On nearly every implementation call for members of The Evidence Based Chiropractor I receive questions about case notes. Doc's are concerned about the how, what, when, and where about sending them to other physicians. Often, they have been reluctant to do so because they don't want to send something amateurish or incorrect. (Top priority is always to be in compliance with HIPAA and government law regarding sharing protected health information)
Research shows us that Primary Care Physicians received case notes approximately 70% of time when referred a patient to another MD. PCP's only receive case notes 50% of the time when a patient is referred to a chiropractor.
By sending case notes you are 1) accurately adding health information to the patients chart in their Primary Care office which is important for continuity of care 2) positioning yourself as a local health care professional who is confident and thorough when communicating with other health professionals.
We recommend our members send case notes at 3 different times- Initial Evaluation, Re-Evaluation, and Discharge from Active Care. Often these notes can be process and faxed directly from your EMR/EHR. Quite simply they should include the following-
Who- who is the patient? (patient name, DOB)
When- when did they visit your office? (date of service)
What- what did you find? (diagnosis)
How- how are you going to move forward? (treatment plan)
As you can imagine, these items will usually take up less than a full page. If a doc requests additional information, then you can by all means supply it; however, a vast majority of physicians prefer just the basics as they will look at this page in the patients record prior to entering their exam room.
By supplying case notes you are increasing communication and "touches" with PCP's in your community, they can see the progress of your shared patients, and you are assisting your patients with keeping an accurate health record. If you would like more information regarding case notes I recommend reading my book, "Marketing Chiropractic to Medical Doctors" which is now available worldwide on iBooks.
-The Evidence Based Chiropractor is the leading DC/MD marketing and outreach group in the world. Our service is dedicated to increasing chiropractic utilization by showcasing research. Marketing to medical doctors through research is efficient, cost effective, and can dramatically improve your incoming referrals. Join us. Lets grow chiropractic together.