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The Practice Starters® Program e-book

New Patient Walk Through Procedures ©2008 Peter G. Fernandez


By: PETER G. FERNANDEZ, DC Copyright ©2008 by Peter G. Fernandez, DC All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without prior permission of the publisher. Notwithstanding the foregoing, purchasers of this book from established retail businesses may reproduce any clause recommended in this book without charge for the limited purpose of use in their business. This book is designed to provide accurate and authoritative information with respect to the subject matter covered. It is sold with- the understanding that the publisher is not engaged in rendering legal or other professional services. If legal advice or other expert assistance is required, the services of an attorney in your state should be sought. While every attempt is made to provide accurate information, the author or publisher cannot be held accountable for errors or omissions.


About The Author Dr. Peter G. Fernandez (Dr. Pete) has been honored by the profession for of his remarkable and far-reaching work in - and for the practice of Chiropractic. A 1961 graduate of Logan College of Chiropractic, Dr. Fernandez, is a father of seven children, three of which are Chiropractors. It was because of his struggle entering practice as a new Chiropractor and witnessing the struggle his children had as they entered practice, that Dr. Fernandez created The Practice Starters Program. Dr. Fernandez teaches new doctor’s what Chiropractic Colleges can’t - the business principles of chiropractic practice such as Personal Injury, adding Associate Doctors, Insurance Procedures, Practice Finance, Patient Retention, New Patient Acquisition, Advertising & Marketing, Legal Issues, Staff Training, Exam Procedures, etc. The research, development, and anecdotal background for his teaching came from Dr. Fernandez’ experience practicing chiropractic in Florida from 1965 to present, examining and treating High School athletes (up to 200 per year), performing IME’s for insurance companies and other chiropractors; owning a chain of 12 chiropractic clinics, directing five associate doctors; as a professional football trainer; President of Central Florida Academy of Chiropractic Studies; Chairman of the Public Information Committee of the Florida Chiropractic Association; Board of Directors of the Florida Chiropractic Association; Member of the Florida Chiropractic Association Insurance Review & Peer Review Committees; President of the Pinellas County Chiropractic Society; Treasurer of the Florida Chiropractic Association; and President of the Florida Chiropractic Association. Dr. Fernandez taught management procedures to over 10,000 Chiropractors and over 20,000 Chiropractic support personnel; consulted in opening over 3, 000 practices and 5, 000 in-practice doctors; authored 18 books on how to manage a chiropractic practice; and authored over 100 articles relating to athletic injuries; examination procedures; neurology and management procedures. Dr. Fernandez has been honored for his entrepreneurial and management training skills by the states of Maine, Indiana, Florida, Tennessee, Missouri, Louisiana, Virginia, Indiana, Nebraska, Ohio, Kansas, Kentucky and was a Adjunct Professor at Texas Chiropractic College.



GENERAL POINTS The “New Patient Walk Through Procedures” will take you through all the steps a new patient takes, i.e., the new patient’s telephone call, scheduling their appointment, the first visit, new patient paperwork, the consultation, examination procedures, the new patient’s second visit, report-of-findings, the new patient’s first adjustment, scheduling an appointment for a Spinal Care Class, follow-up visits, doctor’s daily visit procedures, office visit guidelines for the doctor and the CA, Throughout this “New Patient Walk Through Procedures” manual there will be references to Fernandez Consulting office forms. The Practice Starters® Program recommends the use of the Fernandez Consulting office forms and procedures because they are the best in the chiropractic profession. OFFICE NAME 

Professional Yellow Page ad. –

This is the first impression a potential patient has of your office.

Professional Web site.

Professional name for your office. –

Name your office after yourself. DR. PETER G. JONES CHIROPRACTOR

4 

If you have a name that’s not easy to remember, unusually spelled or difficult to pronounce, name your office after the section of town in which you are practicing or after a nearby town monument, i.e.:

North East Chiropractic Office.

Stadium Chiropractic Office.

The word, “Clinic” denotes a large multiple doctor facility, free care for indigents, welfare clinic, abortion clinic, etc. –

This word attracts indigent and welfare patients and keeps others away.

The word, “Center” gives the impression of a large medical center, multiple doctors (like a medical school) and does not communicate warmth or personal service.

The word, “Institute” has the connotation of an extremely large facility and impersonal service.

By evoking a picture of a huge practice, people associate these three words with cold and impersonal care. –

This is a new patient detractor.

Shorter names are better as they are easier to remember.

Avoid using the words:

“Doctor of Chiropractic.”

“Chiropractic Physician.”

Use the word, “Chiropractor”, it’s short and simple. –

Everyone knows what it means.


9:00 AM-12:00 PM and 1:00 PM-6:00 PM, Monday through Friday, 9:00 AM 12:00 PM on Saturday.

In an “Industrial” town. –

8:00 AM-12:00 PM and 3:00 PM-7:00 PM, Monday through Friday and 9:00 AM - 12:00 PM on Saturday.

5 

If you encounter difficulty in getting a CA to work these split hours, you may consider hiring a part-time CA (college student, etc.) to work from 4:30 PM-7:00 PM. –

Your regular CA would work from 8 AM to 5 PM.

Statistics show that: –

30-40 percent of your patients will come to your office during the early morning hours.

60-70 percent of your patients will come later in the afternoon.

Monday – late afternoon is your busiest time.

Friday – late afternoon is your second busiest time.


The difference between the professional and the novice in chiropractic practice is how well he/she performs the following four steps: Step #1:


Step #2:

Talking Orthopedic, Neurological, Chiropractic and Physical Examinations.

Step #3:


Step #4:


These four steps must be completed in the order listed and prior to giving the patient their first adjustment.

These four steps can be performed over three days, two days or one day, depending upon individual circumstances, however, all four steps must be covered thoroughly in the previously listed order.

The standard Practice Starters® office procedure is a two-day processing procedure.



When utilizing a three-day procedure, professional care is scheduled as follows: –

1st Day: Consultation, Talking Preliminary Examination and X-rays.

2nd Day: Talking Orthopedic, Neurological, Chiropractic and Physical Examinations and additional X-rays, if necessary.

– 

3rd Day: Report-of-Findings and Treatment.

The three-day procedure is to be used whenever: –

A doctor is practicing alone and cannot do all the necessary procedures over two days due to insufficient time available.

The doctor is dealing with a chronic problem that necessitates a more extensive diagnostic work-up.


This is the standard Practice Starters® procedure.

When utilizing a two-day procedure, professional care is scheduled as follows: –

1st Day: Consultation, Talking Orthopedic, Neurological, Chiropractic and Physical Examinations, and X-rays.

2nd Day: Report-of-Findings and Treatment.

The two-day procedure is recommended for the majority of patients.

It is used whenever the doctor has sufficient time in his schedule to thoroughly perform each of the four procedures.


All four pre-adjustment procedures are completed in one day: i.e., Consultation, Talking Orthopedic, Neurological, Chiropractic and Physical Examinations, Xrays, and Report-of-Findings.

The one-day procedure is recommended only when a patient is in acute pain and needs immediate attention and the doctor has sufficient time to perform these procedures.


When utilizing a free exam procedure, professional care is scheduled as follows: –

1st Day: Consultation, Free Talking Orthopedic and Neurological Examination, and X-rays.

– 

2nd Day: Report-of-Findings and treatment.

Do the entire talking orthopedic, neurological and chiropractic examination when a free exam has been advertised. –

By doing so, a claim of a “bait and switch” is avoided.


