered or reversed.
A
S
The carrier’s denial is an insurance decision, not a medical one. It is my belief that you need
additional care. I encourage you to continue coming to us for treatment until you reach
maximum medical/chiropractic improvement. I am aware that a denial of benefits is an
unpleasant economic development.We will work with you in every way to permit you to pay for
your continuing care in reasonable installments if you cannot persuade your company to reverse
its decision.
Please contact this office if you would like to discuss this matter further.
Sincerely,
Dr. RICHARD ROE
RR/ss
1
Practitioners should feel free to use MCI if recommended by your legal counsel.
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LETTER TO INSURANCE COMPANY
AFTER PAPER REVIEW
BACKGROUND
Even doctors who are within the normal fee range will occasionally receive insurance denials or
claim reductions based upon an “independent” paper review. For many doctors it is a
dismayingly frequent occurrence.
This form is intended primarily for the doctor who faces such situations only infrequently. It
emphasizes that the doctor’s intervention is for the benefit of the patient…the doctor will be
paid anyway. That should be the focus. Doctors need to avoid becoming emotionally involved
in combating insurance companies. These denials are generally not personal affronts.
OBJECTIVES
1. Identifying and contacting the reviewer can be helpful, particularly if there are unusual
circumstances which justify prolonged treatment or extensive tests. The doctor may also find
that the reviewer is not qualified by license or training to evaluate care. Identifying those
consultant shortcomings may allow the doctor to convince the insurer to re-evaluate its position.
2. Perhaps most important are the benefits of copying the letter to the patient. It will remind
him that:
• If the insurance company does not pay the bill, it is his responsibility to do so.
• The doctor is making a special effort to assist him in collecting everything he is entitled
to from his company.
• The company is causing the problem, not the doctor.
PRACTICE SUGGESTION
A copy of this letter should always be sent to the patient and, if applicable, to the patient’s attorney.
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LETTER TO INSURANCE COMPANY
AFTER PAPER REVIEW
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
MARY SMITH
STATEDAIRY INSURANCE COMPANY
100 MERCENARY AVENUE
ANYTOWN, STATE 99999
E
L
Re: JOHN DOE
YOUR CLAIM NO: 6237-144
Dear MRS. SMITH:
I have received your denial of benefits for my patient named above. Even though the patient
is responsible for my bill, I want to assist HIM in obtaining proper reimbursement.
P
M
You indicated that your decision was based upon the recommendation of your “consultant.”
Please be advised that I have not discussed this case with any consultant and no one has
examined my patient’s X-rays or other test results. Therefore, I assume that your consultant
only reviewed billing and related information. I do not consider that to be a fair or
reasonable way to determine what you should pay for my patient’s care.
A
S
Please have your consultant let me know what additional documentation is necessary for a
fair reconsideration of the pending charges. If I can speak directly with another professional
who will identify his areas of concern, I believe we will be able to work this matter out more
to my patient’s satisfaction.
Thank you.
Sincerely,
Dr. RICHARD ROE
RR/ss
CC: JOHN DOE
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MEDICARE SUPPLEMENTAL CARRIER
PROTEST LETTER
BACKGROUND
See page 305: Medicare Explanation Form
Complying with expanding Medicare regulation becomes more troublesome all the time. As
Medicare pays less, more elderly patients are purchasing Medicare “supplemental” policies
which are adding to the confusion and administrative burden in accepting Medicare patients.
These supplemental policies generally pay only what Medicare will not. Therefore, many
supplemental carriers will return chiropractic bills without payment until the claim submission
contains an explanation of benefits (EOB) from Medicare denying payment. That may work for
M.D.’s charges, but it has the potential for great difficulty for th D.C. whose only “covered
service” is the spinal manipulation.
To receive a denial from Medicare—for anything other than spinal manipulation—the
chiropractic physician would have to bill for therapy, X-rays or whatever service he really wants
the supplemental carrier to pay. Billing for non-covered services is a violation of the Social
Security Act and in contravention of the certification attested to by the doctor each time he
signs a claim form. (Doctors should read the attestation provision on the reverse side of the
claim form.) Violation can have onerous results including monetary penalties, exclusion from
the system, disciplinary action and criminal charges.
Some Medicare administrators will give written advice which doctors can follow. Some
administrators approve use of special “rejection codes” for billing such services
Some consultants recommend that the D.C. submit a bill for the non-covered services with the
written indication: “SUBMITTED FOR REJECTION PURPOSES ONLY.”
OBJECTIVES
1. This letter is intended to be used in addition to other attempts to secure payment from the
supplemental carrier. If enough doctors bombard the carriers with such correspondence,
perhaps they will liberalize their documentation requirements and eliminate the need for this
unnecessary and burdensome billing. If an aggressive, effective insurance commissioner receives
enough correspondence, he may take action.
2. The letter will document the doctor’s good-faith attempts to avoid contributing to the
administrative burden on the Social Security Administration of evaluating and rejecting claims
for non-covered services.
3. The letter focuses on attempts to help the patient—not on the doctor’s personal economic
interest in being able to easily treat Medicare patients.
>>
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MEDICARE SUPPLEMENTAL CARRIER
PROTEST LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
E
L
BILL SMITH
MEDICARE PLUS INSURANCE COMPANY
100 BENEFITS ROAD
ANYTOWN, STATE 99999
P
M
Re: JOHN DOE
SSN: 000-00-0000
Your Claim No: 6231847
Dear MR. SMITH:
A
S
I have reviewed a copy of your denial of my patient’s claim under his Medicare
supplemental insurance policy.Your denial is supposedly based upon the failure to obtain a
denial from Medicare for my services.
As you know, the only chiropractic service covered under Medicare is the spinal adjustment.
As you are similarly aware, whenever I sign and submit a Medicare claim form, I certify that
each line item submitted is for a “covered” service.
I am unwilling to submit a claim for rejection purposes when Medicare requires me to
certify to the contrary.Your conditioning payment on receipt of a Medicare EOB under such
circumstances is unnecessary, unreasonable, and in bad faith.
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Please consider altering this requirement for payment. My patient has paid you for this coverage
and you should pay the claims. Your conditions work a hardship on him and ask an already
overburdened Medicare system to do your administrative review. I am sending a copy of this
letter to the Insurance Commissioner in the hope that HIS office will assist in eliminating this
duplicate and non-productive paperwork.
E
L
P
M
Sincerely,
Dr. Richard Roe
A
S
RR/ss
cc: Department of Insurance
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DOCTOR’S REQUEST FOR RECORDS
FROM PREVIOUS DOCTOR
GUIDELINES
• A copy must always be kept of pertinent copies of health record from previous or concurrent
health care providers
• A reasonable attempt should be made to obtain recent X-Rays relevant to the presenting problem
BACKGROUND
When, as is often the case, the D.C. has a new patient who has been treated elsewhere for the same
problem, the doctor should always attempt to obtain pertinent records from the previous doctor.
Even if the doctor has every reason to believe that the previous doctor or hospital will not release
the records (or will take so long and be so expensive as to discourage the patient from paying for
copies), he should still request them, in writing. The following letter is for use if previous
experience suggests the former doctor will respond more promptly if the request for record comes
directly from the patient. This letter is more formal: a professional’s request to a colleague.
OBJECTIVES
Making a reasonable effort to obtain the records protects the doctor’s reputation and his
patient’s interests. In an automobile liability trial, for example, the insurance company lawyer
may claim that the X-rays taken by the D.C., for which the patient is seeking compensation,
were not necessary since the hospital emergency room had already taken several views. If the
D.C. is able to testify that he sought those existing films but they were not sent, or he reviewed
them and they were not adequate for his needs, his testimony will be much more credible than
if he just says: “I didn’t ask for them. I know they wouldn’t help from a chiropractic standpoint.”
>>
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DOCTOR’S REQUEST FOR RECORDS
FROM PREVIOUS DOCTOR
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
E
L
JOHN SMITH
100 MAPLE ST.
ANYTOWN, STATE 99999
Re: JOHN DOE
P
M
Dear Dr. SMITH:
Please find enclosed a release of records form1 signed by your patient. MR. DOE is now under
my care. A review of your testing and treatment will, of course, be helpful and will possibly avoid
duplication of services and thereby reduce expense and inconvenience to this patient.
A
S
Your assistance in promptly forwarding copies, HIS file and X-rays along with your notes will
be very much appreciated. If there is a charge for this service, please bill MR. DOE.
RR/ss
cc: JOHN DOE
Enclosure
1
Release of records form is found at page 243.
Sincerely,
Dr. RICHARD ROE
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PATIENT’S REQUEST FOR RECORDS
FROM PREVIOUS DOCTOR
GUIDELINES
• A copy must always be kept of pertinent copies of health record from previous or concurrent
health care providers
• A reasonable attempt should be made to obtain recent X-Rays…relevant to the presenting
problem
BACKGROUND
When, as is often the case, the D.C. has a new patient who has been treated elsewhere for the
same problem, the doctor should always attempt to obtain pertinent records from the previous
doctor.
The response will often be more prompt if the patient is the one requesting the records. This
letter is to be sent by the doctor after it is signed by the patient.
PRACTICE SUGGESTION
The doctor should explain to the patient that he will incur reasonable copying costs but that
time savings and avoidance of duplication should far outweigh the cost.
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PATIENT’S REQUEST FOR RECORDS
FROM PREVIOUS DOCTOR
(NOTE: The letter is from the patient; do not use office letterhead.)
AUGUST 15, 0000
JOHN SMITH, M.D.
100 MAPLE ST.
ANYTOWN, STATE 99999
E
L
Re: JOHN DOE’S RECORDS
Dear Dr. SMITH:
I have appreciated your past efforts in my behalf and look forward to additional professional
dealings with you in the future. I am currently under the care of Dr. ROBERT ROE and
understand that I can avoid needless expense and inconvenience if you will cooperate with HIM
by promptly providing copies of my records.
P
M
Please accept this letter as my authorization for you to provide any materials HE or HIS office
may request and to talk with HIM as either of you may deem helpful, about any of my health
related matters.
A
S
I will, of course, be responsible for your reasonable copying charges in connection with this request.
cc: DR. ROBERT ROE
Sincerely,
JOHN DOE
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RESPONDING TO PATIENT’S OR
PROVIDER’S REQUEST FOR RECORDS
GUIDELINES
• With the consent of a competent patient or guardian, records may, and in most situations
must, be provided.
• The original record should never be released unless compelled by law, only copies.
• It is mandatory that health care data requested by another provider be forwarded as
expeditiously as possible.
• Chiropractic practitioners referring a patient should provide information from the case history and
diagnostic findings to minimize unnecessary testing or repetition of diagnostic procedures.
BACKGROUND
It is imperative that immediate attention be given requests for records from patients or other
health care providers. Otherwise, if resulting treatment delay causes the patient injury, the
doctor may be found liable.
The doctor cannot condition the release of records on payment of a past-due bill. While that may be
tempting, there are no exceptions in the laws requiring production of records which allow providers
to condition compliance on payment in full. It is also improper to attempt to thwart patient access to
records by assessing an unrealistically high copying charge or conditioning production on the signing
of an agreement that releases the doctor from liability for his own negligence.
The same urgency does not apply to a request from an attorney although it is good office policy to
act expeditiously even upon a request by a patient’s agent. Delays are perceived negatively, and if a
patient is already contemplating a malpractice suit, delay in furnishing records will only generate
more animosity. (See page 348 for a sample letter to an attorney requesting records.)
OBJECTIVES
1. No release of records or viewing of X-rays is proper except upon written patient authorization.
This letter is intended to respond to a request when proper authorization has been received.
2. In addition to facilitating the prompt transmittal of requested documents, these letters make
the doctor’s position on release of X-rays clear. Films which are lost in the mail or misfiled in
another doctor’s office are of no help in defending a malpractice claim.
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APPLICATION
The following letters are intended for use when the patient requests his own records, requests that
they be sent to another health care provider, or when another provider seeks them with the
patient’s authorization.
PRACTICE SUGGESTIONS
Risk management principles and basic, human compassion forbid jeopardizing a patient’s health
in retaliation for his refusal or inability to pay a few dollars in copying charges. Good judgment
dictates liberal — even free — providing of records to successor physicians and the patient. Patient
well-being is the paramount concern. Whatever decision the doctor makes about billing for copies,
the best policy is to send them immediately. If a charge is to be imposed, an invoice may be
enclosed with the records.
POTENTIAL DISADVANTAGES
There is much to be said for providing records to patients and subsequent treating doctors without
charge. Asking for a few dollars in copying charges, particularly if the bill for treatment was
substantial, may generate considerable patient resentment. If a payment request is directed to
another health care provider who does not himself make such charges, or whose patient is unable
or unwilling to pay the charges, it will also create a negative impression with that doctor.
If a patient has decided to go elsewhere for treatment, but has not seriously considered making a
malpractice claim, seeking payment for records may be the final annoyance which sends him off to
see the lawyer.
>>
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RESPONDING TO PATIENT’S OR
PROVIDER’S REQUEST FOR RECORDS
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
E
L
Dear MR. DOE:
We are in receipt of your request for copies of your records. We will, of course, comply with that
request. We will bill you for applicable copying costs.
P
M
The X-rays are a bit more of a problem. We don’t release originals of X-rays and do not have
the capability to copy them. We will be happy to make the originals available, in our office, for
viewing by whomever you would like, during normal office hours.
A
S
If that arrangement is not satisfactory, we can have the films copied. Copying charges are $00.00
per film.You have SEVEN views so you will need to sent $00.00 if you want all the films copied.
We will await your instructions.
Sincerely,
Office Manager
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RESPONDING TO PATIENT’S OR
PROVIDER’S REQUEST FOR RECORDS
GUIDELINES
• With the consent of a competent patient or guardian, records may, and in most situations
must, be provided.
• The original record should never be released unless compelled by law, only copies.
• It is mandatory that health care data requested by another provider be forwarded as
expeditiously as possible.
• Chiropractic practitioners referring a patient should provide information from the case history and
diagnostic findings to minimize unnecessary testing or repetition of diagnostic procedures.
BACKGROUND
It is imperative that immediate attention be given requests for records from patients or other
health care providers. Otherwise, if resulting treatment delay causes the patient injury, the
doctor may be found liable.
The doctor cannot condition the release of records on payment of a past-due bill. While that may be
tempting, there are no exceptions in the laws requiring production of records which allow providers
to condition compliance on payment in full. It is also improper to attempt to thwart patient access to
records by assessing an unrealistically high copying charge or conditioning production on the signing
of an agreement that releases the doctor from liability for his own negligence.
