patient report of findings

Report of Findings A report of findings should be comprehensive, well written, and enlightening to the patient. It is the first step to increasing case acceptance rate, improving patient retention and moving your practice into a higher revenue range.

Full Answer

What is a patient medical report?

A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has.

Who has the access to the patient medical report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patients’ access to the patient medical report is a must.

What should a doctor document in a medical report?

One thing that a doctor should have documented in the patient medical report is the medical diagnosis that he has found in the patient. Whatever disease that a patient has should be clearly stated in the medical report. The name of the disease should be clearly written and some explanations about the current condition of the patient.

How to avoid conflict between patient and patient medical report?

So, to avoid conflict, the patient medical report should be shown to the patients. HIPAA (Health Insurance Portability and Accountability Act) has been passed in the Congress of United States.

What is a chiropractic report of findings?

The chiropractic report of findings is the cumulative byproduct of many aspects of a chiropractor's belief system, confidence, knowledge and compassion for the patient. It's a culmination of everything, and the patient will know immediately if this is an office they feel good about or not.

What is the CPT code for report of findings?

If you spend 15 minutes face-to-face with an established patient in the office, and more than half of that time was spent counseling the patient or coordinating his or her care, you could use CPT code 99213. Example #1: A report of findings was provided to the patient today.

Can chiropractors Bill 99213?

If a Review of Systems is not documented, the highest level of exam you can bill is 99201 for a NEW patient and 99212 for an ESTABLISHED patient. If PFSH (past, family, and social history) is not documented, the highest level exam you can bill is a 99202 for a NEW patient and 99213 for an ESTABLISHED patient.

What is the difference between CPT code 99212 and 99213?

A tip for billing 99212 is that the presenting problems are usually self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. A tip for code 99213 is to think of expanded visits as a sum of the continued symptoms or another extended form of the problem.

What is the difference between CPT code 99211 and 99212?

CPT 99211 Description: An outpatient visit or office visit of an established patient. A qualified healthcare professional (physician or other) may not be required. CPT 99212 Description: An outpatient visit or office visit of an established patient. The visit involves management and evaluation.

What is a 99212?

CPT® code 99212: Established patient office or other outpatient visit, 10-19 minutes.

What is the medical code 98941?

Chiropractic Manipulative Treatment ProceduresCPT® 98941, Under Chiropractic Manipulative Treatment Procedures. The Current Procedural Terminology (CPT®) code 98941 as maintained by American Medical Association, is a medical procedural code under the range - Chiropractic Manipulative Treatment Procedures.

What modifiers do chiropractors use?

While there are several modifiers, the two most commonly used in modifiers by chiropractors are modifier 25 and modifier 59. The key to using modifiers to ensure maximum reimbursement is to understand each payer's specific recommendations on the matter.

What is procedure code 99358?

99358. Prolonged evaluation and management service before and/or after direct patient care, first hour.

What is the ICD 10 code for lab results?

ICD-10 Code for Person consulting for explanation of examination or test findings- Z71. 2- Codify by AAPC.

What is the CPT code for lab review?

Code 99211 describes a face-to-face encounter with a patient consisting of elements of both evaluation (requiring documentation of a clinically relevant and necessary exchange of information) and management (providing patient care that influences, for example, medical decision making or patient education).

What is the CPT for lab work?

CPT code 86334 is used for any specimen not requiring concentration, 86335 is used for any specimen (including serum) that requires concentration.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physic...

Who Can Have Access to a Patient Medical Report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patien...

Is a Patient Medical Report a Legal Document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patie...

What is a Patient Medical Report?

A patient medical report is a comprehensive document that contains the medical history and the details of a patient when they are in the hospital. It can also be given as a person consults a doctor or a health care provider. It is a proof of the treatment that a patient gets and of the condition that the patient has.

What You Should Include in a Patient Medical Report

A patient medical report has some important elements that you should not forget. Include all these things and you can learn how to write a patient medical report.

Importance of a Patient Medical Report

The reason why a patient medical report is always given is because it is important. Here, you can know some of the importance of a patient medical report:

How to Write a Good Patient Medical Report

A doctor is a doctor. They are not writers. They can be caught in a difficulty on how to write a patient medical report. If this is the case, turn to this article and use these steps in making a patient medical report.