When utilizing the test adjustment procedure, professional care is scheduled as follows: –

1st Day: Consultation, Talking Orthopedic, Neurological, Chiropractic and Physical Examinations, X-rays and Test Adjustment.

– 

2nd Day: Report-of-Findings and Treatment.

This procedure: –

Relieves the patient’s pain.

Tests the mobility of the patient’s spine.

Tests the effectiveness of the doctor’s adjustment.

This procedure is only to be used on a patient who is in acute pain and who has scheduled his first appointment just before the close of a work day, thus prohibiting the doctor from having enough time to give a report-of-findings.

This procedure will be used on less than one percent (1%) of a doctor’s patients.


How your office telephone is answered is the second impression most people receive of your office.

8 

This is a lasting impression, which makes your telephone procedures just as important as your doctoring skills.

Improper telephone procedures can ruin a practice by giving potential and existing patients, a feeling of indifference, rudeness, etc.

The purpose of answering the telephone is to: –

Make an appointment.

And give the impression that you’re friendly, knowledgeable, caring and are there to help them.

Prior to answering the telephone: –

Place the “CA Telephone Script” (FO212) next to the telephone that is used to receive incoming calls.

Place a “Smile” mirror next to the telephone(s) that is used to receive incoming calls. 

The “Smile” mirror is about 5" wide x 7" tall.

Answer the telephone by the second ring.

When the telephone rings:

9 S

The C.A. should clear her mind of irritations and distractions.


Look into the “smile” mirror.


Get into a happy, caring mood.




Answer the telephone giving the impression she is delighted to hear from the caller.

Greeting: 

Identify your office, then yourself, then say, “May I help you?” S

The “May I help you” is said in an uplifting voice.

Names. S

Never say, “Who’s calling?” 

Focus your attention on the caller. –

Say, “May I say who’s calling?”

Visualize the patient as if he/she was standing there in front of you.

If needed, clarify the pronunciation of the patient’s name. –

Say: “We are having a problem with our telephones today, would you please repeat your name (what you said)?

Spell their name phonetically.

Repeat the caller’s name three times during the course of your conversation. 

Qualification. S

Never say, “Are you a new patient?” 

Always call them by their last name.

Say, “When was your last visit to our office?”

Give the patient a choice of two appointments. –

Today or tomorrow.

Morning or afternoon.

Early or late.



“Mr./Mrs. _____, I can schedule you with Dr.


Which would be more convenient for you, morning or afternoon?” 




“That will be fine, Mr./Mrs. _____. I will place you on the schedule at _____. May I have a phone number where you can be reached during the day, please?” Telephone number (home)



Repeat the caller’s appointment time and his/her name at the end of the


conversation. LOCATION: 

Offer to give directions to the office. – –


“Do you know where we are located?” _____________________________________________________

CLOSE:  CA: 

Repeat Appointment Time. “Mr./Mrs. ______, we will see you at ________.” Give instructions to look you up when they come to your office so you can help them with their paperwork.

Avoid putting people on hold. –

If you must put someone on hold: 

Don’t, until they have stated their reason for calling.

Don’t say, “Dr. Fernandez’ office, please hold.”

Report back to the caller every 30 seconds. –

Be polite and apologetic.

Give an explanation. 

“I’m putting you on hold while I locate Dr. Fernandez. Thank you for waiting.”

11 

Don’t lay the telephone on a counter, leaving the telephone line open.


Do use the “New Patient Analysis”(PGF21) form for all new patients. –

Log all new patient calls received, appointments made, if the patient showed for their appointment and if the patient accepted care.

Do follow the C.A. Telephone Script (F0212).

Don’t dig for all the insurance information over the telephone. –

The patient doesn’t know if he/she likes you yet.

It is okay to ask, “Is this an accident, injury, or emergency case?”

Do, if at all possible, schedule the new patient the same day as his/her call.

Do give the potential patient an appointment time 20 minutes prior to the time they will actually be seen by the doctor. 

Do so to get their paperwork done.

Don’t perform a consultation on the telephone … you’ll lose the patient.

Don’t use an answering machine during office hours.



“How much do you charge?”


“There is no charge for the consultation. The doctor will determine, at that time, whether or not your condition is a chiropractic case. We have an appointment opening at either 2:00 or 5:15 this afternoon. Which is most convenient for you?”


“How much do you charge for an office visit?”


12 “Anywhere from $0 to $120 (always quote a fee 2-3 times the normal). It depends upon whether or not the doctor accepts your case, and the type of treatment you will need... fair enough? There is no charge for the initial consultation on your first visit. Mr. Brown, I have an appointment available (today/tomorrow), (morning/afternoon), (early/late), which would you prefer?”


“Do I have to be x-rayed?”


“That depends entirely on your specific condition. Dr. Fernandez never x-rays a patient unless absolutely necessary. However, all serious cases are x-rayed so the doctor can do his very best in finding the exact cause of the patient’s health problem. He can then determine what should be done to fix the problem. At the time of your consultation, for which there is no charge, the doctor will determine whether or not x-rays are necessary in your particular case.”


“How much do you charge for x-rays? Surely, you have some idea!”


“The fee for x-rays could be somewhere between nothing and hundreds of dollars. If the doctor doesn’t accept you as a patient, it won’t cost you anything. If he doesn’t take any x-rays, there is no charge. Fair enough? And, again, there is no charge for the initial consultation and examination on the first visit. Mr. Brown, I have an appointment available (today/tomorrow), (morning/afternoon), (early/late), which would you prefer?”


“Can the doctor cure backaches?”


“The doctor has corrected many cases of backache. In your particular case, the doctor must examine you to see if your type of backache is one that he can help. I can give you a consultation appointment for either 9:30 or 11:00 this morning. Which would be most convenient for you?”

13 


“What type of adjustments does the doctor give?”


(You are better off answering this question with a question for obvious reasons.) “What type of adjustments have you had previously? The doctor is schooled in many methods of chiropractic care. What seems to be your problem, Mr. Brown?”


“Backaches in my lower back.”


“The doctor has corrected many cases of backache. In your particular case the doctor must examine you to see if your type of backache is one that he can help. I can give you a consultation appointment for either 3:00 or 6:00 this afternoon. Which would be most convenient for you?”


“Does Dr. ________ use

(a certain type of procedure, equipment,

etc.?) 


“Dr. __________’s office is equipped for complete chiropractic diagnostic and treatment procedures.


The appointment book is the pivot upon which the entire practice revolves! It allows the CA to efficiently conduct all scheduling activities of the practice, i.e.: –

Number of patients seen.

Time allotted for patients.

Proof of: 

Recapture activities. (Rescheduling patients who miss their appointments.)

 –

Recall activities. (Re-activating former patients.)

Doctor’s outside-of-the-office appointments, seminars, etc.

14 

The appointment book reveals how capable the CA is who is using it.


Mastering appointment book procedures should be the priority for the front desk CA.



Have an appointment book that has twice as many spaces for appointments than the number of patients you are presently seeing.

Why more spaces? Quite simply - for growth!

If your book has 28 appointment spaces and you have 28 appointments scheduled, forget about treating 50 patients per day.

When your CA looks at the book and sees it is full, she won’t schedule any more patients that day. –

If she thinks you can’t see any more patients, you won’t!

Use an appointment book that gives you plenty of growing space.

Rule #2: 

Use the Fernandez Consulting Appointment Book.

There is a Fernandez Consulting Appointment Book designed for every size of practice.

Rule #3: 

Appointments are always written in pen.

Erasures should never be allowed, as they will affect the accuracy of your statistics.