The same urgency does not apply to a request from an attorney although it is good office policy to
act expeditiously even upon a request by a patient’s agent. Delays are perceived negatively, and if a
patient is already contemplating a malpractice suit, delay in furnishing records will only generate
more animosity. (See page 348 for a sample letter to an attorney requesting records.)
OBJECTIVES
1. No release of records or viewing of X-rays is proper except upon written patient authorization.
This letter is intended to respond to a request when proper authorization has been received.
2. In addition to facilitating the prompt transmittal of requested documents, these letters make
the doctor’s position on release of X-rays clear. Films which are lost in the mail or misfiled in
another doctor’s office are of no help in defending a malpractice claim.
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APPLICATION
The following letters are intended for use when the patient requests his own records, requests that
they be sent to another health care provider, or when another provider seeks them with the
patient’s authorization.
PRACTICE SUGGESTIONS
Risk management principles and basic, human compassion forbid jeopardizing a patient’s health
in retaliation for his refusal or inability to pay a few dollars in copying charges. Good judgment
dictates liberal — even free — providing of records to successor physicians and the patient. Patient
well-being is the paramount concern. Whatever decision the doctor makes about billing for copies,
the best policy is to send them immediately. If a charge is to be imposed, an invoice may be
enclosed with the records.
POTENTIAL DISADVANTAGES
There is much to be said for providing records to patients and subsequent treating doctors without
charge. Asking for a few dollars in copying charges, particularly if the bill for treatment was
substantial, may generate considerable patient resentment. If a payment request is directed to
another health care provider who does not himself make such charges, or whose patient is unable
or unwilling to pay the charges, it will also create a negative impression with that doctor.
If a patient has decided to go elsewhere for treatment, but has not seriously considered making a
malpractice claim, seeking payment for records may be the final annoyance which sends him off to
see the lawyer.
>>
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RESPONDING TO PATIENT’S REQUEST
FOR RECORDS (ALTERNATIVE VERSION)
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
Dear MR. DOE:
We are in receipt of your request for copies of your records.We will be happy to comply with your
request in the most expeditious fashion possible. A review of your records indicates there are
NINETY-SIX pages in your file. These include our progress notes, case history, examination and
other relevant information regarding your case. There is a copy charge of $00.00 for your file and
upon receipt of this charge we will copy and mail your records to you or whomever you direct, in
writing. We have enclosed an “authorization to release records” form1 which you can use to
designate the name of the doctor or individual to receive your records.
E
L
P
M
X-rays are a bit more of a problem. We do not have the capability of copying them and we are
required to retain the originals of these for our records. We will make the original X-rays
available, in our office, for viewing during normal office hours by anyone you designate.
A
S
If that arrangement is not satisfactory, we can have the X-rays copied. The charge for copy
service is $00.00 per film. Your file has NINE X-rays so the cost to have the copies made and
mailed to you will be $00.00.
Therefore, if you would like copies of the X-rays, please send a total of $00.00 for the records
and X-rays. If we can be of any further service, please feel free to contact the office.
Sincerely,
Dr. RICHARD ROE
RR/ss
1
See authorization to release records form at page 243.
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RESPONDING TO PATIENT’S OR
PROVIDER’S REQUEST FOR RECORDS
GUIDELINES
• With the consent of a competent patient or guardian, records may, and in most situations
must, be provided.
• The original record should never be released unless compelled by law, only copies.
• It is mandatory that health care data requested by another provider be forwarded as
expeditiously as possible.
• Chiropractic practitioners referring a patient should provide information from the case history and
diagnostic findings to minimize unnecessary testing or repetition of diagnostic procedures.
BACKGROUND
It is imperative that immediate attention be given requests for records from patients or other
health care providers. Otherwise, if resulting treatment delay causes the patient injury, the
doctor may be found liable.
The doctor cannot condition the release of records on payment of a past-due bill. While that may be
tempting, there are no exceptions in the laws requiring production of records which allow providers
to condition compliance on payment in full. It is also improper to attempt to thwart patient access to
records by assessing an unrealistically high copying charge or conditioning production on the signing
of an agreement that releases the doctor from liability for his own negligence.
The same urgency does not apply to a request from an attorney although it is good office policy to
act expeditiously even upon a request by a patient’s agent. Delays are perceived negatively, and if a
patient is already contemplating a malpractice suit, delay in furnishing records will only generate
more animosity. (See page 348 for a sample letter to an attorney requesting records.)
OBJECTIVES
1. No release of records or viewing of X-rays is proper except upon written patient authorization.
This letter is intended to respond to a request when proper authorization has been received.
2. In addition to facilitating the prompt transmittal of requested documents, these letters make
the doctor’s position on release of X-rays clear. Films which are lost in the mail or misfiled in
another doctor’s office are of no help in defending a malpractice claim.
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APPLICATION
The following letters are intended for use when the patient requests his own records, requests that
they be sent to another health care provider, or when another provider seeks them with the
patient’s authorization.
PRACTICE SUGGESTIONS
Risk management principles and basic, human compassion forbid jeopardizing a patient’s health
in retaliation for his refusal or inability to pay a few dollars in copying charges. Good judgment
dictates liberal — even free — providing of records to successor physicians and the patient. Patient
well-being is the paramount concern. Whatever decision the doctor makes about billing for copies,
the best policy is to send them immediately. If a charge is to be imposed, an invoice may be
enclosed with the records.
POTENTIAL DISADVANTAGES
There is much to be said for providing records to patients and subsequent treating doctors without
charge. Asking for a few dollars in copying charges, particularly if the bill for treatment was
substantial, may generate considerable patient resentment. If a payment request is directed to
another health care provider who does not himself make such charges, or whose patient is unable
or unwilling to pay the charges, it will also create a negative impression with that doctor.
If a patient has decided to go elsewhere for treatment, but has not seriously considered making a
malpractice claim, seeking payment for records may be the final annoyance which sends him off to
see the lawyer.
>>
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RESPONDING TO ANOTHER
PROVIDER’S REQUEST FOR RECORDS
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN SMITH, M.D.
100 MAPLE ST.
HOMETOWN ,VA 99999
Re: JOHN DOE
Dear DR. SMITH:
E
L
I am in receipt of your request for copies of records on the above named patient. I will, of
course, comply with that request.
The X-rays are a bit more of a problem. I don’t release originals of X-rays and do not have the
capability to copy them. I will be happy to make the originals available for your viewing in my
office, during normal office hours.
P
M
If that arrangement is not satisfactory, I can have the films copied. Copying charges are $00.00 per
film. This patient has SEVEN views so the cost to have them copied and mailed is $00.00.
A
S
By copy of this letter to MR. DOE I am asking for HIS instructions and will comply with them.
RR/ss
cc: JOHN DOE
Very truly yours,
Dr. RICHARD ROE
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RESPONDING TO PATIENT’S OR
PROVIDER’S REQUEST FOR RECORDS
GUIDELINES
• With the consent of a competent patient or guardian, records may, and in most situations
must, be provided.
• The original record should never be released unless compelled by law, only copies.
• It is mandatory that health care data requested by another provider be forwarded as
expeditiously as possible.
• Chiropractic practitioners referring a patient should provide information from the case history and
diagnostic findings to minimize unnecessary testing or repetition of diagnostic procedures.
BACKGROUND
It is imperative that immediate attention be given requests for records from patients or other
health care providers. Otherwise, if resulting treatment delay causes the patient injury, the
doctor may be found liable.
The doctor cannot condition the release of records on payment of a past-due bill. While that may be
tempting, there are no exceptions in the laws requiring production of records which allow providers
to condition compliance on payment in full. It is also improper to attempt to thwart patient access to
records by assessing an unrealistically high copying charge or conditioning production on the signing
of an agreement that releases the doctor from liability for his own negligence.
The same urgency does not apply to a request from an attorney although it is good office policy to
act expeditiously even upon a request by a patient’s agent. Delays are perceived negatively, and if a
patient is already contemplating a malpractice suit, delay in furnishing records will only generate
more animosity. (See page 348 for a sample letter to an attorney requesting records.)
OBJECTIVES
1. No release of records or viewing of X-rays is proper except upon written patient authorization.
This letter is intended to respond to a request when proper authorization has been received.
2. In addition to facilitating the prompt transmittal of requested documents, these letters make
the doctor’s position on release of X-rays clear. Films which are lost in the mail or misfiled in
another doctor’s office are of no help in defending a malpractice claim.
>>
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APPLICATION
The following letters are intended for use when the patient requests his own records, requests that
they be sent to another health care provider, or when another provider seeks them with the
patient’s authorization.
PRACTICE SUGGESTIONS
Risk management principles and basic, human compassion forbid jeopardizing a patient’s health
in retaliation for his refusal or inability to pay a few dollars in copying charges. Good judgment
dictates liberal — even free — providing of records to successor physicians and the patient. Patient
well-being is the paramount concern. Whatever decision the doctor makes about billing for copies,
the best policy is to send them immediately. If a charge is to be imposed, an invoice may be
enclosed with the records.
POTENTIAL DISADVANTAGES
There is much to be said for providing records to patients and subsequent treating doctors without
charge. Asking for a few dollars in copying charges, particularly if the bill for treatment was
substantial, may generate considerable patient resentment. If a payment request is directed to
another health care provider who does not himself make such charges, or whose patient is unable
or unwilling to pay the charges, it will also create a negative impression with that doctor.
If a patient has decided to go elsewhere for treatment, but has not seriously considered making a
malpractice claim, seeking payment for records may be the final annoyance which sends him off to
see the lawyer.
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RESPONDING TO ANOTHER PROVIDER’S REQUEST FOR
RECORDS WHEN NO PATIENT AUTHORIZATION WAS INCLUDED
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN SMITH, M.D.
100 MAPLE ST.
HOMETOWN,VA 99999
Re: JOHN DOE
Dear DR. SMITH:
E
L
I am in receipt of your request for copies of records on the above named patient. I wish to
cooperate with you and will, of course, comply with that request. Unfortunately, however, I have
received no authorization from the patient to provide you with these materials. Without the
authorization, as I am certain you understand, I cannot send you the records. I will await
authorization from MR. DOE.
P
M
The X-rays are a bit more of a problem. I cannot release originals of X-rays and do not have
the capability to copy them. I will be happy to make the originals available for your viewing, in
my office, during normal office hours.
If that arrangement is not satisfactory, I can have the films copied. Copying charges are $00.00
per film. MR. DOE has SEVEN views so the charge to have the copies made and mailed to you
is $00.00.
A
S
By copy of this letter to MR. DOE, accompanied by a form to authorize release of records,
I am asking for HIS instructions and will comply with them.
Very truly yours,
Dr. RICHARD ROE
RR/ss
cc: JOHN DOE
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RESPONDING TO ATTORNEY’S
REQUEST FOR RECORDS
GUIDELINES
• With the consent of a competent patient or guardian, records may, and in most situations
must, be provided.
• The original record should never be released unless compelled by law, only copies.
BACKGROUND
When the records request is from a lawyer rather than the patient or another doctor, insisting
on advance payment of copy charges is less objectionable since the patient’s health will not be
jeopardized by the delay.
OBJECTIVES
1. This simple letter is intended to facilitate prompt payment for copying without wasting time
and effort on billing. The doctor may also want to include a copy of the state statute allowing
the charging of a “reasonable fee” or whatever other provision is applicable
2. The letter also makes clear that the doctor will not release original X-rays. Films which are
lost in the mail or misfiled in the lawyer’s office are of no help if they are ever needed to defend
against a malpractice claim.
PRACTICE SUGGESTIONS
Doctors are not free to condition the release of records on payment of a past-due bill. While
that may be tempting, there are no exceptions in the laws requiring production which allow
providers to condition compliance on payment in full. It is also improper to attempt to thwart
patient access by assessing an unrealistically high copying charge or conditioning release on the
signing of an agreement that releases the doctor from liability for his own negligence.
NOTE
No release of copies of patient records or viewing of patient X-rays is
proper except upon in written patient authorization.
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RESPONDING TO ATTORNEY’S
REQUEST FOR RECORDS
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN Q. GREEN, ESQ.
100 COURTHOUSE SQUARE
ANYTOWN, STATE 99999
Re: Your letter dated:
AUGUST 14, 0000
Patient: JOHN DOE
E
L
Dear MR. GREEN:
We are in receipt of your request for records on the above named patient. We will, of course,
comply with the request. As you know, however, we are entitled to be reimbursed for our
copying expense. A review of the file indicates that the copying charge will be $00.00. Upon
receipt of that amount we will copy and mail the files to you.
P
M
The X-rays are a bit more of a problem. We cannot release originals of X-rays and do not have
the capability to copy them. We will be happy to make the originals available for viewing, by
whomever you would like, in my office, during normal office hours.
A
S
If that arrangement is not satisfactory, we can have the films copied. Copying charges are $00.00
per film. This patient has SEVEN views, therefore you will need to send an additional $00.00
if you want all the films copied.
RR/ss
cc: JOHN DOE
Very truly yours,
Dr. RICHARD ROE
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CONFIRMATION THAT DOCTOR IS
DECLINING TO ACCEPT THE PATIENT
BACKGROUND
• Doctors of chiropractic frequently accept patients despite knowing they will cause problems.
While no “legitimate” patient who has been unable to find relief through traditional medical
treatment, should be denied care, a D.C. need not accept “red flag” individuals who place an
enormous burden on the emotional well-being of doctor, staff and patients.
• Experienced doctors know these patient types: some are constant complainers; others have
been to every D.C. in town and “know” that they will finally find relief through you. In many
cases the “red flags” are apparent to the doctor during the first visit, but he still treats that
individual because he believes he has little choice. If he rejects the individual as a patient, the
doctor reasons, he will be sued for abandonment.
• Doctors are justifiably concerned that these types of individuals could bring a lawsuit for
abandonment if treatment is not provided after the first visit or for malpractice if the individual
becomes a patient.These are the types of patients who look for any excuse to sue.
OBJECTIVE
These letters clearly indicate that the doctor has the right to refuse an individual as a patient
even after taking a his or conducting a physical exam. They clarify a doctor’s procedures for
accepting patients since legal authorities are unclear as to when the doctor-patient relationship
begins.
Both letters serve the above purposes while being customized according to whether doctor has
or has not orally advised the patient of his decision.
PRACTICE SUGGESTIONS
• The doctor’s patient information form should also state that the doctor has the right and
professional obligation to accept or reject individuals as patients after the history and physical
exam are completed. See page 19 “Patient Information Form” and page 23 “Heath History
Form.”
• During the history and physical exam, the doctor should make it a practice to state to the
individual that these procedures are designed to determine “if we can help you.”
• When declining to accept a patient, it is always a good idea to suggest alternative treatment
sources such as an M.D. or D.C. referring group.
