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very clinic has to keep a certain amount of paperwork on their patients and Chinese medicine clinics are no exception. Also, with the new requirements of the Health Insurance Portability and Accountability Act (HIPAA), some forms and paperwork are no longer optional. In this chapter and the next, we discuss the records that you must keep and others that you may want to keep on every patient you treat. We have included samples of most of these records on the companion CD Rom. We encourage you to download these and “tweak”them for your own use.
Basic Intake/Medical History Form
This is the form that a patient fills out to explain all their major and minor symptoms and medical history. Many practitioners use this form as the basis for the questioning phase of the four examinations. Use of a written intake form can help you save time, looks professional, and can protect you from certain legal liabilities. For instance, it can help prove that you
did or did not know about certain signs, symptoms, pre- or coexisting conditions, or medications. You can either have new patients fill out the intake form on their first visit while they are sitting in the waiting room or you can mail it to them before their first visit.
This latter option is particularly professional looking. At the same time, you can send the patient written directions to your clinic or any other appropriate pamphlets or brochures.
Educational/Professional Disclosure Form
This form is required in some states and tells the patient what your educational background is, who has licensed you to practice, what examinations you have passed, etc. It allows the patient to decide if your education and professional history are adequate for the treatment they seek. You may also include your fee schedule and cancellation policy on this form.
Informed Consent Form
This form is how the patient gives you specific, written permission to treat. It is a short statement of the risks involved with acupuncture and has a statement declaring that the patient understands those risks and is requesting treatment.
Patient Confidential Information Form
This form is useful especially if you will be billing any type of medical insurance and if you do mailings or other marketing directly to your patients. It gives you a great deal of
demographic information about your patients, their family, their insurance coverage, their contact information, social security number, etc.
SOAP Notes Form (Optional)
This is a form you use to record subjective, objective,
assessment, and treatment plan information. Subjective means the patient’s report of what they feel, i.e., their symptoms.
Objective means the signs that you observe in your
examination, such as tongue and pulse signs, colors, smells, sounds, etc. Assessment means what you believe is happening based on the combination of the subjective and objective information. Plan is obviously what you decide to do to treat the patient. The information on this form can be very helpful if you ever need to give a deposition, support your treatment plan in a lawsuit, or for remembering why you did what you did when the patient goes away for several months and then returns.
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Report of Findings Form (Optional)
This can also be a PARQ form, which is short for procedure, alternatives, risks, and questions. This form is used to help you explain to the patient what you plan to do for them and why, what alternative therapies they might investigate, what the risks of the procedures might be, and then gives the patient a chance to ask any questions. You can give this form to the patient and keep a copy in the patient’s file.
Assignment of Benefits for Insurance Form (Optional) This form is used for insurance patients and tells the insurance company that you and your clinic are to be reimbursed directly for medical services provided instead of reimbursements going to the patient or any other third party. This form will go to the insurance company being billed and a copy will remain in the patient’s file.
Financial Policy Form
This form discloses to the patient how your clinic operates financially. It tells them your fees for various services, your cancellation policy, whether and how you bill for insurance, what happens if the insurance does not pay, and, in general, what will be expected of them financially.
Follow-up Care Form (Optional)
This optional form is where you write down what was done during each office visit and why. It is a short version of your SOAP form.
Request for Release of Patient Information Form If your patients want you to have access to their current or past healthcare information from other practitioners of any type, you need to use a release form that is sent to the practitioner in question with the patient’s signature and information about where the information is to be sent.
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Consent to the Use & Disclosure of Health Information for Treatment, Payment, or Healthcare Operations Form This form is a HIPAA requirement explaining to the patient that their personal healthcare information may be used to plan their care, for financial and billing purposes, and other routine operations and information processing within your clinic. It also explains to the patient that they have the right to object to their private information being used in any published directory, to your sharing any information about HIV/AIDS, drug or alcohol abuse, or mental health conditions, and that they may give you permission and later revoke it, which revocation must be done in writing.
Below is a checklist that you may use to be sure that you are keeping your records in accordance with good risk management procedures. Remember, if a patient sues you for any reason, your chart notes are your only defense and will be the first thing your malpractice insurance agent or the lawyers on either side of any case will subpoena. If you are doing all the things on this list, your charts will be relatively unimpeachable, unless you are simply doing things that are outside your scope of practice or are, for some other reason, indefensible.
Clinic Recordkeeping Checklist for Each Patient
❒ The patient name must be on all pages in your files.
❒ All pages should be secured into the treatment folder.
❒ All notes organized chronologically (most recent date on top)
❒ Always write legibly, be consistent, clear and concise.
❒ Maintain records in ink, use the same pen for each entry on the same day.
❒ Do not alter the records after the fact, do not erase or use correction fluid.
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❒ Fill in all blanks, do not skip lines or leave spaces, or line through large blocks of empty space
❒ Do not “squeeze in” notes at a later date and do not indent on any line.
❒ Make additions and changes appropriately on a different line. You may reference the line on any specific page that you need to change and give a reason for that change.
❒ Record all patient contact.
a. Missed appointments documented b. Telephone messages documented c. Entries dated, timed and initialed d. Patient noncompliance documented
❒ Initial all reports from an external source (X-ray, lab, diagnostic, consultant) before filing them.
❒ Dictation, correspondence, and reports to insurance companies or other practitioners should be proofread and initialed before filing.
❒ Maintain a legend for any abbreviations used if needed for later reference.
❒ Document the reason for the visit, any unusual events and avoid or explain contradictions.
❒ All clinical findings (positive or negative) should be
documented and the problem or complaint list kept current.
❒ Treatment plan documented and updated with each visit.
❒ Entries are objective and do not criticize other providers or their treatment methods.
❒ Properly identify the record, the record keeper, the technique employed, the table and/or room used and the details of each treatment.
❒ Any patient instructions are documented.
❒ Informed consent is in the chart.
❒ Be certain that the “Release of Records Authorization” form in the chart is correct and valid.
❒ Referral letters or prescriptions are in the chart.
❒ Herb list is current, when due to refill, reactions or allergies.
❒ Patient education materials given to patient is documented.
❒ Customize the forms you use.
❒ Keep financial and clinical information separate.
❒ Retain the records forever because of the statue of limitations on malpractice cases.
❒ Signature of the provider of services.
Keep your patient records forever. A patient has, in some cases, up to two years from the discovery of a problem to sue you.
While it is unlikely that a patient’s problem would arise 10 years from your treatment and be traceable to you and a specific clinical event, it is not impossible. Basically, that means that you should keep all files in storage or on a CD or tape memory drive forever.
POINTS TO PONDER FROM CHAPTER 8
• There are many forms that are required by law in your patient interactions.
• There are other forms that are optional but can streamline patient care and make your clinic feel professional, caring, and organized.
• If you take nothing else from this chapter, read and follow the recordkeeping checklist.