Cluster booking is the scheduling of patients one after the other without empty spaces between adjustment times.

Cluster booking allows the doctor to treat one patient right after the other without interruptions in his/her schedule.

16 

Cluster booking is the CA's primary method of patient control and provides increased efficiency in patient scheduling.

Cluster Booking: –

Increases the effectiveness of the doctor’s treatment and the number of patients he can see per day.

The doctor gives better adjustments because he/she gets into a “treatment rhythm”.

Allows the doctor uninterrupted examination or paperwork time between treatment clusters.

Cluster booking involves establishing four (4) treatment clusters per day in which you schedule patients for adjustments and therapy. –

There are two (2) morning clusters and two (2) afternoon clusters.

Each treatment cluster has a specific start time from which you begin scheduling patients.

For example: 

The morning clusters may start at 9:00 a.m. (whatever time you actually open) and at 11:00 a.m.

 

The afternoon clusters are at 1:00 p.m. and 5:00 p.m.

When scheduling morning patients: –

The CA fills the 9:00 a.m. time slot first, then consecutively (one patient is scheduled immediately after the previously scheduled patient) schedules patients towards 10:30 a.m.

The CA fills the 11:00 a.m. time slot first, then consecutively schedules patients back towards the 10:30 a.m. time and forward to noon.

When scheduling afternoon patients: –

The CA fills the 1:00 p.m. time slot first, then consecutively schedules patients towards 4:30 p.m.

The CA fills the 5:00 p.m. time slot first, then consecutively schedules patients back toward the 4:30 p.m. time slot and forward to the time you close.

17 

By scheduling treatment in clusters, there may be blocks of time between the treatment clusters. –

These blocks of time are used to schedule new patients and other special services such as re-exams, report of findings, reports, lab work, paperwork, etc.

By using the "cluster booking" procedure, the doctor is able to devote sufficient time to new patients without making his other patients wait.


When scheduling a new patient, make sure he/she does not have to wait and that his/her first visit is a successful experience.

Block out 30 - 45 minutes for the new patient. –

This amount of time will vary depending on the individual doctor, and whether or not he/she has an examination doctor/CA, or a certified x-ray technician on staff.

When making the new patient appointment use the following procedures: –

Write “NP” in the services column to the left of the patient’s name.

Write the patient’s daytime telephone number under his/her name in case the patient has to be called to be reminded of the appointment, or to be rescheduled in the event he/she misses the appointment, an emergency, etc.

Block out the necessary amount of time below the new patient’s name so that another CA or doctor does not inadvertently schedule a patient in that time slot and cause the new patient’s appointment time to be cut in half.

Highlight the new patient appointment time in yellow so that it stands out in the appointment book.

Do the necessary paperwork preparation prior to the new patient appointment.

You can schedule 1 – 2 regular patients between: 

Consultation and examination.

Examination and x-rays.


New patients should be scheduled in the opening between the early and late morning treatment clusters.

The new patient should be scheduled 20 minutes earlier than the time actually scheduled in your appointment book. –

This assures that the new patient is not seated in an empty office.

No matter how good the doctor is, if a new patient finds that he/she is the only patient in the office, he/she will seriously doubt that the doctor is any good.

It allows time for the patient to complete all the necessary paperwork prior to seeing the doctor.

If the new patient were to arrive at the actual time the doctor can see him/her, the doctor would have to wait while the patient fills out all the required forms, and consequently the doctor would be thrown at least 15 minutes behind schedule. –

This creates an undesirable waiting time for his/her next patients.

When the patient has finished filling out the forms, the doctor should be almost done with his/her early morning treatment cluster and be ready to shift his/her mind from “treatment mode” to “new patient consultation and examination mode.”

When the doctor completes his/her consultation, examination, and x-ray, the next treatment cluster of patients should be in the adjusting and reception rooms.

The new patient will be impressed that the doctor took the time to give him/her such personable, thorough and high quality care, when the doctor had a reception room filled with patients. –

The new patient will not realize that he/she was seen during the opening between the early and later morning clusters of regular patients.

19 

If there is no available time between treatment clusters (you are filled up), schedule new patients: –

One hour before the morning treatment cluster starts. 

This allows the doctor time to complete the consultation, exam and x-ray procedures before starting the morning treatment cluster.

– 

Or, 15 minutes prior to the end of the late morning cluster.

As a last resort, a new patient can be worked into a schedule by "piecemealing" the consultation, exam, and x-ray procedures. –

In this case, the new patient will be told that the doctor will have to work them in between his/her scheduled patients.

The new patient will be told that he/she will be in your office for approximately two (2) hours.

“Piece-mealing” is most efficiently done as follows: 

The doctor performs a two (2) minute history of the patient's chief complaint.

A qualified exam CA performs an in-depth past and present history, while the doctor is treating patients.

The new patient is then placed in an exam room by a CA, and the CA checks the patient’s height, weight, etc.

A few minutes later, the doctor will perform the Orthopedic exam, then excuse him/herself to treat a few more patients.

The doctor returns, performs the Neurological exam and then excuses him/herself to treat a few more patients.

The doctor returns, finishes the Chiropractic portion of this exam and then asks the CA to escort the patient to the x-ray room while he/she leaves to treat a few more patients. –

The new patient won't mind or be surprised by the long office visit because the patient has been told he/she

20 would have to be worked in between the other scheduled patients. 

Alternative: –

The doctor may choose to piece-meal a brief consultation, examination, and x-ray and then schedule the complete Chiropractic, Orthopedic, and Neurological exam for the following day.


The same procedures as morning appointments for new patients apply to afternoon new patient appointments.

The afternoon new patient appointments are scheduled in the opening between the early and late afternoon treatment clusters, or: –

One hour before the start of the afternoon treatment cluster.

15 minutes before the end of the afternoon treatment cluster.

Example of the new patient appointments:



Never schedule a new patient in the middle of a cluster of regular patients.

Never take a new patient ahead of a regularly scheduled patient, making the previously scheduled patient wait. –

If you make your regular patients, who have kept their appointments, wait, you'll lose them.

Always give your present patients, especially maintenance patients, first priority. –

Your regular patients pay your overhead, refer, and build your practice.



The successful D.C. has a professionally designed sign that portrays a professional image.


Your office building should be: –




With adequate parking.

Impeccably maintained.


The landscaping is professionally maintained, neat and picked up.


These signs present a professional image.


The office is professionally decorated.

Special decorations for the various holidays can be used inside and out, so long as they present a professional appearance.


Literature racks are not placed in the reception room as this is a room of “reception.”

23 The reception room is cheerful, bright and relaxing, not a place of blood and guts posters, etc.

Paintings, prints etc. adorn the reception room walls, with one wall dedicated to the doctor’s diplomas, awards etc.


Perception is reality.

How the doctor and each staff member looks is vital to patient acceptance.

Every staff member should have impeccable personal hygiene, and dress professionally and appropriately for their position.

CAs should all wear the same color polo shirts as chosen by the doctor.

The polo shirts should be embroidered with the clinic’s logo on the outside right sleeve and also on the upper left front side (about where the top of a pocket might be).

The CA’s name, either embroidered on the shirt or engraved on a name plate, should appear just below the clinic logo on the front of the polo shirt.

The Polo shirts should be clean and well pressed at all times.

The CAs should be given the choice of wearing either clean and pressed business pants (no jeans), or a business type skirt that falls at or a little below the knee and is clean and pressed.

Hosiery should always be worn and in a neutral shade.

