Chiropractors and other medical professionals in today's world fear medical malpractice lawsuits. One way to avoid this issue is to improve documentation within the office.

Doctors often try to save time and end up taking poor notes. However, this can eventually lead to major problems such as malpractice suits, insurance denials and audits. Also, a state board of chiropractic examiners will have specific guidelines and laws regarding the proper documentation procedures within a chiropractic office. A chiropractor should heed these guidelines as they will be investigated if a patient or staff files a complaint, according to Steven Conway's article from the American Chiropractic Association.

The people more likely to file a complaint tend to be recently fired chiropractic assistants, insurance workers and patients that have had insurance denials. There are major issues poor documentation brings. If certain codes or performed services are absent, a chiropractor may be accused of billing for services not performed, unprofessional conduct and even fraud, Conway writes.

There are several things that can be done to improve documentation within a chiropractor's office. Conway recommends purchasing ACA's Clinical Documentation Manual and ACA's Coding Solutions Manual. Along with this, Conway suggests using a handheld recorder and dictating one's notes by speaking. Afterward, a transcriptionist can type and print out the medical notes.

Handwritten notes, however, are not the best way to document medical procedures and diagnostics. Usually, illegible handwriting presents itself as the main problem. Often chiropractors and medical professionals use abbreviations and codes without identifying what each symbol stands for. This makes handwritten notes all the more difficult to understand. Also, a chiropractor could save on paper costs by implementing other documentation systems. 

A great way to improve documentation and reduce a chiropractor's risk of being investigated is to adopt chiropractic EHR systems. Web-based EHR software will not only save on paper costs but also on high installation prices.