Who Writes the Patient Medical Report?

Health care providers do the patient medical report. The health care professionals make the documentation for a patient. It includes all the physicians, nurses, and doctors of medicine. It also includes the psychiatrists, pharmacists, midwives and other employees in the allied health.

Who Can Have Access to a Patient Medical Report?

The health care providers have the access to the patient medical report. They keep the medical report as a history of medical records. Also, patients’ access to the patient medical report is a must. It is their right to see their medical report. It is against the law not to show them their medical report.

Is a Patient Medical Report a Legal Document?

If it is signed by a health care professional, then it is a legal document. It is permissible in any court of law. It is an evidence that the patient is under your care. Thus, it can be used in court as an essential proof. So, keep a patient medical report because you may need it in the future.

Why do patients interrupt their busy lives to see you?

Patients interrupt their busy lives to see you because something is amiss. Whether we like it or not, most patients try a medical solution first, usually medication. They see you because the medication is no longer working or its side effects have become intolerable.

How long has the spine been adapting to the car accident?

Their body has been adapting to their car accident six years ago or the birth trauma of 43 years ago. If the growth plates are no longer present, you probably have an adult whose spine has a permanent weak link. It’s unlikely to ever be fully “fixed,” even if they enjoy symptomatic improvement.

Do chiropractors give patient reports?

Yet, many chiropractors neglect to give a formal report. That’s probably due to the reputation that patient reports are merely a manipulative sales tactic. Let’s not do that.

Comprehensive Reports: Just Add You!

The VIP Report of Findings Starter Set brings order and consistency to your reports and equips your patients to recreate your explanations when they get home. Increase the impact of your reports by bringing consistency and order to your presentation. Here are the essential report documents you need.

Patients Take Your Recommendations More Seriously..

When you present your findings and recommendations for care in a serious manner, patients do too. Used in the busiest practices around the world, this time-tested approach to patient reporting is simple and effective.

The Financial Report of Findings

After the initial exam, the patient returns to the office for their report of findings. At this appointment, the doctor reviews the findings and the treatment plan with the patient. When the patient has said yes to care, the baton is then handed off to the CA to review the financials.

About the Author

Holly Jensen has served the chiropractic profession since 2002 as a CA and Office Manager where she oversaw the operations of Dr. Miles Bodzin’s Chiropractic Wellness Center in San Diego, CA.

1. Reports That Are Too Short

If you don’t invest enough time, you can communicate a casual and superficial tone that can compromise patients’ perceptions.

2. Reports That Are Too Long

A far more common mistake is delivering a report of findings that doesn't end until your staff taps on door.

3. Reports That Are Too Technical

It’s so tempting to geek out when you have a captive audience. When you do, it’s easy to confuse data with information. A cervical range of motion compromised by 15 degrees is data.

4. Reports That Are Too Verbal

The easiest mistake to make is to rely mostly on the spoken word for your patient reports. It’s convenient. You can mint word after word for free. And you can quickly adapt your message should you detect a lack of interest or if the reception room is backing up.

5. Reports That Are Too Manipulative

Many chiropractors think the intent of a report of findings is to get patients to accept and act on their clinical recommendations. They want to “counter objections” and “close the sale” and secure one more chiropractic conquest. You do this when you need the patient more than they need you.

6. No Report of Findings Because You're Too Busy

The biggest report of findings mistake of all is not giving one. This is often justified by one or more of the following excuses:

Give a Better Chiropractic Report of Findings

Get your report objectively reviewed by chiropractic patient communication expert Bill Esteb. His assessment can reveal the underlying cause of impaired practice growth. Discover the strengths of your report, plus missed opportunities.

12 Elements of Effective Reports

Countless nuances can affect a patient's willingness to embrace your care plan. A word choice. A raised eyebrow.

A One-Time Investment In Your Report

The one-time fee of $495 will give you specific, actionable feedback. Expect an instant return on your investment. Plus, the dividends from better patient compliance and retention for years to come. As your certainty increases, your confidence surges. Patient respect soars.