Shoes should be of a duty type (no sneakers, athletic shoes, high heels, sandals, etc.), and always clean and polished.

If the doctor chooses for his/her staff to wear whites (no scrubs). The clinic logo and CA’s name should appear on the whites just as it would have appeared on the polo shirts.


When the new patient arrives at the office, the C.A., with a smile:

24 –

Gets up from behind the CA counter, and enthusiastically greets the patient by name.

Shakes the patient’s hand and identifies herself (if she hasn’t already met the patient).

The new patient is instructed to have a seat in the reception room and asked to fill out an “Application for Treatment” form (F1025A) which is handed to him/her on a clipboard:

The Application for Treatment form includes: –

A request for the patient’s e-mail address, which will allow the doctor to send the patient a no cost monthly newsletter.

A request for the patient’s permission to place his/her name on the Referral Board and in the doctor’s newsletter. (HIPAA.)

When the patient returns the filled out form, the CA reviews it to make sure the patient has answered all applicable questions. –

If the form is not completely filled out, the CA asks the patient for the missing information and places it in the appropriate space.

The CA says kind words about the referrer.

If the patient has insurance, the CA will ask for the patient’s insurance card and driver’s license. –

The CA makes a photocopy of each of these items and immediately returns the originals to the patient.

If the patient has no insurance, the CA will simply say, “The doctor will be with you momentarily.”

The CA then prepares the patient’s file folder by: –

Stapling the photocopies of the patient’s insurance card and driver’s license to the inside of the file.

Inserting a Diagnosis Code form into the file. 

This form is a list of the doctor’s most commonly used diagnosis and their corresponding code numbers.

25 

The CA makes sure the consultation room is tidy and then gives the new patient a tour of the office.


An office tour educates the potential patient and removes their fear of the unknown.

Make the new patient feel special. –


“Have you ever been given a tour of our office?”




“I’d love to show you our office if you have a minute to

spare.” 

During the tour, the Front Desk CA introduces the new patient to the other employees.

Reception Room: 

The CA tells the new patient your patients only have to wait a short period of time because your office is so efficient.

The CA tells the new patient that you give a bi-weekly Spinal Care class and invites them to attend one free of charge.

If possible, the CA introduces the new patient to some of your referring patients who are in the reception room.

Hallway: 

The CA points out the referral board and tells the new patient that most of your new patients come from referrals and how much you and your doctor appreciate the referrals.

Massage Therapy Room: 

The CA informs the new patient that all your massage therapists are: –

Certified and licensed.

26 –

Practice gentle, local trauma massage and full body massage.

Consultation Room: 

The Consultation Room is neat, clean and up-to-date.

Wall Charts and view boxes are placed on the wall behind the doctor.

Framed art or posters are placed on the other walls.

Awards and diplomas are placed on the wall behind the doctor as he/she faces the patient.

A medical/chiropractic library is placed below the awards and diplomas in the consultation room.

The CA explains that the doctor performs a free consultation in this room as well as report of findings to let people know what their problem is and how he/she can help them.

The CA points out special equipment, like the Neuropatholator.

Business/Insurance Office: 

The CA explains how your office is computerized for fast, efficient service.

Exam Room: 

The CA explains that the doctor does thorough exams to determine his/her patient’s health problems, and that the preliminary exams are done at no charge because it is the doctor’s way of keeping health care costs down while allowing people to find out if they have a health problem that a chiropractor can help.

The CA places the patient on a bilateral weight scale, Posture Pro to illustrate what these instruments do.

X-ray Room: 

The CA explains that your doctor insists on the most modern x-ray equipment to insure the very least amount of radiation to his/her patients.

27 Adjusting Room: 

The CA points out the special adjusting tables used in the specialized technique the doctor utilizes.

He/she also tells the patient how good an adjustment feels, “so relaxing”, etc.

Physical Therapy Suite: 

He/she points out your modern “state of the art” equipment that’s used for pain relief and to promote faster healing. –

Hydroculator Packs: “This is used when deep, moist heat is needed.”

Diathermy: “This is called our “miracle worker”. 

It reduces recovery time by increasing the blood supply to the deep areas of the lower back.

It is particularly helpful in treating inflammation of the female organs and prostate gland in the male, along with bronchitis and asthma.”

Muscle Stimulation: “Sometimes muscles get congested and have to be decongested, and then stimulated back to normal.”

Ultrasound-Sine Wave Combination: “This is actually two-treatmentsin-one.” 

“It stimulates muscles in cases where the muscle has been weakened or damaged or cannot be exercised by the patient.

It is specifically used on sprains, strains and dislocations.”

“Ultrasound is especially beneficial for joint injuries, neuralgia, bursitis and arthritis.”

The CA puts water on the ultrasound head to demonstrate the molecular activity.

Motorized Long-Axis Traction: “This is the finest, safest, most modern equipment money can buy for treatment of disc and whiplash injuries.”

28 

It restores spinal discs without surgery and helps restore the neck curve without pain.”

Intersegmental Traction: We call this machine the “Magic Fingers Machine.” 

It is great for unlocking locked vertebra, restoring the necessary spinal curves and keeping spinal distortions from becoming worse.”


“To summarize, all this equipment is available to assist the care given by the doctor. They help the doctor treat nerve problems, muscle spasms, and injuries to discs and ligaments. As you can tell, we provide a very complete scope of care. This completes your tour of our office. I hope it has been interesting for you.”

The CA escorts the patient to the consultation room and tells the patient what seat to sit in.

The CA tells the patient how much she has enjoyed meeting him/her.

The patient waits 4 – 5 minutes to view the diplomas, etc.

The CA gives the doctor a clipboard with the following patient information on it: –

A filled out Application for Treatment form (F1025A).


Fernandez Consulting C/O/N Exam form (F1557).

Fee Slip.

Diagnosis Code Sheet.

NOTE: The doctor does not accept the patient’s file folder unless all questionnaires are properly completed.

30 

While the doctor is in consultation with the new patient, the CA will call the patient’s insurance company to: –

Verify coverage.

The amount of the deductible, exclusions and limitations, etc. 

The CA can use the verbiage as outlined on the Insurance Company Questionnaire form (PGF291).

The CA also begins completing items on the New Patient Checklist that is on the Fernandez Consulting File Folder.


The abbreviations on the right side of the file folder are used to assist the doctor and CA’s in making certain that all procedures have been accomplished on a new patient.

Each time a procedure is completed, the abbreviation should be circled or checked off and initialed by the person performing that task.

Using this checklist eliminates a number of potential mistakes including: –

Something not getting done.

One CA assumes the other has done it.

31 – 

Duplication of effort.

The abbreviations are defined as follows: –

FORM: The Application For Treatment form (F1025A) has been filled out and returned.

SIGNED: The patient has signed the Application For Treatment form. (F1025A).

MINOR: If patient is a minor, their parent or guardian has signed “Consent to Treatment of Minor Child” form on the inside of patient file, or a separate form (PGF61).

INS: This account is to be billed to insurance.

INS CARD: The CA has obtained a photocopy of patient’s insurance card and the copy has been stapled inside the patient’s file.

INS CALLED: The CA has called the insurance company for verification of coverage and to determine the limitations and exclusions.

PTS FORM: The patient has brought in their insurance form with his/her portion filled out and signed. (Even though this appears on the Fernandez Consulting File Folder, this is no longer applicable.)

OUR FORM: The patient has signed the new CMS Insurance form.

32 –

ASSNS: The patient has signed the assignment on inside of the patient’s file folder (and all other assignments and/or authorizations that are necessary). 

