Seminar Topics

TBCE Required Course on Recordkeeping, Documentation, Risk Management, Coding, TBCE Rules, & Ethics

By Roger Clifford, D.C., D.A.C.N.B. & David Ragsdale, J.D.

I.  Introduction:  How proper record keeping, documentation, and coding ties into ethics and risk management;

II. Recordkeeping: the fundamentals and why it is so important;

1. How to take good records;
2. New patient records;
3. Progress notes/S.O.A.P. notes; and
4. P.A.R.T. notes.

III.  Documentation in personal injury:

1. The latest updates on requirements for medical bills and record affidavits;
2. Escabido case requirements concerning paid/incurred amount of healthcare bills;
3. Assignment of Benefits;
4. PIP updates; and
5. Effective billing in personal injury cases.

IV.  Documentation & Coding

1. Electronic vs. paper;
2. How much detail is needed, how much is too much;
3. What do peer reviewers, insurance adjusters, and defense attorneys look for;
4. Causation;
5. Medical necessity;
6. Office visit and procedure codes;
7. Diagnosis: is it supported by the records?
8. Diagnostic studies: do the records support them?
9. Evidence based medicine: are the services supported?

V.  Risk management & ethics for Chiropractors:

1. Discussion of definition of malpractice;
2. Sexual harassment issues;
3. Board complaints; and
4. The importance of being honest and objective.