Despite all the warnings, ranting, raving and rumors about audits, there is still a lot of — for lack of a better term — chiropractic  documentation “slop” out there.

I use the term “slop” as opposed to “sloppiness” because I am not simply referring to messy or illegible handwriting on chiropractor’s notes, although there is definitely plenty of that to go around.  Instead by “slop” I am referring to a much more broad-based problem that encompasses a lack of legibility, lack of completeness and a lack of effort.

Yes, sloppy, incomplete and lazy documentation will get you in trouble.  Worse, there is little to no defense on your part.  No auditor is ever going to call you up and ask you to translate your hieroglyphics that are masquerading as your notes.  No nurse who is reviewing your notes (yes, many nurses and few DC’s will ever see your documentation) and ask you to explain exactly what you mean by your chiro-speak.  And unless you are very unfortunately called into court, you will not get the chance to explain your rationale for care, the kinetic chain and why you adjusted the patients big toe when their only chief complaint was neck pain (and if you are, you may be even less fortunate than the DC whose care was just denied in the first place).

Here it is, served up unadorned on a tin platter for your eatin’: like it or not, in 2013, you’ve got to change your documentation “slop” — or else.

Now that we got that big glass of cheer out of the way, here’s how: Read More