If a separate form is to be used, use the Master Assignment/Lien Authorization form (PGF71).

ATT: If the patient has an attorney, the attorney’s name, address, telephone number, and necessary information has been obtained.

P.I. FORM: The 8-page “Traumatically Injured Patient Questionnaire (PGF300) was given to the patient, filled out and returned.


W/C C: The patient was given a Workers’ Compensation Treatment Authorization card (PGF81) for the purpose of getting authorization for the doctor to render treatment.

W/C R: The Workers’ Compensation Treatment Authorization card (PGF81) was returned by the patient with the necessary information and signature.

SS NO: The patient’s Social Security number has been recorded.

HEALTH QUES: The Cornell Health Questionnaire (F116 - Male or F115 - Female) was given to the patient, filled out and returned.

34 –

FAMILY QUES: The Family Health History Questionnaire (PGF91) was given to the patient, filled out and returned.

SPOUSE: The spouse was invited to attend the report-of-findings.

MAIL L: The patient’s name has been added to the mailing list.

B. CARD: The patient’s name and date of birth have been added to the birthday card list.

I W/C FORM: The initial Workers’ Compensation form was filed within 3 days of the patient initiating care.

NP LETTER: The “New Patient Welcome Letter” was sent.

T LETTER: The “Thank You For the Referral” letter was sent to the referrer.

REPORT: The patient has received the report-of-findings.

10 APP: The patient was given a 10 visit multiple appointment card (F010A).

35 

Additional items that may be added to a new patient checklist are: –

X-rays taken.

Picture taken (on P.I. cases).

Referral board posted.

Video watched.

Financial plan given.

Spinal Care class scheduled.

The CA then places the filled out Insurance Company Questionnaire (PGF291) into the Fernandez File folder.



The doctor enters the consultation room with the patient’s case history in hand and greets the seated patient.

Male Doctors Attire: –

Clean and pressed white or pastel colored dress shirt.

Tasteful and conservative tie.

Sharply pressed dress pants.

Clean and polished shoes.

Doctor’s white coat that falls just below the hip.

The doctor’s name with “D.C.” after it, should appear over the left side chest pocket, either embroidered on the coat or an engraved name plate.

– 

The doctors’ white coats should always be clean and pressed.

Female Doctors Attire: –

A business type skirt or pants.

Clean and pressed white or pastel colored business blouse.

Neutral shade of hosiery.

Clean and polished business pumps/shoes.

Doctor’s white coat that falls just below the hip.

The doctor’s name with “D.C.” after it, should appear over the left side chest pocket, either embroidered on the coat or an engraved name plate.

The doctors’ white coats should always be clean and pressed.


With direct eye contact and firm handshake, the doctor states: –


“Mrs. Jones? – Dr. Smith. It’s a pleasure meeting you.”

The doctor makes a complimentary statement about the referrer:

37 –


“Oh I see Mrs. Berry referred you to my office. Isn’t she great?”

Then the doctor asks: –


“Mrs. Jones, what can I do to help you?”


“Tell me about the problem you have.”

Or – 

The doctor listens to what the patient tells him/her, and makes notes on the Application for Treatment Form (F1025A).

It is especially important for the doctor to make a genuine and assertive effort to listen to the patient.

The concept here is “THE BIG EAR.”

The doctor relays this to the patient by: –

Bending slightly forward as he/she listens to the patient.

Nodding his/her head to indicate he/she understands what the patient is trying to communicate.

Asking the patient questions that clearly tell the patient the doctor is listening and would like a little more detail.

Once the patient is confident that the doctor is sincerely interested and understanding of his/her problem, he/she will welcome the doctor’s help to fix it.

The patient does not want to hear a “sales pitch for something that’s good for him/her” from someone who has not taken the time or interest to clearly understand what his/her condition is.


The doctor touches the painful area, and asks: –


“Does it hurt here, here or here … etc.?”


The doctor determines the progression of the patient’s health problem, by asking questions like: –


“Does pain radiate ... spread ... etc.?”


“Is there numbness in this area yet?”

It is the doctor’s responsibility to make sure his/her patients understand the progression of the patient’s syndrome if not treated, (if true).



“When is the last time you’ve had an attack like this? …Think back.”

Patients who believe their problems are acute, will only stay under care until they are relieved of their symptoms.

Patients who understand that their problems are chronic, will usually stay under care until the doctor releases them.

The doctor is seated and with direct eye contact asks the patient: –


“Is there anything else I should know about your health problem that will help me help you?”



“Let me see if I understand your problem like you understand it.”

The doctor parrots the patient’s symptoms back to them.


“Did I get it right? What did I miss?”

The doctor repeats the patient’s problem to them until he/she gets it right.



“Do you mind if I contact your family doctor to see if he/she has any information that will help me help you get over your (health problem) faster?”




“Mrs. Jones, at this time I would like to explain our clinic procedure to you.”


“The first thing I must do is find the underlying cause of your problem.”


“I will then determine the amount of secondary tissue damage that has occurred to see what condition you are in at this time.”


“ Then I will determine what can or cannot be done to help you.”


“At that point, I will explain my findings and make whatever recommendations I feel necessary in your case.”


“Then you can decide what you would like to do about it. Fair enough?”



“Mrs. Jones, Mary (the CA) will take you to an examination room and I will be with you shortly.”

If the CA is occupied, the doctor will say: –


“Come with me, Mrs. Jones.” (The doctor takes the patient to the examination room.)

The doctor or CA will instruct the male patients to remove their clothes from the waist up and the female patients to get into a gown.

The CA will offer her assistance to a patient who is in too much pain to undress themselves.

While the patient is getting is getting ready for the examination, the doctor will adjust one or two patients.

After the consultation:

40 –

The doctor will check off the patient’s diagnosis(es) on the Diagnosis Code form.

The CA will advise the doctor if the patient has good or limited insurance.



“Doctor, do I have to have an exam? Can’t you just adjust me?”


“Mrs. Jones, I wouldn’t know what to adjust until I examine you, and I will not jeopardize your health or my reputation.”


“Doctor, do I need x-rays?” or, “Doctor, I won’t need x-rays, will I?”


“I won’t know that until I examine you, Mrs. Jones.”


“Doctor, how much will the x-rays cost?”


“I am unable to state that at this time, Mrs. Jones. It depends on what x-rays I need and I won’t know that until I examine you.”


“Doctor, do you think you can help me?”


“I sure hope so, Mrs. Jones. I’ll be able to answer that only after our examination has been completed.”


“Doctor, will my insurance pay for the exam?”


“That depends, Mrs. Jones, on the type of insurance you have. Most insurance companies pay for chiropractic service.”



The hallmark of a quality practitioner is the thoroughness of his examination procedures.

The more thorough a doctor’s examination procedures are: –

The more accurate his/her diagnosis will be.

The more effective his/her treatment program will be.


The Fernandez Consulting C/O/N examination form (F1557) is divided into red and black colors.

The procedures that are printed in red are used for a patient who has a mild to moderate problem.

Whenever a patient has a severe problem, the doctor should use the examination procedures printed in red and black.

The same examination form can be used four times: –

1st exam: Use “blue” color ink.

2nd exam: Use “red” color ink.

3rd exam: Use “black” color ink.

4th exam: Use “green” color ink.

Write the date of your examination in the color ink that you will use to write your findings.



If the patient has upper extremity symptoms with no present or past history of lower extremity problems: –

Only perform the talking examination of the upper extremity.