• If the doctor declines to accept an individual as a patient, he should consider making no charge
for the first visit. If a diagnosis/assessment is made and referral to an appropriate doctor resulted,
charging for the service is no problem. For the disgruntled, litigious patient or if the person was
not accepted because the doctor otherwise believed that he would be a “problem” patient, it adds
“insult to injury” to charge for the visit. Moreover, imposing a fee gives a disgruntled party a
stronger claim that he was “accepted” should he later make a malpractice claim.
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• Some individuals respond better to a personal discussion rather than a harsh “letter for
rejection.” Doctors should consider speaking personally with individuals who will not be
accepted as patients and then confirming this discussion with a letter.1
POTENTIAL DISADVANTAGES
Any “rejection” letter to an individual of this type is apt to be taken negatively. A more personal
approach should be used if judgement suggests these letters will only fuel a particular recipient’s
anger.
1
Two letters are offered. The first confirms the doctor’s conversation that he will not accept the individual as a patient. The second assumes
that the individual left the office without a decision having been made as to whether or not he would be accepted as a patient.
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CONFIRMATION THAT DOCTOR IS
DECLINING TO ACCEPT THE PATIENT
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
Dear MR. DOE:
As we discussed on AUGUST 15, 0000 and as stated on our Patient Information Form, the
purpose of taking your history and conducting a physical examination is to determine if we can
assist you by accepting you as a patient. I informed you after theses procedures were completed
that we will be unable to do so.
E
L
It is not possible for us to help everyone. When it appears unlikely that our care will be of
substantial benefit, we believe that it is in your best interest to know that at the earliest possible
time so you can secure other care promptly.
P
M
There are many capable doctors in this area who may be able to offer treatment.We suggest that
you contact the local medical association referral service at 000-0000 or the State Board of
Chiropractic Examiners at 000-0000 for information about other doctors in your area.
Please contact this office after you select a doctor, and we will forward copies of our records and
X-rays to him or her. There is no charge for this service or for your initial visit.
RR/ss
A
S
Sincerely,
Dr. RICHARD ROE
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LETTER ADVISING INDIVIDUAL THE DOCTOR
WILL BE UNABLE TO ACCEPT HIM AS A PATIENT
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
Dear MR. DOE,
E
L
P
M
Thank you for taking the time to come to our office on AUGUST 15, 0000. As stated on our
Patient Information Form, we will not accept individuals for treatment unless we feel confident
that we can help them. I have concluded that we cannot accept you as a patient.
It is not possible for us to help everyone. When it appears unlikely that our care will be of
substantial benefit, we believe that it is in your best interest to know that at the earliest possible
time so you can secure other care promptly.
A
S
There are many capable doctors in this area who may be able to offer treatment.We suggest that
you contact the local medical association referral service 000-0000 or the State Board of
Chiropractic Examiners at 000-0000 for information about other doctors in your area.
Please contact this office after you select a doctor, and we will forward copies of our records and
X-Rays to him or her. There is no charge for this service or for your initial visit.
Sincerely,
Dr. RICHARD ROE
RR/ss
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LETTER CONFIRMING THAT PATIENT
DISCONTINUED CARE VOLUNTARILY
BACKGROUND
When a disgruntled patient discontinues care, the natural inclination may be to say “good
riddance” and take no protective action. Sound risk management principles, however, require
the prudent doctor to follow up under such circumstances.
The patient who discontinues care prior to physician discharge is probably dissatisfied with
some aspect of his care. That dissatisfaction is the breeding ground for malpractice litigation.
Claims of abandonment, failure to make a proper referral and improper diagnosis all share a
critical element of the timeliness of the doctor’s actions. Confirming the date and circumstances
of the dissolution of the doctor-patient relationship may insulate the doctor from some
negligence claims.
PRACTICE SUGGESTIONS
Alternative letters have been provided for use in differing factual situations. The doctor should
choose an appropriate letter whenever he learns that a patient has determined to discontinue
care
Any discussion of the patient’s care should only occur after receipt of an appropriate release for
the authorization of information.
OBJECTIVES
1. To prevent the patient who develops a serious health problem from claiming that the doctor
never told him that he should continue care.
2. To confirm the date of termination of the professional relationship so that the malpractice
statute of limitations will begin to run.
3. To gather information on what, if any, specific conduct of the doctor or staff contributed to
the patient’s dissatisfaction so that, if possible it may be avoided in the future. See page 197
“Patient Satisfaction Survey.”
4. To learn if the patient believes he suffered an injury for which he is considering litigation.
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LETTER CONFIRMING THAT PATIENT
DISCONTINUED CARE VOLUNTARILY
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
Dear MR. DOE:
I understand that you came by the office to pick up your records and indicated that you will be
receiving treatment elsewhere in the future. It is my professional opinion that your condition
does require further care, so I urge you not to delay in finding and visiting another doctor.
Please feel free to have your new doctor contact me so that I may describe, in more detail, your
diagnosis and course of treatment while a patient at this office.
E
L
P
M
In keeping with our goal of providing the best possible service, I ask that you share with us the
reason(s) for your discontinuing care. If you had any problem with this office, your sharing that
information will allow us to seek to avoid such situations in the future. For your ease in
responding, I have enclosed a short survey form1 with a postage-paid, self-addressed envelope.
Please let us hear from you.
A
S
Thank you for the opportunity to be of service to you in the past, and be assured that you are
always welcome to return should circumstances warrant.
RR/ss
Enclosures
1
A sample survey is found on page 197.
Sincerely,
Dr. RICHARD ROE
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CONFIRMATION OF TELEPHONE
MESSAGE DISCONTINUING CARE
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
Dear MR. DOE:
This will confirm our conversation of AUGUST 15,0000, during which you discharged me as
your doctor. It is my professional opinion that your condition does require further care. If you
have not already done so, I urge you not to delay in finding and visiting another doctor.
E
L
Please feel free to have your new doctor contact me so that I can provide information
concerning your diagnosis and course of treatment while a patient at this office.
P
M
In keeping with our goal of providing the best possible service, I ask that you share with us the
reason(s) for your discontinuing care. If you had any problem with this office, your sharing that
information will allow us to seek to avoid such situations in the future. For your ease in
responding, I have enclosed a short survey form1 with a postage-paid, self-addressed envelope.
Please let us hear from you.
A
S
Thank you for the opportunity to be of service to you in the past, and be assured that you are
always welcome to return should circumstances warrant.
RR/ss
Enclosures
1
A suggested survey is found on page 197.
Sincerely,
Dr. RICHARD ROE
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FAILURE TO FOLLOW INSTRUCTIONS
PRE-WITHDRAWAL LETTER
GUIDELINES
Patients who prove to be insincere or noncompliant to treatment/care recommendations should
be discharged from care, with referral when appropriate.
BACKGROUND
A doctor generally has a right to with draw from a case if he so desires. Prudence dictates that
he do so if he has a “personality conflict” or other irreconcilable problem with the patient.
Refusal to follow instructions is also sufficient cause for discharge.
OBJECTIVE
This letter should be used when the doctor-patient relationship has deteriorated, but may still
be salvaged. This is the last effort to retain the patient before sending a letter of withdrawal such
as the one which follows.
PRACTICE SUGGESTION
When the patient has failed to comply with recommendations, the doctor should identify all
shortcomings in detail. Among the more common problem areas are:
•
•
•
•
•
•
repeated failure to keep appointments
failure to lose weight as recommended
returning to work contrary to instructions
failing to regularly perform recommended exercises
continuing to drive contrary to instructions
continuing to participate in various other physical activities contrary to instructions
POTENTIAL DISADVANTAGES
Some patients will be sensitive to their shortcomings. The patient who cannot or will not lose
weight, for example, may be angered by the letter and discontinue care or shift blame for his
failings onto the doctor and consider filing a suit.
The letter should include only those conditions or subjects which the doctor has discussed with
the patient. If failure to lose weight is listed, for example, on a patient who is very thin, the
doctor will appear foolish. Worse, inclusion of items which the doctor never warned the patient
about can form the basis for a lawsuit.
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FAILURE TO FOLLOW INSTRUCTIONS
PRE-WITHDRAWAL LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Re: Failure to follow instructions
E
L
Dear MR. DOE:
I am very much concerned about your health. Despite prior warnings, you have:
1) REPEATEDLY FAILED TO KEEP APPOINTMENTS,
2) FAILED TO LOSE WEIGHT AS RECOMMENDED, AND
3) RETURNED TO WORK CONTRARY TO MY INSTRUCTIONS.1
P
M
It is my professional opinion that each of these acts is an impediment to your recovery and/or
injurious to your health.
Please remember that I cannot help you unless you are willing to help yourself. Your condition
did not develop overnight and certainly will not respond to treatment overnight either. Without
your cooperation, however, it is unlikely that you will ever achieve your maximum level of
improvement.
A
S
Unless you assure me that you are going to begin making a genuine effort to assist in your care,
I am reluctant to continue treating you.
My receptionist will soon call you to schedule a conference so that we may either agree to the
terms upon which I will continue to see you, or discuss the transfer of your care to another
doctor. There will be no charge to you for that conference.
I look forward to seeing you soon.
Sincerely,
Dr. RICHARD ROE
RR/ss
1
List only those issues which are applicable to this patient.
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WITHDRAWAL LETTER
GUIDELINES
Patients who prove to be insincere or non-compliant to treatment/care recommendations should
be discharged from care, with referral when appropriate.
BACKGROUND
A doctor generally has a right to withdraw from a case if he so desires. Prudence dictates that
he do so if he has a “personality conflict” or other irreconcilable problem with the patient.
Refusal to follow instructions is also sufficient cause for discharge.
Upon deciding on this course of action, the doctor must provide the patient sufficient notice of
withdrawal to afford him a reasonable opportunity to engage a new doctor. In giving such
notice, the doctor need not cite a reason for his withdrawal.
What constitutes reasonable notice depends on the circumstances. Factors affecting
reasonableness include the patient’s health and the availability of other comparable services.
PRACTICE SUGGESTIONS
• Send the withdrawal letter certified, return receipt requested.
• Keep the certified receipt when it is returned.
• Maintain a copy of the letter in the patient’s file with the receipt attached.
• Prior to sending this letter, the preceding “gentle” noncompliance letter may be appropriate.
See page 357 “Failure to Follow Instructions.”
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WITHDRAWAL LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Re: Withdrawal as doctor
E
L
Dear MR. DOE:
I find it necessary to withdraw from providing you further chiropractic care because you have
persisted in refusing to follow my advice and treatment. Since your condition still requires
professional attention, I suggest that you place yourself under the care of another doctor without delay.
P
M
I will be available to treat you for a reasonable time after you receive this letter, but in no event
for more than 10 DAYS.
This will give you ample time to select another doctor of your choice from the many competent
practitioners in the area. To assist you in receiving additional care, we will make copies of your
records available to your new doctor, without charge, as soon as you sign and return the
enclosed authorization.
A
S
If it will assist you, we will suggest the names of two or more doctors and assist you in making
an appointment.
Sincerely,
Dr. RICHARD ROE
RR/ss
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PATIENT REFUSAL TO ALLOW X-RAY
GUIDELINES
The decision on whether or not to use diagnostic imaging studies is made following a carefully
performed history, physical and regional evaluation, and consideration of cost/benefit/radiation
exposure ratios. It is based on sound clinical reasoning and the likelihood that significant
information can be obtained from the study. The decision remains solely the domain of the
examining (primary) practitioner.
BACKGROUND
When the doctor believes that the patient’s complaints and history require X-Rays, he must take
them. Allowing the patient to dictate what examinations he will undergo exposes the doctor to
substantial malpractice risk.
An adult, competent patient has every right to decline any test or treatment. He does not,
however, have the right to receive treatment unless he is willing to abide by the doctor’s
professional judgment.
The patient most likely to insist upon treatment without X-Rays is the former chiropractic
patient whose previous doctor always adjusted without them. Doctors eager to provide service
and to obtain a new patient may be tempted to treat such a patient if he signs a “waiver” of some
kind. Those ploys are hardly as safe as simply refusing to treat.
PRACTICE SUGGESTIONS
Another patient likely to balk at X-Rays is one who has had many taken by other doctors and
who does not want any more radiation exposure. Prior to taking further views, the doctor should
make reasonable efforts to obtain copies of previous films. That effort demonstrates respect for
the patient’s concerns and a conscientious approach to patient management.
When a D.C. abdicates his professional judgment and agrees to forego some needed test or
procedure, he has malpracticed. The only issues then will be whether the patient suffers injury
as a result and whether the doctor has taken sufficient cautionary steps to make him at least
partially liable for his own injury. Why take the risk?
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PATIENT REFUSAL TO ALLOW X-RAY
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Dear MR. DOE:
E
L
After conducting a physical examination at your request today and taking into account the
history you have related to me, I concluded and explained to you that an X-Ray analysis is
necessary in your case.
P
M
I remind you now that my conclusion was based on the need to rule out the possibility of a
fracture, tumor or other structural or bio-mechanical problem which might complicate your
condition and perhaps make treatment contraindicated. I refused to treat you without benefit
of those X-Rays. You were obviously annoyed at not being treated and I regret that you left the
office with the matter unresolved.
I strongly urge you to reconsider and allow me, or another doctor, to X-ray you without further
delay. The history and condition you described to me warrants further examination and
treatment. If, in fact, there is a fracture or other underlying condition involved, your refusal to
obtain further examination and treatment could be harmful. If you fail to obtain treatment at
all, your condition could continue to deteriorate into a serious, chronic state or some health or
life-endangering problem could go undetected.
A
S
If you would like to discuss this matter further, please give me a call.
Sincerely,
Dr. RICHARD ROE
RR/ss
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FAILURE TO FOLLOW ADVICE LETTER
TO PARENT/GUARDIAN OF MINOR CHILD
GUIDELINES
Patients who prove to be insincere or non-compliant to treatment/care recommendations should
be discharged from care, with referral when appropriate.
OBJECTIVES
• Practice Management. This form is primarily aimed at encouraging the parent or guardian
to follow advice to have a child treated.The written follow-up will reinforce the doctor’s concern
and professionalism in caring enough about his patients to keep track of who follows through
on recommendations and who does not. It seeks to strike the delicate balance of expressing
concern for the patient’s health without appearing to be aggressive.
• Risk Management. The doctor-patient relationship may be established well before the
doctor has completed his examination and made a report of findings. Failure to follow up on a
patient who does not undertake recommended treatment exposes the D.C. to allegations that
he did not sufficiently express that the condition was serious and required care. When sent
certified, return receipt requested, the letter helps protect the doctor against claims of
abandonment and failure to refer.
