030- The Essentials of Chiropractic Case Notes

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. This week we're going to switch things up a little bit and I want to dive deep into case notes. So earlier this week, yesterday as a matter of fact, I went on Facebook Live and did a short video regarding case notes. But today I wanted to dive a little bit deeper into case notes, how to share them and how to be most efficient and effective with with your implementation of sending them. So I'm excited about this episode. I think there's a lot of really actionable content that you're going to be able to get regarding sending of case notes. But first, let me say a few words about Rocktape. Rocktape is proud to be a sponsor of the evidence based Chiropractor. Rock Tape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rock Tape is Rocksauce Chill, a powerfully cool pain relief topical in a convenient roll on menthol. It's stronger than the freeze competition. They are more than a tape company, they are a movement company. Learn more and get access to your medical discount by visiting rocktape.com so without further ado, let's dive into case notes. Case notes are what I consider to be one of the three pillars of relationship building, about building relationships, interdisciplinary referral relationships. Ultimately, case notes are one of those pillars. The other two pillars ultimately are meeting with those physicians, MD meetings, do meetings. And the third, and perhaps the most important in my opinion, is reaching out through monthly research. Reaching out through monthly research is really going to position your practice as the local leader. Meeting the doctors one on one is really what I think of as the gasoline or the accelerant to the entire process. And then the sending of case notes is a foundational layer. Now, sending case notes by themselves. I know there's probably many docs listening to this podcast right now saying I've been sending case notes for years or I did and I never saw a single referral from it. That is not surprising. Case notes by themselves are not going to build referral relationships. That's why it is one of the three pillars or foundational tenets of building those relationships. You can't just go 33% of the way you have to go all the way. But case notes are part of of that equation, which is why they are in fact very important. So let's set things up as far as before we dive into, I should say before we dive into what should be or shouldn't be in a case note or how to be the most effective with it. Let's talk a little bit first about how case notes are implemented and how they are processed on the other doctor's end, because that will provide a lot more clarity up front on the how and why of what you should or should not include. So when you send a case note over, number one, truly the purpose is twofold, number one, to accurately communicate what's going on in your office, which is extremely important for the best continuity of care for patients. That's primary objective, number one, Number two, is to show off the results that the patients receive in your office. As chiropractors, we are extremely fortunate to be involved in a profession that's unequivocally safe, unbelievably effective at a variety of things, whether it's performance, whether it's injury prevention and healing, and certainly from a functional standpoint, as far as making sure patients have decreased pain and improved function. So showcasing those results is absolutely imperative. So that's the why. Now, when a case note is sent over, of course, consult with your local attorney and make sure you're within the guidelines of HIPAA anytime you're communicating patient information. But when you do sen that case note, whether manually or electronically, that note goes to that physician's office. Now, at that point, again, even on your end and on their end, whether manually or electronically, it's then added to that patient's chart. Very few percent of the time will the physician look at the note when it's faxed over. It's pretty much picked up, whether through email, fax or traditional fax, and inserted directly, again, electronically or manually into that patient chart, basically at that point, never to be seen again until the patient arrives in that physician's office. So the next time that that note's going to be looked at, and really the first time from healthcare or from a physician and not an office staff point of view is going to be when the patient arrives back at their office, the physician, of course, just as we do, walks down the hallway. They know they have X amount of patients on their schedule for that day. And before they enter the room to speak with that patient, they review the char. Here is the key issue. If you had sent over every orthopedic test in the book. If you had sent over four to five pages, the doctor is going to look at that in the hallway and it's information overload. They're going to basically skip through or not read it at all at that point and enter the room and start their typical conversation, which is a massive, a massive missed opportunity to communicate accurately, to position your office and certainly to showcase the results that the patients received. So what I look for are really four items that are imperative on a case. Note. Number one is date of service. Number two is patient name. Number three, diagnosis. And number four, treatment plan. You can see that's an extremely simple set of criteria. Again, number one, date of service. Number two, patient name. Number three, diagnosis number four, treatment plan. That's going to be an ABCD list that gives that physician. Now let's do that counterpoint. That physician walks up to that room, they open a note, whether in a chart or on their iPad, and they're going to see date of service last week. Patient name John Smith. Diagnosis xy treatment plan xyz. That's going to give them the ability to very quickly read through what's, and get a feel for what's going on with that patient and guess what occurs then that's when the physician can step into the room and say, Mr. Smith, I see that you've seen chiropractor Langmaid down the street. Dr. Langmaid, how are you doing? And that is the key opportunity that all of us are looking for. So again, twofold. Number one is that you're accurately displaying what's going on with the patient. You're accurately displaying to their primary care physician what the patient's being seen for and how you're going to go about taking care of them in the best manner possible. That's just part of having a complete health record. We all should be doing that. But the second part about that is when they're very clear, when they're very transparent and when they are approached with brevity, it gives the best opportunity for that physician to ask questions and inquire about the services. Now, sometimes I have been asked, well, what if the doctor wants more information? That's the best news ever. So if a physician reaches out to your office and says, we love the case note, but we'd love to know more about what happened with XYZ Test, well then by all means. Now from that day forward, you know what that doctor wants and that's a great opportunity. Again, now you have a conversation regarding the co management of the patient. So that's a fantastic problem. To have if they reach out and want more information but you don't want to overload them too early. Make sure again date of service, make sure that you have patient name, make sure that you have diagnosis codes and fourth, make sure that you have the treatment plan. This is going to give the best opportunity to reach out through case notes. Now when do you send case notes? My recommendation is on initial evaluation, reevaluation and discharge from active care. You don't need to send a case note every time the patient is adjusted in your office. That'll be massive overkill as far as information. But initial evaluation is important because of course that's when you're taking the time to first learn about and co manage the patient. Number two during any reevaluation is important because it gives the opportunity to showcase progress, showcase challenges and further clarify the next step of care. The third component is discharge from active care. So discharge from active care is the patient may choose to go to a maintenance care plan, a wellness plan, whatever we want to discuss as that it doesn't preclude the patient from continuing in your office. Now at that point, in my opinion, that's between you and the patient whether or not they're going to pursue ongoing care in your office. But the discharge from active care is important because that's the conclusion of the issue for which you sent the original case note on that evaluation. So again, initial re eval and discharge from active care are the best opportunities and the best times to send those notes over. And as you can see and as we've spoke of today, this is all in the interest of highlighting the co management of these patients. Case notes are one of the three pillars. Case notes, monthly research and meeting those physicians. That's going to give you the most breadth and depth of ongoing relationships with other care providers in your community. Going to give you the best opportunity to position your practice and the best opportunity to showcase the wonderful results patients are getting. Don't miss an opportunity to do that. Most EHR or EMR systems can spit out these case notes practically automatically once you have a macro set up. So there is absolutely no excuse if you are doing it manually. You can make a simple word doc template and then insert the information as necessary. If you are a member of the evidence based chiropractor, I actually have my personal template located in the member's vault. You can access it there. You can use that template from Word Document or you can use it as the basis of a macro within your EHR system of your choice. So I hope this gave you a lot more clarity regarding the how and why regarding case notes. As always, if you have any questions, don't hesitate to reach out to me directly to jeffeevidencebasedchiropractor.com or through any communication channel, including Facebook, Instagram, YouTube, and the like. So docs, I hope you have a fantastic week in practice and I will talk to you soon.

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