The doctor will perform a talking examination of the upper extremity and a minimal talking examination of the lower extremity, i.e:


Palpation for edema or spasms.

Bilateral Kemp Test.

Bilateral Advancement Sign Test.

If these lower extremity tests are negative, the doctor does not need to proceed further with tests to the lower extremity.

Fees for the preliminary examination of the lower extremity should be minimal or included in the upper extremity examination fee.


The doctor should perform a talking Orthopedic, Neurological and Chiropractic examination on the upper and lower extremities.


If the patient has a lower extremity problem with no present or past history of upper extremity problems:

The doctor only performs a talking Orthopedic, Neurological and Chiropractic examination of the lower extremity.

43 LOWER EXTREMITY PROBLEM WITH A HISTORY OF UPPER EXTREMITY PROBLEMS, BUT NO PRESENT UPPER EXTREMITY SYMPTOMS  The doctor will perform a talking Orthopedic, Neurological and Chiropractic examination of the lower extremities and a talking minimal examination of the upper extremity, i.e.:


Bilateral Maximum Foramina Encroachment Test.

Palpation for Spasm and Edema.

If these upper extremity tests are negative, the doctor does not need to proceed further with tests to the upper extremity.

Fees for the preliminary examination of the upper extremity should be minimal or included in the lower extremity examination fee.


A physical examination may be performed at the same time as an Orthopedic, Neurological and Chiropractic examination.

Always examine the pain part.


The CA, according to her qualifications, may conduct the preliminary part of the examination (height, weight, blood pressure, etc.).

After she performs these duties, the CA will say: –

“The doctor will be with you shortly.”

The doctor enters the room and performs the talking Orthopedic, Neurological and Chiropractic examination, and perhaps a physical examination.


The doctor does not explain each test performed. –

He or she explains a series of tests or the examination of a system.

His or her explanations are no longer than 10 seconds.

44 

The Talking Examination: –

Builds the patient’s confidence in the doctor.

Changes the patient’s concept away from, “It’s only a crick in my back” to a “I’m really hurt” concept.

– 

Educates the patient as to what’s wrong with him/her.

The recommended verbiage is overly simplistic and not 100% anatomically accurate. –

This is not a doctor-to-doctor conversation.

The most effective way to communicate with your patients is to speak to them in terms that they can easily comprehend.


At the beginning of the exam, the doctor will say to the patient: –

“This is where a doctor does his/her detective work to see what is wrong with a patient. This is the fun part for a doctor.”

When performing spinal percussion, the doctor will say to the patient: –

“Now we are checking to see if any of your vertebrae have been injured or sprained.”

When a muscle spasm is found, the doctor will say to the patient: –

“You have a muscle spasm here.”

When palpating for edema, the doctor will say to the patient: –

“Now I’m checking to see if you have swelling around an injured joint.”

When edema is found at the spine, the doctor will say to the patient: –

“You have swelling here which indicates there is a bone out of place.”

When performing the range of motion tests, the doctor will say to the patient:

45 –

“Now I’m going to test the motion of your spine. If the joints of your neck/back have been damaged, you won’t be able to bend your neck/back as far as you should.”

When examining the nervous system, the doctor will say to the patient: –

“The body has various types of nerves: one controls your organs, one controls your skin, another controls your muscles. When you have a pinched nerve, it will show up in one of these nervous systems.”

When performing the pinwheel test, the doctor will say to the patient: –

“I am going to check the nerves that control the feeling of your skin to see if your skin sensitivity has been affected by a pinched nerve. If you have a pinched nerve, your skin will feel numb or overly sensitive.”

When checking muscle strength, the doctor will say to the patient: –

“I’m checking the strength of your muscles to see if the nerves that control muscle strength are partially paralyzed.”

When a problem is found, the doctor will say to the patient: –

“Here is your problem (or a part of your problem). I can fix that (if true).” 

Always tell the patient you can fix their problem, if true.

When a problem is not found, the doctor will say to the patient: –

“There is no problem with your ______. You don’t have to worry about that, i.e., the blood flow to your arm/leg (nerve flow) is okay, you don’t have to worry about that.”


Prior to palpating the trapezius muscles, the doctor will say: –

“I’m going to examine the muscles that start in your

46 shoulder and attach to the vertebra in your neck. If the muscles are painful, this will indicate these muscles have been injured. Please let me know if these areas are painful.” 

When examining the superior occipital nerves, the doctor will say: –

“I’m checking to see if the nerves going up over the back of your head are swollen. Do you hurt here?”

When examining the cervical ganglions, the doctor will say: –

“I am going to check the nerve centers on the side of your neck to see if they are injured.”

While performing the maximum foramina encroachment test, the doctor will say: –

“If the nerves at the bottom of your neck are swollen, this test will produce pain here and possibly produce pain going into your shoulder and down your arm. Please let me know if you feel any pain, numbness, tingling or electric-like feelings when I perform this test.”

Prior to testing the cervical flexors/extensors, and lateral flexor muscles, the doctor will say: –

“I’m going to test the muscles of your neck to see if they were injured by the accident/trauma/condition, etc. If the muscles are injured, they will be weak.”

When examining the cerebellum, the doctor will say: –

“We are testing the back of your brain which controls your coordination.”

When examining for a thoracic outlet syndrome , i.e., Adson’s, Allen’s and Wright’s test, the doctor will say: –

I am now checking to see if the blood flow into your arms and hands is being cut off by a muscle spasm in your shoulder area.”

47 When performing the biceps/triceps/brachioradialis reflexes, the doctor will say: –

“I’m now going to test the nerves that exit at the bottom of your neck and supply the muscles that bend your lower arm. If these nerves are pinched, they will cause a partial paralysis of these reflexes.”

When testing grip strength (dynamometer), the doctor will say: –

“I’m going to test the nerves that exit from the base of your neck and go down your arm into your hand. These nerves control your grip strength. If these nerves are pinched, it will cause a weakness in your grip strength.”

When checking for a carpal tunnel syndrome, i.e, thumb-little finger strength, Tinel’s and Phalen’s tests, the doctor will say: –

“I am checking to see if the nerves and blood vessels that go to your hand are pinched as they go through your wrists. This is called a carpal tunnel syndrome. You have heard of carpal tunnel syndrome, haven’t you?”

If weakness is found, the doctor will say to the patient: –

“The weakness of this hand indicates you have pressure on the nerve that goes through the wrist. This is a problem I can fix (if true).”


When performing the tripod test, the doctor will say: –

“This test tells me if the nerve going down the back of your leg is swollen. If you have a swollen nerve, this test will be painful. If you feel any pain, please tell me.”

When performing the patellar and Achilles reflexes, the doctor will say:

48 “I’m now going to check the nerves that exit at the bottom of your spine and control the muscles of your legs. If these nerves are pinched, they will cause a partial paralysis of the leg reflexes.”

When palpating the lower back muscles, the doctor will say: –

“I’m examining the muscles of your lower back. If the muscles are painful, this will indicate they’ve been injured. Please let me know if these areas are painful.”

When performing the Kemp test, the doctor will say: –

“If the nerves at the bottom of your spine are pinched, this test will produce pain here, and possibly produce pain going into your buttocks and legs. Please let me know if you feel any pain, numbness, tingling, electric-like feelings when I perform this test.”

When performing the toe walk, heel walk test, the doctor will say: –

“I’m checking the nerves that are affected when someone has a slipped disc.”

Prior to performing the forced leg lowering test, the doctor will say: –

“I’m going to test the muscles of your leg that are controlled by the nerves from your lower back. If you have a pinched nerve you will have one leg weaker than the other.”