POTENTIAL DISADVANTAGES
This letter may offend some parents who will feel they are being pressured. Its use should be
limited to situations where follow-up care is truly important.
Doctors with the time and personality to do so effectively, may wish to call a parent prior to
using this impersonal letter.
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FAILURE TO FOLLOW ADVICE LETTER TO
PARENT/GUARDIAN OF MINOR CHILD
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
E
L
JOHN DOE
MAIN STREET
ANYTOWN, STATE 99999
Re: Your child’s health and treatment
P
M
Dear MR. DOE:
We have not seen YOUR SON, DAVID, since presenting you our report of findings. As I
explained at that time, we found some structural and muscular conditions which could continue
to cause HIM problems if they go untreated.
I am concerned about your child’s health, as I am certain you are.The treatment we recommended
was not decided upon lightly. I believe it to be necessary for HIS present condition and to reduce the
chances of more serious problems developing later if treatment is not begun now.
A
S
If you have any questions about my recommendations or other concerns about beginning
treatment, please call soon so that we may discuss the matter further.
If you have decided not to seek further treatment, I urge you to reconsider. I will be happy to
arrange for another doctor to perform an examination and provide you a second opinion, or you
can certainly do so on your own. If you provide written authorization, I will forward the records
from this office to the doctor of your choice. Securing proper treatment — from whatever source
— is the primary issue now.
Please let me know how I can help you, and your child.
Sincerely,
Dr. RICHARD ROE
RR/ss
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PATIENT NOT SATISFIED AND
WILL NOT RETURN
SEND ONLY WITH MALPRACTICE
INSURANCE CARRIER PERMISSION
BACKGROUND
No one is perfect. At some time, every doctor will face a dissatisfied patient. Sometimes it is best
to simply waive amounts owed and forgive the bill.
CAUTION!
A doctor should not send this letter unless he receives permission from his insurance carrier to
do so. A malpractice carrier could construe such a letter as an offer of settlement and deny
coverage if a malpractice suit is subsequently filed. A call to the doctor’s carrier is required
before sending this letter. Some policies expressly forbid this type of arrangement without the
insurer’s approval.
PRACTICE SUGGESTIONS
• If the malpractice insurance carrier gives the doctor permission to send this letter, the doctor
should confirm the conversation by letter and by noting the name of the person approving and
the date and time of the conversation.
• Faxing a copy of the letter to the person granting permission a day before mailing the original
to the patient affords an additional opportunity for the carrier to voice any objection.
POTENTIAL DISADVANTAGE
• Complaining patients will take advantage of a doctor who waives all past bills any time there
is a complaint. Obviously this letter should only be used on rare occasions. If the doctor feels
the patient’s complaint may be valid, this strategy may preclude a malpractice claim. Candor
with the insurer is essential.
• Some jurisdictions and some judges may allow testimony concerning the doctor’s waiver of his
fee. Such evidence alone may make some jurors believe that the doctor was guilty of malpractice.
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PATIENT NOT SATISFIED AND
WILL NOT RETURN
SEND ONLY WITH MALPRACTICE INSURANCE CARRIER PERMISSION
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Dear MR. DOE:
During your last visit, I understand that you were not satisfied with your care. While we make
our best effort for every patient who comes to the office, we recognize that we cannot please
everyone. Since you are obviously unhappy, we will not send you a bill for YOUR LAST
VISIT;THE UNPAID BALANCE.
P
M
It would be appreciated if you would provide us with an explanation of what you believe to be
the problem. I always want to learn of areas in which we can improve.
A
S
RR/ss
Sincerely,
Dr. RICHARD ROE
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FOLLOW-UP WHEN PATIENT DOES NOT
COMPLY WITH REFERRAL INSTRUCTIONS
BACKGROUND
A doctor may not avoid malpractice liability simply by suggesting to a patient that he be
examined by another specialist. The D.C. must make reasonable attempts to assure that the
patient understands the seriousness of his condition and the possible adverse effects of not
following through with recommendations.
Continuing to treat a patient who does not comply with a referral recommendation actually
assists the patient in avoiding optimum appropriate care by maintaining his condition at a level
he can tolerate without complying with the doctor’s advice. Continued noncompliance in this
regard should warrant dismissal just as would a failure to follow treatment recommendations.
OBJECTIVES
1. This letter is intended primarily to convince the patient to follow recommendations which
may be critical to his health.
2. A secondary objective is to demonstrate, should the need arise, that the doctor was persistent
in his efforts to see that the patient sought necessary referral services and that any failure to do
so was of his own volition rather than the result of the doctor’s oversight or failure to properly
emphasize the importance of the referral.
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FOLLOW-UP WHEN PATIENT DOES NOT
COMPLY WITH REFERRAL INSTRUCTIONS
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 17, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Re: Referral to another doctor
Dear MR. DOE:
When you were in the office on AUGUST 15,0000, I told you that I was not satisfied with your
response to treatment. As I told you then, I am concerned about your health and feel strongly
that you need to be examined by a NEUROLOGIST. 1
P
M
I told you that we would set up the appointment, but my staff reports that you declined, saying
that you weren’t sure you wanted to see any more doctors. I understand that you are growing
frustrated with the limited relief you have gotten, but I am satisfied that further evaluation of
your condition is very important. It is not my intention to alarm you, but I made this
recommendation because it is possible that you have (LIST POSSIBLE
COMPLICATIONS). We certainly hope you have none of these conditions, but early detection
of such problems can help doctors deal with them when they do arise.
A
S
Please do not ignore your health. If we may assist you in any way in arranging an appointment
please call. If you wish to make the appointment yourself, please do it today. Whatever you
decide, please call and let us know. We care.
Sincerely,
Dr. RICHARD ROE
RR/ss
1
cardiologist, orthopedist, internist or other
368
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REFERRAL “THANK YOU” LETTER
BACKGROUND
A doctor’s “personal” relationship with his patients is arguably as essential to successful practice
as is his clinical proficiency.
Patients who make referrals to any professional office are often the ones most pleased with the
services. They are also, ironically, sometimes the ones most offended at any perceived “slight.”
OBJECTIVES
1. The letter is intended to further cement the positive doctor-patient relation which caused the
patient to make the referral.
2. It is also intended to encourage future referrals.
PRACTICE SUGGESTION
Some patients may be more pleased with a hand-written note from the doctor. Those who refer
frequently should definitely receive a more personal letter rather than the same one each time.
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REFERRAL “THANK YOU” LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Re:Your recent referral
Dear MR. DOE:
Many people are apprehensive when they visit a doctor for the first, time. It is comforting to
them when they have been referred by a relative or friend who is already a satisfied patient. This
was the case recently when JOHN SMITH was seen in our office and during the course of
conversation mentioned that you recommended us.
P
M
I would like to take a brief moment to express our appreciation for this referral, and even more
importantly, for your confidence in our care.
A
S
Chiropractic is a relatively young healing art. Because of that, it is often misunderstood by those
who have not had personal chiropractic experience. When a friend or relative makes a
recommendation, it is valued. This was evident in your recent suggestion.
We appreciate your kind words of confidence in chiropractic. Through your referrals you may
make the lives of many friends, neighbors and relatives happier and healthier, because you took
a few moments to care.
Best personal regards,
Dr. RICHARD ROE
RR/ss
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“THANK YOU” LETTER TO PATIENT
WHO SENDS NOTE OF APPRECIATION
BACKGROUND
The reasons for and benefits of extending appropriate courtesies are obvious. The following
letter is one example of the consideration patients appreciate.
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“THANK YOU” LETTER TO PATIENT
WHO SENDS NOTE OF APPRECIATION
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Dear MR. DOE:
P
M
There are some rewards that are beyond measure. One is the satisfaction a doctor receives from
knowing that someone has been helped by HIS care. Such experiences enable those of us in the
health care services to continue to deal with human suffering.
Your kind note of appreciation for our services was certainly a day brightener! Many people
complain when they are dissatisfied with something, but fail to compliment when they are
pleased.Your taking the time to tell us what we did right is very much appreciated.
A
S
Wishing you good health, I remain:
Very truly yours,
Dr. RICHARD ROE
RR/ss
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APOLOGY – PATIENT KEPT WAITING
BACKGROUND
Maintaining good patient relations is often a time-consuming and difficult task. Ignoring
problems and potential problems has a tendency, however, to end up costing the doctor
considerably more time, and potentially money, than would seeking to satisfy unhappy patients.
One way to make a patient angry is to keep him waiting to see the doctor until well after the
appointment time.
OBJECTIVE
This letter is intended to serve as a genuine apology for a delay which was unavoidable. It should
not be used as a constant excuse for late morning arrivals extended lunches. A patient who
experiences such discourtesies and receives more than one of these within a short time will
quickly determine that the doctor cannot run an efficient office.
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APOLOGY – PATIENT KEPT WAITING
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Dear MR. DOE:
E
L
I was unhappy to learn that we let you down this morning that you tired of waiting and left
the office without treatment. I try to stay on schedule because I know that your time is just
as important as mine. I am reluctant to “rush” any patient, however, and sometimes patients
require more time than expected and I get behind. That is what happened this morning.
P
M
It always annoys me when I have to wait for a scheduled appointment, so I do know how
you feel. Would you please tell me how to “patch things up”? I would be happy to come in
earlier than usual for your next visit so that you will be absolutely first—no waiting. Or
perhaps you would rather come during our regular lunch hour—again, no waiting.
A
S
I hope you can tell that I do feel badly about inconveniencing you. If you will call to
schedule another appointment, I’ll let the receptionist know to give you any of these special
times, and we’ll talk some more when you come in.
There will be no charge for your next visit.
Sincerely,
Dr. RICHARD ROE
RR/ss
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PATIENT RE-CALL LETTER
GUIDELINES
Wellness Care may include those interventions that may influence a person’s attainment of
optimum performance and behavior, and in so doing, improve health status.
BACKGROUND
This letter is designed to serve as positive reinforcement of what was previously a satisfactory
doctor-patient relationship. The focus on wellness will encourage a patient to schedule an
appointment even if he is feeling well.
PRACTICE SUGGESTIONS
See managed care section of this text which will address wellness care in a managed care
environment.
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PATIENT RE-CALL LETTER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Re: “Check-up”
Dear Mr. Doe:
P
M
In reviewing our records, we notice that several months have passed since your last visit. We’d
like to see you soon for a wellness checkup—not because there’s anything “wrong,” but to make
sure there are no problems developing.
Ailments discovered before they become serious or chronic are more easily controlled and yield
to chiropractic treatment much more readily than if neglected.
A
S
Your good health is too precious to leave to chance. To set an appointment for a “problempreventing” checkup please call JANE OR SUSAN at 000-0000 for an appointment this week.
Sincerely,
Dr. RICHARD ROE
RR/ss
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CONFIRMATION THAT PATIENT’S
SYMPTOMS ARE BEING ADDRESSED
BACKGROUND
One of the reasons for eliciting a full and complete patient history is to identify conditions
suggesting or requiring the services of another professional. The doctor who obtains that
information must act appropriately upon it, however.
An example: The section in many history forms inquiring of women about gynecological
symptoms will often result in the patient’s reporting that she is under the care of an OB/GYN.
Doctors should note that information on the form which evoked that response.
If the symptoms reported or other responses result in a conversation in which the patient reports
that there is no other health care provider involved, the doctor must make proper referral
instructions.
OBJECTIVES
Much malpractice litigation focuses on what a doctor told a patient. The doctor may recall
recommending a gynecological examination, Pap Smear and related services while the patient
vehemently denies the conversation. This letter is intended to confirm the doctor’s instructions
to the patient, not only to provide malpractice protection, but to emphasize to the patient the
importance of following the doctor’s suggestions.
For those instances in which the patient advises that he is already seeing another doctor, a letter
confirming that representation will aid in the doctor’s defense should he be sued for
malpractice. It will also encourage the patient to maintain his relationship with the other
provider—or to develop one if his report that he had another doctor was not accurate.
PRACTICE SUGGESTION
The following letter refers to symptoms suggestive of gynecological problems. The same
principles apply, however, to vision, cardiac, proctological or other medical specialty areas.
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CONFIRMATION THAT PATIENT’S
SYMPTOMS ARE BEING ADDRESSED
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Dear MR. DOE:
E
L
Thank you for allowing us to evaluate you BACK AND NECK PAIN. I am hopeful that the
treatment we have begun will assist you.
In your paperwork and during our consultation, you mentioned a number of symptoms of
possible GYNECOLOGICAL origin. You told me that YOU ARE UNDER THE CARE OF
AN OB/GYN WHOM YOU HAVE SEEN WITHIN THE LAST SEVERAL WEEKS AND
THAT YOU HAVE HAD A PAP SMEAR WITHIN THE LAST SIX MONTHS.
P
M
I just wanted to confirm that the importance of continuing to see that doctor and maintaining
your regular diagnostic checks is in no way altered by your coming to see me. In fact, should
your GYNECOLOGICAL problems persist, I encourage you to schedule an appointment
before your routine check up.
A
S
Should you have question about this, or other areas of concern about your health, please feel
free to talk with me.
Sincerely,
Dr. RICHARD ROE
RR/ss
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REFERRAL LETTER TO M.D.
BACKGROUND
D.C.s who successfully work with M.D.s have found that one of the key ingredients in the
development of such relationships is the quality of the chiropractor’s patient records. Medical
doctors are more likely to work with D.Cs whose records demonstrate a high level of
professionalism.
Since each referral letter is written for a particular patient, it is impossible to provide a letter that
can be used under all circumstances. Consequently we have included a sample letter which is
intended to serve as a guide for the doctor to adapt to individual cases.
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REFERRAL LETTER TO M.D.
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN SMITH, M.D.
100 MAPLE STREET
ANYTOWN, STATE 99999
Re: JOHN DOE
Dear Dr. SMITH,
E
L
Thank you for agreeing to see Mr. Doe for evaluation. He saw you three years ago for a
disability evaluation.You will recall that he is disabled with neck and low back pain. He has
had multiple spinal surgeries, including diskectomy of C5/6 with surgical fusion in 1975 as
well as diskectomy and laminectomy at LA/5 and L5/S1 performed in 1978 and 1979.
P
M
Mr. Doe continues to complain of chronic pain and radicular symptoms in the neck and
lower back which seem to be creating greater disability with time. I have been following him
for the past several months and his condition is deteriorating.
My primary concern at this time is his cervical spine. There is marked limited and aberrant
motion with associated joint dysfunction. Right side radicular pain is reproduced with
extension, lateral flexion, rotation, and compression to the right, relieved with distraction.
Deep tendon reflexes and motor power of the upper extremities are fairly well preserved;
however, I believe he experiences true radicular pain and some dysesthesia, primarily in the
right upper extremity. There is marked tenderness over the bony and soft tissue structures
of the posterior cervical and upper thoracic regions. He carries his head in a markedly
anterior position.
