As I have traveled around the country, many doctors that I have spoken with have the misconception that creating a cash practice will excuse them from proper documentation. Their belief is since they are not submitting claims to third-party payers, that they are not required to meet the standards that are dictated using the S.O.A.P. or P.A.R.T. formats. This myth must be addressed in order to protect both their patients and their assets.

While I believe that all of these doctors are providing the best of care for their patients clinically, I also believe they may be doing their patients a disservice that is inexcusable. As professionals we are required to have good records regardless of the patient’s payment method, and there are multiple reasons why we should want to do so.

As doctors, our records are a way of tracking what is happening for that patient from visit to visit. Your notes aid you in assessing patterns of subluxations, create plans for follow-up visits, and record methods of treatment. These records can also be beneficial for associate doctors who step in and care for their patients or in the event of selling a practice.

Without detailed notes a patient’s medical records can become more of an obstacle than a help.  In the future, that patient may have an accident or a work injury and their chiropractic care record will be part of that person’s overall medical history, and can have an impact on their settlement. Poorly documented notes may be the difference between a patient winning or losing their case.

Requests for notes can also come from organizations other than third party payers. State boards and other regulating agencies can request a review of a doctor’s notes on a number of occasions. One of the most common reasons for an audit is a complaint from a patient. When a doctor’s notes are scrutinized it is with the understanding that “if it is not documented, it didn’t happen.”

Lastly, I believe when a patient entrusts their care to their chiropractor, it is with the expectation that a good record is being kept on their behalf. If a problem with their records were to occur, for whatever reason, it could destroy that patient’s confidence and fracture the doctor-patient relationship.

The fact is…that in this current climate of healthcare, a doctor’s best way to bullet-proof his or her practice is to be as thorough as possible in taking notes, and this includes cash only patients.

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