Documenting Chiropractic Patient Intake and History

Begin Your Chiropractic Patient’s Journey with Their History

Taking a history on a chiropractic patient is a required component of the Evaluation and Management service (E/M) that will establish the episode of care, whether it is a new patient, new condition, or new episodes of care. A basic intake history is required for all of these cases.

Not All Histories Are Created Equally

Keep in mind, you may need specific information from your chiropractic patient, for example, when there is a motor vehicle accident or a workers’ compensation incident. Your first step is to establish your office procedure for how you gather all relevant information and how you review your chiropractic patient’s intake information.

There Are Many Right Ways

There is no right or wrong answer as to what should be included in the intake paperwork.  The gathering of clinical and demographic information is important for proper treatment and to ensure payment when billing a third-party payer. Evaluate your current intake paperwork, to make an informed decision about what questions are important for your chiropractic treatment philosophy and to your chiropractic practice.

Patient Flow Can Be Effected by Your Data Collecting Process

Consider that patient flow may be interrupted if you overload the patient with stacks of paper

to fill out immediately upon entering your office. Perhaps providing your intake paperwork on your website, or emailing it when the initial appointment is scheduled, would allow for the patient to be more thoughtful and complete with the information they provide when they’re doing so in the comfort of their home.

Search below for more information and support on documenting your chiropractic patient intake and history process in your chiropractic practice.

Join the KMC University Library to learn what you need include in your patient intake and history process in your chiropractic documentation, so that your chiropractic patients story makes sense to anyone who reviews your chiropractic documentation.