A
S
Enclosed are reports of an MRI and X-Rays of the cervical spine. You will note marked
degenerative change at the C6/7 level. The MRI demonstrates “fairly severe spinal stenosis
due to a combination of vertebral body spondylosis and disc bulging, as well as neural
foraminal stenosis, greater on the right.”
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I am concerned about the risk of future myelopathy with progression of his degenerative
condition. I ask your opinion regarding the feasibility of surgical decompression, its risks
and likely outcome.
E
L
Thank you for your cooperation and assistance in this matter. If you have any questions,
please feel free to contact me personally.
Sincerely,
P
M
Dr. RICHARD ROE
RR/ss
Enclosure
A
S
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COLLECTION LETTERS
OBJECTIVES
• To reassure the patient that despite his failure to pay his bill, the doctor and staff still care
about him.
• To encourage payment without alienating someone who could still be a good patient.
• To avoid using collection agencies and threats of litigation.
APPLICATION
The first collection letter is intended to be used with the “good” patient who must have fallen upon
hard times. It is too soft-spoken to be effective with a patient who can pay, but chooses not to.That
person should be sent Collection Letter Two without the abundant civility this letter affords.
The second collection letter is slightly firmer and is the last attempt to collect the account
while still retaining the patient.
PRACTICE SUGGESTION
Doctors vary greatly on their attitudes about the desirability of the doctor being involved in
collection matters. Some doctors prefer to leave all financial dealing with patients to an “office
manager,” while others like for the patients to be aware of their personal involvement.
Doctors who do not find their personal involvement in collection undesirable may find that a
personal, hand-written note at the bottom of the page may make each letter even more effective:
First letter: “John — please call me if there is a problem.” Next letter: “John — what’s going
on?” This technique personalizes the collection effort and tells the patient that the doctor
himself knows of the failure to pay the bill…it is not just a computer-generated letter which was
sent automatically.
POTENTIAL DISADVANTAGE
Some patients will take offense at the mildest collection effort. Good judgment must be
exercised in dealing with each patient in the manner least likely to make him resentful or
defensive. A patient who feels that his honesty or worth is being questioned may begin blaming
his residual physical problems on the doctor.
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COLLECTION LETTER ONE
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
PLEASE HELP!!!!
E
L
Dear MR. DOE:
You have been a valued patient of our office for a long time. In the past, you have always
been prompt in paying your bill and we are concerned about why your present account
balance has been outstanding for so long. If you have some problems or unusual expenses
that prevent you from keeping your account as current as you have previously, please let us
know so we may make special payment arrangements with you.
P
M
If this is just an oversight, please drop a check in the mail today for your present balance
due of $500.00. If that is not possible, I ask that you make a SUBSTANTIAL payment
today and contact MARY BETH at the clinic to set up a payment schedule.
A
S
If payment has already been made, please disregard this notice and accept our thanks.
We look forward to continuing our relationship in the best interest of your health.
ll me
a
c
e
s
a
e
l
John, P a problem
is
if there Roe
Dr.
Sincerely,
Office Manager
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COLLECTION LETTERS
OBJECTIVES
• To reassure the patient that despite his failure to pay his bill, the doctor and staff still care
about him.
• To encourage payment without alienating someone who could still be a good patient.
• To avoid using collection agencies and threats of litigation.
APPLICATION
The first collection letter is intended to be used with the “good” patient who must have fallen upon
hard times. It is too soft-spoken to be effective with a patient who can pay, but chooses not to.That
person should be sent Collection Letter Two without the abundant civility this letter affords.
The second collection letter is slightly firmer and is the last attempt to collect the account
while still retaining the patient.
PRACTICE SUGGESTION
Doctors vary greatly on their attitudes about the desirability of the doctor being involved in
collection matters. Some doctors prefer to leave all financial dealing with patients to an “office
manager,” while others like for the patients to be aware of their personal involvement.
Doctors who do not find their personal involvement in collection undesirable may find that a
personal, hand-written note at the bottom of the page may make each letter even more effective:
First letter: “John — please call me if there is a problem.” Next letter: “John — what’s going
on?” This technique personalizes the collection effort and tells the patient that the doctor
himself knows of the failure to pay the bill…it is not just a computer-generated letter which was
sent automatically.
POTENTIAL DISADVANTAGE
Some patients will take offense at the mildest collection effort. Good judgment must be
exercised in dealing with each patient in the manner least likely to make him resentful or
defensive. A patient who feels that his honesty or worth is being questioned may begin blaming
his residual physical problems on the doctor.
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COLLECTION LETTER TWO
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
SEPTEMBER 30, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Re: Delinquent Account
E
L
Dear MR. DOE:
We have heard nothing in response to our recent friendly reminder about your unpaid account
which is now seriously delinquent.You have not contacted us to make payment arrangements
or even to explain why payment has not been made. In the past you have made payments on a
reasonable basis, so I am writing again, not only to check on your bill, but to check on you.
P
M
Some patients discontinue care and try to ignore their health problems when they have
trouble with their bills…because they are embarrassed. Please be assured that we are
anxious to find some way to work with you, not only to clear your past-due balance but to
enable you to continue to receive the care you need.
A
S
There is very little we can do, however, if you won’t even discuss the problem. Please call
MARY BETH today and let us know when we may expect payment. Better yet, call today
for an appointment, come in and let DR. ROE take a look at you so we can try to continue
your treatment—with a payment plan you can live with.
John,
on?
g
n
i
o
g
s
’
What r. Roe
D
Sincerely,
Office Manager
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COLLECTION LETTER THREE
BACKGROUND
This is the last step prior to turning the account over to a collection agency or lawyer.
Doctors should seriously consider and select carefully the accounts which are “worth” pursuing
to this level. Economic considerations of the time, expense and manpower involved in repeated
billings, collection agencies and litigation often make such a course unreasonable. Often the
doctor and patient will be better served by “clearing the books” and beginning the patient on a
cash basis. See page 389 “Writing Off Debt.”
In addition to the economic inducements to writing off small accounts is the indisputable fact
that many malpractice cases involve patient anger at what the views to be overbearing collection
activity after a less than optimal treatment result.
Resort to vigorous collection efforts is best reserved for unusual situations in which the doctor
feels that he is being taken advantage of.
POTENTIAL DISADVANTAGES
• The disadvantages mentioned in relation to collection letters one and two are largely
inapplicable by the time this letter would be used. The patient has now failed to respond to
reasonable attempts to effect a payment plan and is probably undesirable as a future patient.
• If the patient has claimed an injury from or other dissatisfaction with care, a vigorous
collection effort may be the final antagonizing event which pushes him to see a lawyer about
pursuing a malpractice claim.
• Doctors should be aware that a policy provision of some malpractice carriers requires the
doctor to drop a collection action if doing so will result in the patient dismissing his malpractice
suit. Check with your carrier for specific information on their policy.
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COLLECTION LETTER THREE
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Re: Serious Account Delinquency
Dear MR. DOE:
P
M
As you know, problems wont just go away. I don’t know why you are ignoring our attempts
to work with you to get your bill paid. We are trying to help, but you have not even
responded to the two letters we have sent you. (NOR DID YOU RETURN MY PHONE
CALL1)
A
S
I have always tried to avoid using collection agencies or suing patients over bills. Almost all
of my patients are good, honest people who will pay me when they are able. With that
philosophy in mind, I am happy to work with patients who are having financial problems. At
some point, however, the absence of any response suggests that you are taking advantage of
us. I’m sure you can understand that I take it personally when all attempts at cooperation are
IGNORED.
I don’t want to cause you a problem…but some show of your good faith is needed. Unless
you contact the office within a week of the date of this letter and make satisfactory
arrangements to pay your account, I shall be forced to utilize other collection methods.
Please don’t make me take such drastic action over an issue that we can resolve together.
Sincerely,
Dr. RICHARD ROE
RR/ss
1
Use only if the doctor has actually left a telephone message
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WRITING OFF DEBT
BACKGROUND
Collection agencies are notorious for alienating those upon whom they ply their trade. Their
business, after all, is to extract money from people who do not want to, or who cannot, pay.
Unpleasantness is to be expected.
Use of collection measures or the legal process is often counter-productive. If a patient cannot pay,
threats of litigation or repeated contacts from collectors serve only to alienate the patient. Those
who cannot pay now could possibly be good, paying patients again in the future.
OBJECTIVES
This letter is designed to retain patients who have fallen upon financial difficulty. It may also be
modified to apply to the patient who has filed for bankruptcy and legally is not required to pay the
existing bill. Decent people will often be too embarrassed to return to a doctor after not having
paid him. (Some doctors prefer it that way.) As a practical matter, the doctor will often lose the
previous balance anyway. Keeping the patient with a “clean ledger” may be the best result
salvageable from the situation. This letter encourages that patient to return and will generate good
will which may lead to many referrals.
Aggressive collection efforts have often been blamed for pushing disgruntled patients into filing
malpractice suits. This debt-forgiveness approach should be considered when a patient appears to
have genuine financial problems.
PRACTICE SUGGESTION
Doctors who use a collection agency should turn in a delinquent account using a fictitious
name (to avoid potential damage to their credit rating) with their own home phone number to
monitor the techniques their agency employs. The harsh tactics and language used by some
agencies will likely come as a shock to many D.C.s.
If the agency does not treat the patient with respect and reasonable courtesy, is abrasive or
unduly threatening, it should be replaced.
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WRITING OFF DEBT
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
E
L
Dear MR. DOE:
We understand that sometimes people suffer financial set-backs and need some help. In
view of your present situation, your account which has been overdue in our office will not
be placed with a collection agency and you will receive no further bills from this office for
services already rendered.
P
M
Your current balance with us is $00.00. We have instructed bookkeeping to remove your
name from our collectible list and to enter a zero balance.
A
S
Collection letters and overdue balances are not conductive to good health. We are therefore
attempting to eliminate at least one of the stresses in your life. Obviously we cannot stay in
practice if our obligations are not met. However, in your case, we believe that we will both
benefit from a new beginning with a clean ledger sheet.
If you need chiropractic services in the future, please feel free to come to us as before. Since your
account has been closed, in the future we would expect payment at the time services are
rendered.
Sincerely,
Dr. RICHARD ROE
RR/ss
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NOTICE OF ASSOCIATE LEAVING
BACKGROUND
The discharge or voluntary departure of an associate doctor can be an unsettling experience for
the patients he has been treating. The tenor of the notification to those patients is quite
important to a smooth transition and maximum retention of patients. If they learn of “their
doctor’s” departure by coming into the office for treatment and being summarily told: “He’s not
here anymore,” they may imagine all sorts of dreadful reasons for his leaving…all of them
probably worse than the truth.
A patient who has not been satisfied with treatment may be pleased that he will no longer be
seen by the former associate. Unfortunately, however, he may also conclude that the doctor’s
departure resulted from the inferior quality of his services. Such suspicious circumstances may
lead a somewhat paranoid patient to decide that the departed doctor injured him.
OBJECTIVE
A letter emphasizing the “great opportunity” the associate “couldn’t turn down” will allay many
patients’ concerns and prepare them for seeing a new doctor when they return to the office.
PRACTICE SUGGESTIONS
For patients who were pleased with the departing doctor, the disappointment of his leaving can
be tempered by a simultaneous announcement of some new service or convenience such as
expanded office hours. Patients will be glad to know that their former doctor is moving to a
“great new position,” and will draw no unfavorable conclusions about the remaining doctor
which could result if the separation is perceived as “unfriendly.”
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NOTICE OF ASSOCIATE LEAVING
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
To: All Patients
We are happy to announce that Dr. JONES has accepted a wonderful new opportunity to
practice in ILLINOIS. It is hard to believe, but he has been with us for over THREE
YEARS. We will certainly miss him, but are pleased that he will be able to live and practice
(NEARER HIS FAMILY — IN A BIGGER CITY — ON HIS OWN). We wish Dr.
JONES and his family all the best in their new venture.
E
L
Dr. JONES has agreed to stay with us THROUGH THE END OF NEXT MONTH to
assure a smooth transition while we bring in another doctor. I hope that during this time
you will join us in wishing him well.
P
M
We are already looking for another doctor and are confident that this process will not inconvenience
you.Those of you who have been seeing Dr. JONES may be assured that I will continue to provide
you chiropractic services until we find another doctor who will fit into our “family.”
A
S
This seems like a good time to make another practice change we have been considering to
better suit you needs. Our new office hours after Dr. JONES leaves will be from 8:00 A.M.
TO 6:30 P.M. These extended hours should be more convenient to those of you trying to
find a few moments to look after you own health while juggling jobs, children’s activities and
other responsibilities.
Should you have any questions or suggestions on how we may better serve you, please let
us know.
Sincerely,
Dr. RICHARD ROE
RR/ss
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INTRODUCTION OF NEW ASSOCIATE
BACKGROUND
The departure of an associate who has developed rapport with some patients must be handled
positively. See page 379 “Notice of Associate Leaving.” Simply bringing in a replacement will
often upset patients. They may be interested to know how their former doctor is faring.
The new associate’s introduction should make patients eager to come into the office to meet
him.
OBJECTIVE
This letter is intended to keep patients abreast of developments in the search process. It
reinforces the idea that the doctor has searched carefully and did not just hire the first young
graduate available.
CAUTION
Be certain all statements made in letters to patients regarding current associate leaving or
introducing new associate are truthful and do not contain information which in inaccurate.
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INTRODUCTION OF NEW ASSOCIATE
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
Dear Patients:
E
L
It has been an exciting time for us here at ROE CHIROPRACTIC OFFICE. As you may
know, we have been interviewing applicants to serve as an associate doctor.
We have found a doctor we believe will be perfect complement to our present staff. Dr. JOHN
SMITH is a 0000 graduate of UNITED CHIROPRACTIC COLLEGE. He has practiced
for several years in ILLINOIS and has extensive experience with the APPROPRIATE
LISTING technique(s). This technique emphasizes DESCRIBE THEORY and utilizes
DESCRIBE.
P
M
While I am familiar with the technique, Dr. SMITH has a good deal more experience with
it than do I. I am particularly anxious for those of you with stubborn DESCRIBE
CONDITIONS FOR WHICH THE NEW TECHNIQUE IS EXPECTED TO BE
HELPFUL pain to be treated with that technique. Some patients who have failed to
respond as quickly as one might hope find that this technique makes all the difference. We
are delighted to add Dr. SMITH to our team as we strive to address your health care needs.
A
S
You may also be interested to know that Dr. JONES AND HIS FAMILY HAVE SETTLED
IN OTHER TOWN AND HAVE ASKED US TO REMEMBER THEM TO ALL OF YOU.