When performing the Lasegue and Braggard test, the doctor will say: –

“I’m checking to see if the nerves going down the back of your legs are swollen. Tell me if your leg hurts when I raise it.”

Prior to performing the Sicard’s (big toe) test, the doctor will say: –

“I’m going to test the nerve that exits at the base of your spine and goes to your foot. This nerve controls the muscles that bend back your big toe. If the nerve is affected, the big toe will be weak. This is the number one test for a slipped disc.”

When performing the Gaenslen’s and Ely tests, the doctor will say:

49 –

“I’m going to perform a test that will tell me whether or not you have injured your sacroiliac joints. This test will produce discomfort at the sacroiliac joints. Please tell me where you feel any discomfort.


At the end of the examination, the doctor will check off the patient’s diagnosis(es) on the Diagnosis Code form and say to the patient: –

“I recommend we proceed with x-rays to find out what is causing your health problem, and to see if it can be helped with chiropractic care. Come with me.”


When the free exam is completed: –

The doctor sits on a chair or stool and with the patient seated on the exam table.

The doctor holds his/her hand up in front of the patient and says: 

“This is the end of your free examination. Let me explain what I have found.”

“But, before I tell you what I have found, I need you to sign this form. It simply says…” –

“You received the free examination.”

“The free examination ends here.”

“And, if you need any other examinations, tests or treatment, there will be a charge for them.”

50 

The patient signs the Free Exam form.

The doctor then proceeds to give the prospective patient a mini report describing what he/she has found … not what is wrong with the patient. –

“You have some weakness in this area ...”

“There is evidence of nerve injury here ...”

“The normal motion of the spine is affected here ...”

“There appears to be a curvature in this area ...”

“Mr. Jones, we have some definite indications of a spinal problem.”

“You have a nerve that is pinched in your spine. This nerve goes down your leg and is very swollen and painful. Remember when I raised your leg, etc. and it produced a lot of pain? The pain you felt is the nerve that is pinched. This pinch has also caused a partial paralysis of the nerves that control the sensitivity of the skin of your leg”, and/or “a weakness of the muscles of your leg”. (Or whatever the doctor found) etc!

The doctor should not tell the patient what might be causing his/her problem … because he/she doesn’t know yet.

It is important for the patient to understand the full scope of their health problem(s), and, the necessity for the doctor to perform further diagnostic tests, including any indicated x-rays, prior to making a final determination of what is causing the patient’s problem(s).

51 

The patient must totally understand when the “free examination” stops and when the fee-for-services, examinations, tests, or x-rays starts. –

This must be unquestionably clear. 

If not, the doctor could be accused of false advertising and face serious charges.

If the patient doesn’t accept x-rays and doesn’t become a patient, or the doctor doesn’t accept the patient, none of the questionnaires and necessary forms (except the Application for Treatment form) need to be filled out.

The doctor will state: “Let me give you some self-treatment advice that can help you relieve your (neck/back/etc.) problem.

Then tell the patient the proper use of ice/heat for their particular problem.


The doctor and CA are to say: –

“If your (health problem) ever gets worse and you need our help, please give us a call.”


The doctor will recommend x-rays at this point (if indicated).


“We now know you have a pinched nerve causing ________,

__________, _________, but we don’t know what’s pinching the nerve. In order to find out what’s pinching the nerve, we will need to take xrays and, of course, there is a charge for the x-rays. Would you like me to take the x-rays now?” 


“Yes.” (The doctor proceeds to take the x-rays.)


“ How much are the x-rays?” (The doctor tells them how much.)


“Would you like for me to take your x-rays now?”




52 At this point, the CA will take the patient to the x-ray room and prepare the xray marking system.

The doctor will adjust a patient during this time.


Always x-ray the patient’s pain part.

A.P. full spine x-rays are recommended because patients can relate better to this film than the smaller films.

Some doctors who do not have a full spine buckey or cassettes, substitute two 14x17 films (cervicothoracic and thoracolumbar) to make an A.P. 14x34 x-ray.

Lateral x-rays are always taken of an area to be treated.

X-rays are a diagnostic tool – not a money making tool. Only take necessary views.

Is it necessary to x-ray every patient? –

X-rayed elsewhere.

Transient patient.

Muscle injury.

HOW TO TAKE A FULL SPINE X-RAY USING TWO 14 x 17 CASSETTES (DIRECTIONS) 1. Glue a sewing tape onto the side of the x-ray tube stand that is facing you as you load and unload x-ray cassettes. 2.

Place a 14 x 17 x-ray in the x-ray tray of the Buckey.


Take the lumbar x-ray.


Before taking the cassette out of the cassette tray, determine where the top of the x-ray film is inside the cassette (usually ½ inch below the top of the cassette).


53 Then determine the inch or millimeter level on the sewing tape that is glued on the x-ray tube stand.


Place a new cassette into the x-ray tray.


Raise the Buckey until the bottom of the x-ray film in the x-ray cassette (usually ½ inch above the bottom of the cassette) is at the same inch or millimeter mark on the sewing tape that is on the tube stand.


The following scripts can be used by the doctor or a certified CA.

The CA would simply replace the “I”s with “the doctor”, where appropriate.

Prior to taking the x-rays, make hand gestures while saying to the patient: –

“I will be x-raying you from front-to-back and side-to-side. This way, I’ll be looking all around your spine. If there is anything wrong with your spine, I’ll find it.”


If the patient refuses to be x-rayed, determine the reason why.

Financial: 

If the patient states they don’t want x-rays because they have a financial problem, and the doctor is convinced they really do, it is better to take the xrays, absorb the cost and accept the patient.

54 Unnecessary: 

If the patient states he/she does not have a financial problem, but they do not think x-rays are necessary, the doctor should dismiss the patient.

This patient is questioning the integrity of the doctor and will never follow the doctor’s recommendations.



“Doctor, I had x-rays taken recently.”


“Where were your x-rays taken?”


“In the hospital.”


“Did they x-ray you lying down or in the standing position?”


“Lying down.”


“That may be the reason why the cause of your problem has not been found. It’s like a flat tire on your car. As long as the weight of the car is off the tire and on the jack, the tire will look normal. But it will look different with the weight of the car on the tire. Standing x-rays are better because they give a true picture of the stress factors on the spine.”


“I don’t want x-rays. They just took a whole set of x-rays down at the hospital.”


“Fine. Do you have them with you, we’ll use their x-rays.”




55 “Okay, then please go to the hospital and get your x-rays. I’ll be happy to review them and see if they took all the views I will need to fix your neck/back.”

Note: Hospitals and Imaging Centers usually don’t take weight bearing, flexion and extension, or oblique x-rays. The DC should take these missing x-rays. Or…


“Do I have to be x-rayed doctor? I’m under chiropractic care in my hometown and would just like some relief until I return home next week.”


“Do you have your x-rays with you?”

Or… 


“Do you have a copy of the x-ray findings or listings?”




“Mrs. Jones, we can do one of two things for you. I can call your doctor and get the necessary information from him/her or take new x-rays, treat you and forward the updated information to your doctor. What would you like me to do?”


“Doctor, I just want an adjustment. I don’t want x-rays and all the other stuff. I’ve been to a lot of chiropractors and I’ve always gotten adjusted without x-rays.”


“Mrs. Jones, the examination I have just conducted indicates a definite need for x-rays of your (body part). Mrs. Jones, the two most important things in this office is your health and my reputation. I will not jeopardize either one. Now, Mrs. Jones, what would you like to do?”

