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Can You Differentiate Between Subjective and Objective Findings?

When writing reports, regardless of the type of report (narrative vs. status report), it is important to differentiate between subjective and objective findings. Reporting each type of finding has its purpose, but you must understand the difference between the two.

First, subjective findings consist of the symptoms that the patient reports and the ongoing changes during the course of treatment. On an initial interview, the patient may complain of severe low back pain radiating into the right leg and buttocks. Also, she experiences a secondary complaint of periodic headaches. As her course of treatment progresses, she may report that the pain in her low back has decreased and that the burning sensation in her leg is almost gone. Her headaches, however, have remained the same. All of this information is classified as subjective findings — the patient’s report of his/her condition.

Subjective findings are important because they constitute the patient’s reason for seeking treatment. Changes in subjective findings justify the need for initial treatment and symptomatic changes justify the need for ongoing care. On a status report, you might indicate "patient reports that low back pain has lessened in intensity resulting in a decreased burning sensation in the right leg." Keeping the insurance company apprised of the patient’s progress lowers the risk that the insurance company may choose to stop reimbursement prematurely.

The other type of finding that a chiropractic office should document on every patient is objective findings. Objective findings consist of results of the x-rays and examination and any other procedure used to establish diagnosis. Objective findings are used to formulate and substantiate the patient’s diagnosis; they might indicate fixation or rotation of certain vertebrae. They might also involve muscles, ligaments and tendons which move in conjunction with the spinal column. Objective findings may include indications of pathology or biomechanical dysfunction. They pinpoint the various areas of involvement and the severity of the condition.

When reporting changes to an insurance company in the form of a status report, it is important to identify symptomatic (subjective) changes as well as objective changes which affect the diagnosis. As a result of treatment, a severe sciatic condition may have been alleviated; the patient may still have problems in the cervical region as the result of a whiplash syndrome. This problem may be responding more slowly to treatment. Providing a status report and changing the diagnosis to reflect progress/exacerbation/changes in condition is the type of documentation needed by insurance companies. It avoids the problem of an insurance company making an arbitrary determination that the patient has reached the maintenance phase of care.

As you type status reports, be sure to differentiate in your mind (and in the report) between subjective and objective findings. When you update an insurance company on the changes occurring with the patient, you are justifying the need for ongoing care.

Contributed by:  Marilyn Gard, President, Clinic Pro Chiropractic Software, marilyn@clinicpro.com

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As a chiropractor, the needs for clinic software differ from a medical practice.  Chiropractors primarily use two procedure codes: 98940 and 98941.  In addition, electronic medical records for chiropractic practices differ significantly from medical practices.  Chiropractors do not use electronic prescriptions, lab tests or immunization registries.  Chiropractors need to record x-ray findings, visit plans and functional limitations.  Chiropractic software by ClinicPro provides the best chiropractic practice management software in the industry.
In a chiropractic office environment, the use of chiropractic software streamlines the functioning of the office.  Chiropractic software should include an appointment scheduler that allows chiropractors to set up visit plans.  It should include chiropractic procedure codes for x-rays and adjustments such as 98940 and 98941.  It should include an integrated electronic medical record that allows chiropractors to record Medicare mechanism of trauma.  Using an EMR to record documentation notes and physical exam findings streamlines the overall functioning of the chiropractic office.
In a chiropractic office environment, the use of chiropractic software streamlines the functioning of the office.  Chiropractic software should include an appointment scheduler that allows chiropractors to set up visit plans.  It should include chiropractic procedure codes for x-rays and adjustments such as 98940 and 98941.  It should include an integrated electronic medical record that allows chiropractors to record Medicare mechanism of trauma.  Using an EMR to record documentation notes and physical exam findings streamlines the overall functioning of the chiropractic office.