Should you have questions or any suggestions on how we may better serve you, do not
hesitate to call me or any member of our staff: JENNY, SUSAN OR JANE AT 000-0000.
Sincerely,
Dr. RICHARD ROE
RR/ss
394
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NOTICE OF SALE/RETIREMENT AND
INTRODUCTION OF NEW DOCTOR
BACKGROUND
Part of the “good will” of a professional practice is the loyalty, faith and confidence between
patients, doctor and staff. It may be of more value than computers, adjusting tables and patient
supplies. Most buyers of professional practices are very concerned about what efforts the seller
will make to assist in the retention of patients after the conveyance.
OBJECTIVE
This letter, when adapted to the specifics of the sale, will afford the new doctor an
introduction to the patients and make a low-key appeal to keep them as patients.
PRACTICE SUGGESTIONS
The letter stresses that the selling doctor and purchasing doctor will review the patient
records case-by-case. This encourages the patient to stay with the new doctor since he will
already be familiar with the case. Each doctor should make a brief notation in each file
indicating the review took place. Should a malpractice claim arise, this protection strategy is
designed to allow either doctor to demonstrate that this very reasonable step was taken to
facilitate the new doctor’s familiarity with the case.
The sample letter reports that the selling doctor will remain available for patient care until a
certain date. While the length of time desirable or desirable or possible will vary, there should
be an overlap when both the selling and buying doctors are in the office. A three-month period
will afford treatment opportunity with a quarter cycle of active patients and may be the ideal
time frame. Providing more than a nominal transitional period will optimize patient satisfaction
with the new doctor and act as a further malpractice buffer.
The duration of this transitional period should be specified in the contract of sale. This may
materially alter the sales price. Additional remuneration terms should also be carefully spelled
out.
POTENTIAL DISADVANTAGES
Malpractice Implications. There is some malpractice risk in endorsing the professional skills
of a replacement doctor. Under ordinary circumstances, a referring doctor is not liable for the
malpractice of the doctor to whom he refers unless he knows, or has reason to know, that the
doctor to whom he is referring is not a competent practitioner. Consequently, one should be
careful in vouching for the credentials and technical competence of a purchasing physician.
Investigation into his personal and professional characteristics is most advisable.
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While lack of complete satisfaction with some aspect of the buyer’s personality or clinical
capabilities need not prevent a sale, it should certainly influence the nature or enthusiasm of any
encouragement offered patients to come under his care. If unable to strongly recommend the
new doctor, (e.g., an inexperienced, recent graduate), the selling doctor should modify the letter
accordingly. Individually tailored language will make the letter accurately reflect the selling
physician’s experience with, and assessment of the new doctor. For instance, the third paragraph
of the introduction of a new doctor letter could be changed to read:
I have had the pleasure of knowing Dr__________________
since he graduated from__________________ Chiropractic
College last June. He is an enthusiastic, well-educated doctor
and I hope you will consider allowing him to care for you.
At a minimum, the selling doctor and members of his family and staff should undergo an
adjustment from the new doctor. If members of that select group are “uncomfortable” with his
ministrations, patients are likely to react similarly.
Additional exposure may result from the contractual structure of the sale. If for example, the
buy-out amount is based upon the income generated from the seller’s patients, the seller may
arguably be a “partner” who would be personally liable for the malpractice of the active doctor.
There is also potential for violation of anti fee-splitting regulations enacted in many states.
Moreover, if a patient dissatisfied with the new doctor’s care ever learned that the seller’s
endorsement may have been motivated by his own economics self-interest rather than concern
about his patients’ health, the resentment engendered could magnify his dissatisfaction.
A doctor should obtain legal and accounting professional assistance before any practice
conveyance.
CONFIDENTIALITY
A number of states regulate the “sale” of patient records. The theory is that the reading of the
records by a practice purchaser is a breach of confidentiality. Doctors should check with local
counsel before seeking to sell “good will,” patient records and, certainly, before using this letter.
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NOTICE OF SALE/RETIREMENT AND
INTRODUCTION OF NEW DOCTOR
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
Re: Office Sale
E
L
Dear Patients:
Because of MY RETIREMENT,1 I have sold my practice and office at 18 WATER STREET.
Dr. WILLIAM JONES, the new owner, will begin seeing patients on OCTOBER 1, 0000.
To assure a smooth transition and to introduce Dr. JONES to my many patients and friends,
I will be staying on with him until JANUARY 1, 0000. I will not be in the office after that date.
P
M
Beginning two weeks from today, I will be discussing your file with Dr. JONES who will be
taking over my practice. This time consuming task is for your benefit. I want Dr. Jones to
be familiar with your records so he will be fully prepared to treat you from his first day in
the office. I trust you will notify me if this is not satisfactory, but I have confidence in Dr.
JONES and hope you will consider allowing him to become you new doctor.
A
S
If, for whatever reason, you decide to be treated elsewhere, I will be happy to provide your
new doctor with copies of the necessary records from you file. If that is your preference,
please sign and return the enclosed authorization form2 together with your instructions on
where to send your records.
1
Or other appropriate reason: “my disability,” “relocation,” etc.
2
See authorization on page 243.
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I regret that I will not be able to continue to serve you. My years here have been filled with
many rewarding experiences and memorable patients.
With every good wish for your health and happiness, I remain,
E
L
Sincerely yours,
P
M
Dr. RICHARD ROE
RR/ss
Enclosure
A
S
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NOTICE OF OFFICE CLOSING
BACKGROUND
If a doctor closes his office due to retirement, disability, relocation or any other reason, he must
notify patients far enough in advance to afford them a reasonable opportunity to find another
doctor. Failure to do so exposes the doctor to a claim of abandonment.
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NOTICE OF OFFICE CLOSING
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN STREET
ANYTOWN, STATE 99999
Re: Office Closing
Dear MR. DOE:
E
L
Because of MY RETIREMENT, I have sold my practice and office at 18 WATER
STREET, ANTYTOWN, STATE on DECEMBER 31, 0000. I will not be available to
attend you professionally after that date.
Since your condition requires additional care, I suggest that you arrange to place yourself under
the care of another doctor. To assist you in receiving the care you need, I will be happy to
provide your new doctor with copies of the necessary records from your file. Please sign and
return the enclosed authorization1 together with your instructions on where to send your
records.
P
M
I regret that I will not be able to continue to provide you with the care. My years here have
been filled with many rewarding experiences and memorable patients. I will miss the
practice and particularly the patients.
A
S
With every good wish for your health and happiness, I remain:
RR/ss
Enclosure
1
Authorization found on page 243.
Sincerely yours,
Dr. RICHARD ROE
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CONFIRMATION OF TELEPHONE
CALL TO LAWYER’S SECRETARY
BACKGROUND
Doctors who frequently participate in the legal process have likely experienced an “eleventh
hour” continuance of a deposition or settlement of a case “on the courthouse steps.”
Continuance and settlements would be of little import to the doctor had he not spent so much
time preparing for his testimony. They become more than annoyances when he has not
scheduled any patients for a day in anticipation of testifying and then is not notified of the
change in plans until it is too late to reschedule a full patient load. They become the source of
red-faced, pulse pounding, hysteria when the learns that the schedule was changed a week
earlier but no one thought to tell him.
PRACTICE SUGGESTION
• Opening the lines of communication with the personal secretary of the patient’s lawyer can
save much annoyance and frustration. That secretary will be the one confirming scheduling
changes and may learn of such changes even before the lawyer. Developing a “personal”
relationship with that secretary makes early notification of continuances and settlements more
likely.
• The letter is designed for use after an introductory “get acquainted” phone call to the
secretary.
• This technique will also facilitate obtaining status reports on trauma cases by making a
“friendly” phone call to the secretary, rather than resorting to a confrontational demand to the
lawyer which will likely do little but antagonize him.
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CONFIRMATION OF TELEPHONE CALL
TO LAWYER’S SECRETARY
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
MARK SMITH
100 COURTHOUSE SQUARE
ANYTOWN, STATE 99999
Re: JOHN DOE
E
L
Dear MR. SMITH:
Thank you for speaking with me concerning my deposition in the case of my patient named
above. I know how hectic things can become in the practice of law and that continuances
and settlements often occur at the last minute. Under such circumstances lawyers
occasionally forget to tell all their witnesses. Your agreement to “look after me” and let me
know as soon as possible if plans for the deposition change is very much appreciated.
P
M
Your continuing assistance in advising me concerning a trial date would be even more
helpful. The trial will require that I reserve a block of time during which I would ordinarily
be seeing patients. If I don’t learn of a continuance or settlement until shortly before my
scheduled appearance, I am unable to re-schedule appointments and must bill the lawyer
for that time even if I do not have to appear. Therefore, it is obviously in everyone’s best
interest for someone to let me know as early as possible if my testimony will not be needed.
A
S
Thank you again for your kind assistance.
Sincerely,
Dr. RICHARD ROE
RR/ss
cc: JOHN DOE
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PRE-DEPOSITION LETTER TO
PATIENT’S LAWYER
BACKGROUND AND OBJECTIVE
Doctors who have been active in personal injury practice are all too familiar with some of the
frustrations inherent in that kind of work. This form seeks to avoid some of them by opening
lines of communication with the patient’s lawyer.
PRACTICE SUGGESTIONS
• Pre-deposition Conference. Astonishingly, some lawyers will not schedule a pre-deposition
conference. If the patient’s lawyer does not call for a conference, the doctor should do so.
Copying the patient with this letter alerts him that such a conference is desirable. The patient
may then inquire of the lawyer about the matter. Some lawyers will be much more responsive
to such questions from their clients than from the doctor.
• Payment for “No-shows.” Cancellations and continuances without reasonable notice are
often a problem. By requiring 72 hours notice or demanding partial compensation, the doctor
may reap the benefits of more courtesy and attention to detail. If there is good reason for
inadequate notice, the doctor should be flexible in waiving this requirement. He can generate
considerable good will by being cooperative and not penalizing the patient for the failing of the
lawyer—also by not making the lawyer look bad. Setting out the requirement gives the doctor
the option: to demand payment if the lawyer is habitually inconsiderate and there is no realistic
expectation of working together again or to waive it otherwise.
• Call the Attorney’s Secretary. Another way to avoid being the only one to appear for a
deposition, because everyone else knows it has been canceled, is to open communication with
the lawyer’s personal secretary. See page 401 “Confirmation of Telephone Call to Lawyer’s
Secretary.”The doctor can have a staff member call the attorney’s office the day before the
deposition to assure that everything is still “go.”
• Advance Payment. Requiring advance payment when dealing with a lawyer for the first time
may be advisable. Thereafter, if a reasonable relationship develops, that requirement may be
waived with the ingratiating observation: “I know I don’t have to worry about it in this case.”
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PRE-DEPOSITION LETTER
TO PATIENT’S LAWYER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN Q. GREEN, ESQ.
100 COURTHOUSE SQUARE
ANYTOWN, STATE 99999
E
L
Re: My deposition
Your client: JOHN DOE
Dear MR. GREEN
P
M
I have received the Notice of Deposition in my patient’s case. I wish to provide complete
and accurate testimony, of course, so I have already begun reviewing the file. To assist in my
preparation and scheduling would you please let me know:
1. How much time do you wish me to set aside for the depositions?
2. When do you wish to schedule the pre-deposition conference?
A
S
3. Is there a trial date scheduled? If so, what date?
4. Do you anticipate having me testify live or by video deposition?
My deposition fee is $00.00 per hour, portal to portal. My minimum fee is for one hour,
which must be paid in advance. Cancellations or continuances with less than 24 hours
notice are billed for the entire time set aside. Between 24 and 72 hours notice will be billed
at ONE-HALF the time set aside, while more than 72 hours notice will result in no charge.
Who will be paying for my time in giving this deposition?
Please feel free to make notations on this letter and return a copy rather than taking the time
to send a formal letter.
Sincerely,
Dr. RICHARD ROE
RR/ss
cc: JOHN DOE
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PRE-TRIAL LETTER TO
PATIENT’S LAWYER
BACKGROUND
The difficulties arising from scheduling problems with depositions (see page 403 “PreDeposition Letter”) are even worse when trials are continued or the case is settled. While the
deposition is often scheduled after office hours or other times when the doctor does not
schedule patients, the trial is set for the court’s convenience not the doctor’s. Entire mornings,
afternoons or days may have to be set aside for testifying. If an entire day is blocked out and the
case settles, the doctor may suffer substantial financial loss.
OBJECTIVE
This letter is intended to elicit payment in advance, and assure that the doctor is not “left
holding the bag” should the case settle at the last moment.
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PRE-TRIAL LETTER
TO PATIENT’S LAWYER
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN Q. GREEN, ESQ.
100 COURTHOUSE SQUARE
ANYTOWN, STATE 99999
E
L
Re: My deposition
Your client: JOHN DOE
Dear MR. GREEN:
P
M
I have received the notice of trial in my patient’s case. It will assist in my preparation and
scheduling you will let me know:
1. When and where do you wish to have the pre-trial conference?
2. Will you require my attendance all day or just in the afternoon?
A
S
3. When can I expect to receive copies of pertinent depositions to review?
My fee for time out of my office is $00.00 for just morning or afternoon and $00.00 for the
whole day. To be able to cancel my appointments and make orderly arrangements,
I must know when you wish me to appear and have your payment no later than
SEPTEMBER 8, 0000.
If the case settles, is continued or my testimony is not needed for any reason and I am
notified prior to 5:00 p.m. on SEPTEMBER 12, 0000, I will refund my fee in full. After
that time I would be unable to re-schedule my patients and therefore there would be no
refund.
I will look forward to hearing from you.
Sincerely,
Dr. RICHARD ROE
RR/ss
cc: JOHN DOE
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TRANSMITTAL LETTER ACCOMPANYING
“LETTER OF PROTECTION”
BACKGROUND
Participating in the judicial process as an expert witness can be professionally and personally
rewarding.Knowing that a patient obtains proper compensation is gratifying. A D.C. presenting
himself and chiropractic in a favorable light advances not only his own reputation,but that of the
entire profession.
Unfortunately, participating in that process can also be frustrating. Some automobile injury cases
will involve persons who do not have any medical insurance.Treatment under such circumstances
can often proceed only if the doctor defers payment pending settlement of a liability claim.
One of the most annoying hazards of serving as an expert may well be foregoing payment until
a case is tried or settled and then having the patient’s lawyer give the proceeds to the patient
who promptly spends the money without paying his doctor.
