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;
- How to take good records;
- New patient records;
- Progress notes/S.O.A.P. notes; and
- P.A.R.T. notes.
III. Documentation in personal injury:
- The latest updates on requirements for medical bills and record affidavits;
- Escabido case requirements concerning paid/incurred amount of healthcare bills;
- Assignment of Benefits;
- PIP updates; and
- Effective billing in personal injury cases.
IV. Documentation & Coding
- Electronic vs. paper;
- How much detail is needed, how much is too much;
- What do peer reviewers, insurance adjusters, and defense attorneys look for;
- Medical necessity;
- Office visit and procedure codes;
- Diagnosis: is it supported by the records?
- Diagnostic studies: do the records support them?
- Evidence based medicine: are the services supported?
V. Risk management & ethics for Chiropractors:
- Discussion of definition of malpractice;
- Sexual harassment issues;
- Board complaints; and
- The importance of being honest and objective.