A “lien letter” commonly used by doctors of chiropractic somewhat peremptorily demands that
the lawyer sign and return a document agreeing to pay the doctor. Such high-handed, demanding
correspondence will likely offend or anger many lawyers. (One does not, after all, take up the legal
profession out of an inherent proclivity to peacefully accede to the demands of others.) Moreover,
if the lawyer simply ignores the form or refuses to sign, its utility is marginal.The doctor interested
in expanding his P.I. practice may do better by using a less contentious tactic.
“Lien laws” vary greatly from state to state, with some being easy to enforce and offering
genuine protection, while others have a minimal dollar limit or other procedural shortcoming
rendering them virtually useless.
OBJECTIVE
This letter is an attempt to obtain, without being abrasive or confrontational, the lawyer’s
agreement to pay the doctor out of settlement or judgment proceeds. The next letter “Irrevocable
Instructions to Attorney to Pay Doctor” is less diplomatic and should be used when the lawyer
refuses to sign a letter of protection or just ignores the doctor’s request that he do so.
POTENTIAL DISADVANTAGES
Letters of Protection, liens and similar devices offer defense counsel in personal injury cases the
opportunity to question the doctor’s “financial interest” in the case.While the doctor will likely
respond to such questions that he has no such interest since the patient is ultimately responsible
for payment, these financial forms cast doubt on the impartiality of the doctor’s opinions.
PRACTICE SUGGESTION
The best way to advance a doctor’s credibility as a witness is for him to be paid prior to
testifying either through “PIP,” “med pay,” health insurance or by the patient.The doctor should
not assume, just because a patient was injured in an automobile accident that payment must be
deferred. All sources of payment, direct pay by the patient, PIP coverage, and general health and
accident policies should be explored.
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TRANSMITTAL LETTER ACCOMPANYING
“LETTER OF PROTECTION”
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN Q. GREEN, ESQ.
100 COURTHOUSE SQUARE
ANYTOWN, STATE 99999
Re:Your client: JOHN DOE
E
L
Dear MR. GREEN:
I am treating your above client for injuries which HE indicated occurred as the result of a
collision on JULY 4, 0000. MR. DOE informs me that HE has retained you as counsel.
P
M
It would be greatly appreciated if you would send me a letter of protection which states that
you will protect my fee. With this protection, I will continue to treat MR. DOE without
requiring that full payment be made at the time of service. A sample letter is enclosed for
your consideration.
Your cooperation is appreciated. Please feel free to contact this office if you need to discuss
this matter.
A
S
RR/ss
cc: JOHN DOE
Enclosure
Sincerely,
Dr. RICHARD ROE
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LETTER OF PROTECTION
BACKGROUND
Assignments, liens, and irrevocable instructions to an attorney may all fail to get the doctor paid
after a personal injury claim or suit has been settled or tried. State laws differ in how these
devices are enforced and the D.C. must obtain local counsel to advise on the best way to protect
fees in his jurisdiction.
The doctor may instead want to use Letters of Protection as a means to secure payment in
personal injury cases. A letter of protection is simply a letter from the attorney which states that
he will pay the doctor’s bill from the proceeds of settlement or judgment before giving any
money to his client. The doctor may ask the lawyer to provide this letter by using the preceding
cover letter.
OBJECTIVES
This form and cover letter contain less threatening language than many popular forms which
demand payment or signature on a “lien” form. Many attorneys will not sign such documents
and are offended by the language and tone of the correspondence. The “Letter of Protection”
seeks to secure the same protection without being so confrontational.
The doctor should consider waiving formal protection when dealing with a lawyer with whom
he has had satisfactory dealing in the past. A simple letter setting forth the doctor’s
understanding on which he will rely unless the attorney advises to the contrary, may provide
reasonable protection in such situations.
POTENTIAL DISADVANTAGES
The use of liens, assignment forms and Letter of Protection can be criticized by defense lawyers
in PI cases to make the doctor’s opinion appear less credible because it permits an argument
that he has a financial “interest” in the outcome of the case.
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LETTER OF PROTECTION
AUGUST 15, 0000
RICHARD ROE, D.C.
PRACTICE OF CHIROPRACTIC
18 WATER ST.
ANYTOWN, STATE 99999
Re: Your Patient/My Client
JOHN DOE
E
L
Dear Dr. ROE:
Please be advised that I am counsel for JOHN DOE representing HIS interests in a
personal injury claim arising out of injuries sustained in an automobile collision.
P
M
This will confirm that you have agreed to treat my client for those injuries without requiring
full payment at the time of service if I will agree to “protect” your bill. Please accept this
letter as my assurance that you will be paid out of any proceeds I may obtain by way of
settlement, judgment or other resolution of this case, prior to my distributing any proceeds
to my client.
A
S
I understand that you will rely upon the assurances in this letter and therefore forgo any
collection demands or activities against my client until this case is resolved.
Very truly yours,
JOHN Q. GREEN
GREEN LAW FIRM, CO., L.P.A.
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IRREVOCABLE INSTRUCTIONS TO
ATTORNEY TO PAY DOCTOR
BACKGROUND
See commentary accompanying previous letters on pages 407 and 409.
OBJECTIVES
This letter is designed to be executed by the patient without requiring the lawyer’s signature or
cooperation. It is somewhat “high-handed” and should not be used until the doctor has attempted
to secure a voluntary letter of protection as described in the commentary accompanying the
previous letter.
Unless it states otherwise, any authorization is revocable. Even if it claims to be irrevocable, it
may not be fail-safe. This is an improvement, however, on forms which are silent on the point.
SUGGESTIONS
The “irrevocable instructions to attorney letter” should be on blank paper or the patient’s
stationery if available. It is not advisable that this letter be on the doctor’s stationery.
POTENTIAL DISADVANTAGES
See commentary accompanying previous letters referenced above.
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IRREVOCABLE INSTRUCTIONS TO
ATTORNEY TO PAY DOCTOR
AUGUST 15, 0000
JOHN Q. GREEN, ESQ.
100 COURTHOUSE SQUARE
ANNA, STATE 99999
Re: Payment of my chiropractic bill
E
L
Dear MR. GREEN:
I hereby instruct you, as my attorney, to pay Dr. RICHARD ROE the balance of any
charges I have incurred or may hereafter incur for my care and treatment. This payment is
to be made from any proceeds you may receive on my behalf by the way of judgment,
settlement, insurance payment to include “PIP” and “med-pay” or otherwise.
P
M
In reliance upon my assurances that this arrangement would be made and honored, Dr.
ROE has agreed to treat me without payment at the time of service. In consideration of
that agreement which has enabled me to obtain treatment without financial hardship, I
hereby make and declare the instructions herein contained to be IRREVOCABLE. Your
cooperation in the prompt disbursement of proceeds to Dr. ROE prior to making any
payment to me will be most sincerely appreciated.
A
S
Please make payment directly to:
RICHARD ROE, D.C.
18 WATER STREET
ANYTOWN, STATE 99999
Date:
Signature
Witness:
Print name
Signature
Address
Print Name
City, State and Zip Code
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LETTER TO ATTORNEY WHO
FAILS TO HONOR LEIN
BACKGROUND
If a lawyer ignores a statutory lien or the patient’s irrevocable instructions to pay the doctor and
distributes settlement proceeds directly to the patient, some patients will not pay the doctor.
On occasion the doctor may believe that there was no error, that the attorney and patient sought
to avoid the obligation to pay the doctor. In those rare instances this letter may be warranted.
OBJECTIVE
This letter is intended to demonstrate to the lawyer and patient that the doctor will not quietly
allow them to take advantage of his having deferred payment. It is not designed to coerce
payment…but rather to assure that counsel will not make such distribution in the future.
POTENTIAL DISADVANTAGES
• The lawyer involved could be a popular member of the Bar and there could have been some
good faith misunderstanding. Under those circumstances, his recitation to his colleagues about
the doctor’s threatened complaint could undermine the doctor’s present or future working
relationship with other local attorneys.
• The doctor should not threaten disciplinary action unless he intends to follow through and
actually file a complaint. To make idle threats, particularly to lawyers, will soon foster a
reputation for weakness.
• The doctor should also weigh carefully the inconvenience he will suffer by becoming involved
in such a proceeding. The lawyer will certainly not take the attack lying down and the
proceeding could entail time, expense and aggravation.
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LETTER TO ATTORNEY WHO
FAILS TO HONOR LEIN
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN Q. GREEN, ESQ.
100 COURTHOUSE SQUARE
ANYTOWN, STATE 99999
E
L
Re: YOUR CLIENT, JOHN DOE
Dear MR. GREEN:
You have failed to honor my lien for professional services rendered your above client. I am
told that this may violate the Code of Professional Responsibility and should be reported to
the State Bar Association.
P
M
I am reluctant to take such a harsh step if your distributing proceeds without paying my bill
resulted from some innocent oversight or misunderstanding.
A
S
Therefore, I will take no further action until the close of business AUGUST 25, 0000.
Should you wish to explain this omission, please do so, in writing, before that date. If you
wish to discuss the matter by telephone you will have to do so with my lawyer, TOM
SMITH.
Sincerely,
Dr. RICHARD ROE
RR/ss
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LETTER OF CONDOLENCE TO PATIENT
SERIOUSLY INJURED DURING TREATMENT
SEND ONLY WITH MALPRACTICE
INSURANCE CARRIER PERMISSION
BACKGROUND
If a patient sustains serious injury during treatment, a natural response is to avoid that patient,
pretend that everything will turn out all right and ignore the potential law suit.
Even those doctors who faithfully report the incident to their malpractice insurance companies
often will make no overture to the injured patient or his family.
While a letter expressing concern and wishing a speedy recovery is unlikely to avert a lawsuit if
there are devastating injuries, it may defuse the patient’s anger if the injuries are more modest.
Moreover, even if a suit ultimately results, the letter may have made the process less venomous.
It will certainly prevent the plaintiff ’s lawyer from making some emotional appeal to a jury that:
“Dr. Roe never even had the decency to check and see if John was alive!”
OBJECTIVES
1. This letter is intended to assure the the patient that the doctor is concerned about his injuries
without admitting any responsibility for them.
2. Avoiding some of the unpleasantness which often accompanies litigation will allow the doctor
to better defend himself.
3. Taking affirmative action, rather than just waiting for a lawsuit, often has a cathartic effect.
WARNING
THIS LETTER SHOULD NOT BE SENT UNTIL THE DOCTOR’S
MALPRACTICE CARRIER HAS BEEN PUT ON NOTICE OF THE CLAIM,
HAS REVIEWED THE LETTER AND AUTHORIZED IT USE IN WRITING
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LETTER OF CONDOLENCE TO PATIENT
SERIOUSLY INJURED DURING TREATMENT
SEND ONLY WITH MALPRACTICE INSURANCE CARRIER PERMISSION
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN DOE
100 MAIN ST.
ANYTOWN, STATE 99999
E
L
Dear JOHN:
I am very much concerned about you. I certainly hope that your condition responds to care
and that you will soon be improving.
P
M
I have felt that you and your family would prefer not to be disturbed while you are occupied
with treatment and therapy. I hope my decision not to visit you at this time will be
understood as reflecting consideration for you.
A
S
Please accept my sincere best wishes — my thoughts and prayers will follow you throughout
your recovery.
RR/ss
Sincerely,
Dr. RICHARD ROE
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LETTER TO LAWYER SEEKING STATUS
REPORT ON MALPRACTICE CLAIM
BACKGROUND
The defendant in a malpractice suit has the right to be well-informed by the lawyer the
insurance company hires to represent him. The flow of information may not be self-starting,
however. Many clients take the approach that “no news is good news” and are delighted to hear
nothing from the lawyer.
If the doctor is not receiving reports as frequently or in as much detail as he would like, he
should contact the lawyer, in writing, and request information.
OBJECTIVES
Frequent requests for updates will:
1. Provide the doctor with current, useful information.
2. Remind the lawyer of the case and encourage him to keep the file “active.”
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LETTER TO LAWYER SEEKING STATUS
REPORT ON MALPRACTICE CLAIM
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
JOHN Q. GREEN, ESP.
100 COURTHOUSE SQUARE
ANYTOWN, STATE 9999
E
L
Dear MR. GREEN:
Some time has passed since I have heard anything from you concerning the status of my
case. I don’t want to be a nuisance and realize that you are busy, but I am concerned about
this matter and require frequent updates.
P
M
It would be very much appreciated if, at least once a month, you would just drop me a short
note to advise as to what, if anything, is happening in my case. This would probably not be
necessary if you would just send me copies of all reports and correspondence pertaining to my
case.
A
S
If you prefer some means of communicating, please let me know. I would certainly be
willing to speak with you on the telephone, come to your office or meet you for lunch.
Your consideration for my concern will be appreciated.
Sincerely,
Dr RICHARD ROE
RR/ss
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TEAM PHYSICIAN ROLE LIMITATION
BACKGROUND
The fundamental rules that govern the D.C.’s actions in traditional practice also apply to the
chiropractic physician who deals with sports injuries. The doctor will be held accountable for
his negligence just as he would be in a traditional doctor-patient relationship.
Doctors involved in sports medicine often operate in an environment very different from a
traditional office setting. There may be instances where the specialist’s standard of care is higher
than that of the general practitioner.
Moreover, serving as a team physician without disclosing limitations on his qualification to fill
that role, may place the D.C. in the “sports specialist” category, requiring a higher degree of
knowledge and skill than that of a general practitioner.
PRACTICE SUGGESTION
The doctor should assess the nature of the sport, the locations where he is required to work and
the number of people he must attend. He should recognize that he cannot perform at peak
efficiency when treating on a playing field or conducting mass qualifying examinations for a
large number of players.
OBJECTIVE
Before accepting the responsibility of working with a team, the doctor should establish the
parameters of his responsibilities.
Full and timely disclosure of professional limitations is essential. If there is a firm agreement
on what the D.C. is expected to do, he will be better able to limit his exposure.
The sample letter illustrates how a D.C. may attempt to limit his responsibility when
participating as a team physician. Any doctor proposing to use it should modify it to reflect his
own expertise and his permitted scope of practice under state law.
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TEAM PHYSICIAN ROLE LIMITATION
DR. RICHARD ROE
PRACTICE OF CHIROPRACTIC
ROE CHIROPRACTIC OFFICE
18 WATER STREET
ANYTOWN, STATE 99999
(555) 123-4567
FAX (555) 123-4568
AUGUST 15, 0000
SMITHVILLE HIGH SCHOOL
SMITHVILLE, OH 43023
Dear (COACH)(TRAINER)(ADMINISTRATOR):
E
L
I am pleased to have the opportunity to offer my assistance to the SMITHVILLE BLUE
ACES for the upcoming FOOTBALL SEASON. I am writing to outline the services that I
can provide.
As a doctor of chiropractic, I am licensed to offer treatment as a primary health-care provider.
In this instance, however, I have been asked first to conduct qualifying examinations for each
student and will only attest to their general health. I DO NOT HAVE UNIQUE
KNOWLEDGE OF FOOTBALL AND CANNOT CERTIFY THAT THE ATHLETES
ARE ENTIRELY PHYSICALLY FIT TO PARTICIPATE IN THIS CONTACT
SPORT.1
P
M
A
S
I am trained in CPR AND FIRST AID and will be prepared to provide those services in an
emergency. I must stress, however, that I will not treat athletes on the playing field. I feel
that such conditions present too great a possibility for further harm to the students. In an
emergency, I will stabilize the athlete to the best of my ability and see that he receives
prompt medical attention at a hospital, my office or other suitable location.
Before each game, I will contact SMITHVILLE MEMORIAL HOSPITAL so that
ambulance and emergency personnel are aware that their services may be required. The
HOSPITAL assures me that an ambulance will be present at the stadium for every game.
1
Doctor with special sports qualifications may modify the letter accordingly.
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Please provide me a complete medical history of each athlete and a signed copy of the
enclosed “consent to treatment” form. In case of an accident, this will help provide timely
and appropriate care.
E
L
If you have any questions, feel free to contact me at my office (000-0000) or my home
(000-0000). I look forward to working with the SHS FOOTBALL team and anticipate a
successful and exciting season.
Sincerely,
P
M
Dr. RICHARD ROE
RR/ss
A
S
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COMPLIANCE – CODING & BILLING
E&M Visits and Office Consultations – Billing based on Time is an Option
BACKGROUND
Some patient visits involve a lengthy discussion of test results, continuing treatment options and,
frankly, a good bit of “hand-holding.” The “usual” E&M level of service indicators may not
provide adequate compensation for the time spent in such encounters. Remember that absent
the appropriate level of history, examination and complexity of medical decision
making, it doesn’t matter how much time is spent under the “usual” codes.
OBJECTIVES
1.
2.
3.
4.
To
To
To
To
be fairly compensated for time spent with patients and their families.
properly code so as not to violate any rule, regulation or statute.
withstand any payor or regulatory scrutiny.
avoid even the appearance of “code-gaming.”
So how can a doctor be fairly compensated for such visits without running afoul of the fraud
and abuse snares? There is a billing alternative to the usual three components of history,
examination and medical decision making. If the doctor spends more than half of the face-toface time with the patient and/or the patient’s family in counseling or coordination of care, then
CPTtm E&M codes may be selected based on the total time of the face-to-face time of the
encounter.
What Needs to Be Documented;
1.
The encounter form (“superbill” or internal visit documentation) must show the
total time of the encounter and the time spent in counseling or coordination of care.
2. The clinical record must also show the total time and time spent in face-to-face
counseling or coordination of care. PLUS the clinical record must include a
concise description of the content of the counseling. Just one or two lines,
naming the individuals counseled with a brief description of the subject matter is
sufficient.
Danger!!! — That concise description in the record is essential. Recall also that the time
requirements for new and established patients are not the same. (See the sample form.)
Face-to -face time for these services is defined as only that time that the physician spends
face-to-face with the patient and/or family. This includes the time in which the physician
preforms such tasks as obtaining a history, performing an examination, and counseling the
patient. I does not, however include the time spent performing other services which are being
billed separately.
Counseling is a discussion with the patient and/or the family concernting one or more of the
followinf areas: diagnostic results, and/or rcommended diagnostic studies; prognosis; risk and
benefits of management (treatment) options; risk factor reduction; and patient and family
education
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POTENTIAL DISADVANTAGES
1. More time and paperwork. As an analysis of the following form makes clear, this is a labor
intensive document. It requires not only filling out paperwork, but in carefully monitoring the
time spent in counseling.
2. Decrease in payment. Some doctors will learn that they have in fact been inadvertently
“upcoding” E & M visits by relying on time factors in addition to the base service level. Use of
this form makes clear that the entire time is used to calculate the level of service.
3. Need for modifiers. If an adjustment is performed on the same day as the counseling, the
adjustment needs to be billed under the CMT code and the “counseling” as an E & M visit with
a -59 modifier. Since the time preparatory to and following the “usual” adjustment is included
in the CMT code, there needs to be some time allotted for that patient interaction without also
including it in the calculation for the E & M code.
4. Increased scrutiny. Use of this form and billing strategy should be used only in “unusual”
circumstances. Doctors who routinely bill CMT and E & M visits on the same day will
eventually “blip” on a payor’s or regulator’s radar.
NOTE OF CAUTION
This section is neither to be construed as providing legal advice nor to be interpreted
as providing advice on what is required in order to be fully compliant with the new
rules and regulations of HIPAA. Practitioners are strongly advised to seek
independent counsel and advice on meeting the requirements for any internal
compliance program. Additionally, payor’s and regulators may view billing E & M
and CMT codes in any fashion, which is not viewed as usual and standard as a reason
to initiate an audit.
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E & M CODING COUNSELING AND
COORDINATION OF CARE
To be used only when counseling and/or coordination of care exceeds 50% of the physician/patient
and/or physician/family encounter (face to face time in the office)
Patient Name:
____________________________________
Record Of Total Time/
Counseling Time
>50% of time face to face with patient
and/or family
Date of Service ____________________________________________________________________
Total visit time ____________________________________________________________________
Counseling/Coordination of care time ________________________________________________
I discussed the following with the patient and/or family:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
*Total Visit Time Exceeds: (Round Down)
Level One
Level Two
Level Three
Level Four
Level Five
Initial
10 minutes
20 minutes
30 minutes
45 minutes
60 minutes
Established
5 minutes
10 minutes
15 minutes
25 minutes
40 minutes
Signature: _____________________________________________
Date: ________________
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COMPLIANCE AUDIT TEMPLATE
BACKGROUND
The OIG’s Compliance Program Guidance for individual and Small Group Physician
Practices emphasizes that coding and billing issues are the highest risk areas for practitioners.
Accordingly, auditing and monitoring of claims submissions are an integral part of
any effective compliance program.
OBJECTIVES
This template is designed to allow the practitioner to have a format to facilitate an internal “spot
check” of proper basic coding and documentation of E & M services. It is certainly not all
inclusive and should be considered to be a “starting place.”
APPLICATION
The first block should have the CPT number for the first office visit (E & M). The second block
is to verify that the E & M code selected appropriately differentiated between a “new’ and
“established” patient. A simple “check-mark” in the box can be used to indicate that the
clinical records were checked and confirmed that the proper code had been used.
The “exam level” block should be “checked” to confirm that the documentation supports the
level of exam necessary for the E & M code used.
The “history level” block is likewise used to confirm that the documentation supports the level
of history necessary for the E & M code used.
The “co-pay collected” block should be checked once it is confirmed that payment has been
received. “Hardship” cases or other unusual circumstances, which have resulted in nonpayment, need to be properly documented and attached to the template. If a significant
percentage of the files audited require additional documentation, a more complete sampling
needs to be done and the practice’s policies and procedures for collecting co-pays and
deductibles will need to be re-visited.
PRACTICE SUGGESTIONS
The office standards and procedures could require the Compliance Officer (or contact) to
routinely perform “spot checks” (monthly, for example) utilizing this template. Five patient
files from each of the practice’s primary payor “types” would be appropriate. (Cash,
commercial health and accident, Medicare/Medicaid, personal injury and workers’
compensation).
The completed templates can be stored in the practice’s Compliance “Binder” along with a
recitation of any corrective measures taken in response to deficiencies discovered.
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POTENTIAL DISADVANTAGES
1. As with all elements of a compliance program, the documentation generated provides a
virtual diary of problems. Should a payor or law-enforcement “audit” take place, this
documentation would certainly draw attention to practice deficiencies. This hazard
must be balanced against the benefits of demonstrating a good-faith effort at
compliance.
The longer the practice continues to maintain an effective program and corrects any deficiencies
unearthed, the less problematic this potential disadvantage becomes.
2. If remedial steps were not promptly instituted in response to problems discovered, the “good
faith effort” benefit to having the program would be largely lost.
3. There are a number of potential disadvantages not peculiar to this form, but inherent in the
entire compliance effort: some practices will suffer a decline in revenue as they discover
that they have been inadvertently “upcoding.” Some will suffer additional administrative
time and effort demands as they discover that they are not adequately documenting to support
the level of their billing.
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COMPLIANCE AUDIT TEMPLATE
Cash
Patient Name
FOV1 E & M New vs. Est. Exam Level History Level Co-pay Collected
N/A
N/A
N/A
N/A
N/A
Commercial Health and Accident
Patient Name
FOV1 E & M New vs. Est. Exam Level History Level Co-pay Collected
N/A
N/A
N/A
N/A
N/A
1
First Office Visit
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Medicare/Medicaid
Patient Name
FOV1 E & M New vs. Est. Exam Level History Level Co-pay Collected
N/A
N/A
N/A
N/A
N/A
Personal Injury
Patient Name
FOV1 E & M New vs. Est. Exam Level History Level Co-pay Collected
N/A
N/A
N/A
N/A
N/A
Workers’ Compensation
Patient Name
FOV1 E & M New vs. Est. Exam Level History Level Co-pay Collected
N/A
N/A
N/A
N/A
N/A
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BILLING COMPLIANCE
INVESTIGATION GUIDELINES
BACKGROUND
The Office of Inspector General’s Compliance Program Guidance for individual and
Small Group Physician Practices encourages the creation of a reporting mechanism for
employee’s to alert the practice to potential billing and coding improprieties. An effective
compliance plan must have a mechanism in place to respond appropriately to any such reports.
OBJECTIVES
The following “form” is a template for use in a practice’s compliance program to satisfy the need
for a thorough and appropriate response to reported problems.
APPLICATION
The guidelines can be placed in the practice’s Compliance “Binder” and followed whenever
there are reported or otherwise identified problem areas.
POTENTIAL DISADVANTAGES
The OIG has made it plain that there is no “one-size fits all” compliance program. This
template needs to be modified to reflect the individual circumstances of each practice.
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BILLING COMPLIANCE
INVESTIGATION GUIDELINES
These guidelines outline how to receive, document and investigate allegations of billing
non-compliance.
GUIDELINES
Compliance Plan – The Compliance Plan requires the Compliance Officer or Primary
Compliance Contact to investigate allegations of non-compliance. The Plan also requires
employees to cooperate with any investigation into allegations of non-compliance.
Protection of Privacy – [Practice Name] will attempt to protect the rights of all employees
during any investigation, including taking steps to protect the privacy of the accused and of
those who report alleged non-compliance. The nature of a small practice may prevent the total
anonymity of those involved, however.
No Recrimination – The Plan forbids any recrimination against a person bringing a good faith
allegation of billing non-compliance. Retaliatory conduct against persons acting in good faith
will be subject toe disciplinary action. If it is found that an accusation has been brought
maliciously or in bad faith, however, the filing of the accusation can be cause for disciplinary
action against the complainant.
PROCESS
[Practice Name] has a duty to investigate and respond appropriately to all reports and
indications of billing non-compliance and to oversee and coordinate resolution of all billing
compliance issues (including follow-up, record keeping, communication and education).
Allegations of billing non-compliance may be made by anyone who has reason to believe that
such non-compliance has occurred. Such allegations may be made directly to the
Primary Compliance Contact or through the anonymous drop-box, office manager or directly
to Dr. ________________.
The Primary Insurance Contact will perform an initial inquiry and determine whether there is
evidence that billing non-compliance may have occurred. If evidence of billing non-compliance
is found, [Practice Name] will proceed with an investigation.
After the initial inquiry, and throughout any subsequent investigation [Practice Name] may
require that billing temporarily be discontinued or require pre-billing reviews. [Practice Name]
also may require that a specific staff member be removed from his or her billing-related activity
until the investigation is completed.
Investigation – [Practice Name] will perform an investigation, if an initial inquiry has revealed
evidence that billing non-compliance has occurred.
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[Practice Name] will review it’s policies, federal and state statutes and regulations, intermediary
and carrier communications, or other appropriate sources to identify the proper documentation
or billing standard relative to the alleged billing non-compliance.
The Primary Compliance Contact will interview all individuals involved in the alleged act of
billing non-compliance, as well as other individuals who might have information regarding the
allegations.
Decision – Upon conclusion of the preliminary investigation, the Primary Compliance Contact
will prepare a written report of findings. The written report will indicate whether or not the
investigation found credible evidence that billing non-compliance has occurred and whether or
not corrective and/or disciplinary action is warranted.
In addition to the conclusion reached, the written report will describe the documents reviewed,
and summarize the interviews. [Practice Name] will maintain documentation of the inquiry or
investigation following the termination of the inquiry or investigation.
Corrective/Disciplinary Action – If the investigation concludes that billing non-compliance
has occurred, [Practice Name] will determine any appropriate corrective action needed.
Educate – [Practice Name] will inform staff members of any immediate corrective action in
billing procedure, and the reasons for any such changes. An assessment will be made of the need
for remedial staff training on all compliance related issues.
Subsequent Audits – [Practice Name] may direct post-investigation record and claim reviews
to monitor proactive compliance efforts. [Practice Name] also may perform additional audits.
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PERSONALIZATION INSTRUCTIONS
There are two ways that you can take the blank forms provided and personalize
them for your practice. The following instructions are based on use of
Microsoft Word. Please check your word processor’s help file for specific
instructions.
1.
Print on your own letterhead.
If you have already printed your letterhead stationery, you’re in luck.
The Starting into Practice forms are all designed with a 2-inch empty
header and a ½-inch footer. Simply put your blank letterheads in
your printer and print the appropriate form.
If there is too much or too little space between your logo and the
form, you may need to adjust the top and bottom page margins. Click
on the File menu and select Page Setup. Select the Margins tab and
adjust the Top and Bottom margins.
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PERSONALIZATION INSTRUCTIONS
2.
Insert your logo and other information into the form.
You can customize the form yourself by adding your logo, address,
phone number, etc. directly into the form. Just follow these steps:
a. Open the header and footer. Click on the View menu and select
Header and Footer.
b. If you want to add your logo, you’ll need an electronic version of
it on your computer. Click on the Insert menu and select
Picture, From File. Select your logo and it will be inserted into
the header of the document.
c. The text insertion tool will be in the upper left hand corner of the
Header. You can type directly into this area. You can align your
text left, center or right by using the align buttons in the toolbar.
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Table of Contents
PERSONALIZATION INSTRUCTIONS
d. To add text at the bottom of the page, click inside the box labeled
“Footer” and begin typing.
This will give you a professional looking form, personalized for your
practice that can be printed on your laser printer.