NOTE: After reviewing the patient’s x-rays, the doctor is add any new diagnosis(es) he/she arrives at to the Diagnosis Code form.



After the x-rays and while the patient is getting dressed, the CA gives the doctor the appropriate questionnaires and a urine sample container (if a lower back patient) in a white bag.

Family Health History (PGF91).

Cornell Health Questionnaire (Male - F116; Female - F115).


Traumatically Injured Patient Questionnaire (PGF300). (Eight Pages.)


Neck Pain Disability Index (PGF310).


Low Back Disability Questionnaire (PGF301).

After the patient is dressed, the doctor explains to him/her: S

“Mr./Mrs. Jones, I am going to develop and study your x-rays. I want to see you tomorrow and at that time, I’ll let you know exactly what I have found and whether or not I can help you.


In the meantime, I would like you to fill out these questionnaires for me. I know these questionnaires look rather imposing, but the questions are all very easy. It will take only a few minutes of your time to fill them out.” (The doctor reads a few easy questions from the questionnaires to show how easy they are.)


“Mrs. Jones, I appreciate your help in filling out these questionnaires. I can learn more about your health in 10 minutes with these questionnaires than I can in five hours of talking with you. And, the more I know about your health, the better my chances are of getting you well.


If you are not sure of an answer, ask your mother. Mothers never forget anything. Thanks for filling these out for me.


In this bag (a white bag) is a urine container. I would like your first morning sample so I can evaluate your kidney function.”

57 

At this point, the doctor reviews the patient’s fee slip and the services performed that day with the patient.

Using the “PLUS, IN ADDITION TO, AND” TECHNIQUE,” the doctor says to the patient: –

“Today we performed a consultation, plus an orthopedic exam, a neurological exam, a chiropractic exam, and physical exam.

In addition, we took two x-rays of your neck, one from the front, the other from the side, and a urine test...”

The doctor should not go over the fees for these services unless asked by the patient.

If the patient has responded to an offer of free services, the doctor will explain all the services rendered that day that were free or discounted (using the “PLUS, IN ADDITION TO, AND” TECHNIQUE”) and then explain the services in which there was a charge (x-ray, urine analysis, etc.), again using the “PLUS, IN ADDITION TO, AND” TECHNIQUE.”

At this point, the doctor encourages the patient to bring his/her spouse to the report-of-findings by saying: –

“Mr./Mrs. Jones, it is vitally important that your husband/wife be here for the report of my findings.

I’ll be explaining what I found on your x-rays (if applicable), and the results of your examination and urine test (if applicable), and it will be impossible for you to convey all that back to him/her. He/she really needs to be here to hear for him/herself what is wrong with you and what needs to be done in order to get you well.

I will also be teaching him/her some special treatment techniques that he/she can do to help you get well faster.

He/she may also have some questions or concerns regarding your health problem, and I’d like to be able to answer them for him/her.”

58 

The doctor closes by saying to the patient: –

“It’s been nice meeting you, Mr./Mrs. Jones. I certainly hope I can help you.”

The doctor then walks the patient to the front desk and returns the file with the fee slip to the CA for scheduling and financial arrangements.

NOTE: The CA does not accept the patient’s file back unless the Diagnosis Code form has been checked off by the doctor.

AT THE FRONT DESK THERE IS A PAYMENT POLICY SIGN “All Services Are To Be Paid On The Date Services Are Rendered”


When the doctor has walked the patient to the front desk: –

The CA will report her insurance confirmation to the patient.

The CA does not explain in detail what the patient’s insurance company told her.

The CA simply tells the patient that his/her insurance will pay for chiropractic care (if true).

If the patient has good assignable insurance, the CA will state: –

“The policy of this office is to collect for the initial diagnostic visits and 30% of subsequent visits.

We will accept assignment of your insurance coverage for chiropractic care.

59 –

If there is any balance due after your insurance company pays, you will be billed for the remainder.

If there is any overage when the insurance pays, we’ll be happy to credit your account or give you a refund. Fair enough?”

If the patient’s insurance deductible is over $200 and not yet met: –

The CA should accept insurance assignment and collect for the total services rendered until the deductible is satisfied.

After the full deductible has been paid, the CA would only need to collect 30% of the patient’s services.

When the patient has insurance coverage: –

The CA has the patient sign the necessary forms. 

Irrevocable Assignment, Lien, and Authorization - Insurance Benefits and Attorney form. –

This form is printed on the Fernandez Consulting file folder. If the doctor does not use the Fernandez Consulting file folder he/she should have the patient sign the “Master Assignment, Lien And Authorization Insurance Benefits And Attorney” form (PGF71).

All the Authorizations/Assignments on the standard CMS forms.

Power of Attorney to Endorse Checks form (PGF131).


Consent to Treatment of a Minor Child (PGF61), if applicable.

Authorization Agreement for Pre-arranged Payments Form (PGF141). –

This form authorizes you to charge the patient’s charge card for any balance the patient’s insurance company has not paid.

The patient is then instructed to bring a copy of their insurance policy to their next scheduled office visit.

If the patient is a member of a HMO or PPO in which the doctor participates, the CA states: –

“You are a member of ________ health plan in which you have a $25 co-pay per visit. Is this to be paid by cash, check or credit card?”

If this is a Workers’ Compensation injury: –

The CA will give the patient a Workers’ Compensation Treatment Authorization card (PGF81) to take to his employer for authorization.

The patient is required to return the signed Workers’ Compensation Treatment Authorization card (PGF81) on their next visit.

If the patient doesn’t want to use their insurance, the CA will say to him/her:

61 –

“You can pay by cash, check or credit card for each office visit. We’ll give you a receipt for the visit. You can then send your receipts to your insurance company for reimbursement.”


Then the CA will state the fees: –

The CA always starts the collection verbiage by reiterating to the patient all of the services he/she received that day, using the “PLUS, IN ADDITION TO, AND” TECHNIQUE.”

If x-rays have been taken, the CA will include a brief description of the views taken and then ends the sentence with the fees.

When stating the patient’s fees, the CA always says, “Your fee”, never “Our fees, or Our charges, etc.”

He/she also never adds the word, “dollars” to the fee. The patient’s fee should be stated as, “Your fee for today is 85”, not “Your fee for today is 85 dollars.” –

“Today, Dr. Fernandez provided you with a consultation, an orthopedic examination, plus a neurological examination, and a chiropractic examination, in addition to, a urine analysis and two x-rays, one from the front, plus one from the side. Your fee for today is 85.”

NOTE: The reason both the doctor and the CA review the patient’s fee slip using the “PLUS, IN ADDITION TO, AND” TECHNIQUE,” is to remind the patient, and to create an emphasis on, all the services that the patient received that day. –

By doing so, the patient will be far more acceptable of your fee.

The CA collects the total amount due for this visit. –

The amount due will depend on the patient’s insurance coverage, and whether the patient’s insurance deductible has been met.

62 –

If the patient is covered by insurance that pays 100%, i.e., some accident insurances, Workers’ Compensation, etc., the amount due for the visit is zero.

Having stated the fee, the CA will then say to the patient: –

“Is this to be paid by cash, check or credit card?”

The CA then looks down and immediately begins writing the receipt.

The CA acts as if she has no doubt the patient is expecting to pay and is prepared to do so.

The CA never asks a patient, “Do you want to pay?” –

The CA never asks, “How do you want to pay?” –

They’ll answer, “Hell, no!” They’ll respond, “Bill me.”

NOTE: If the first office visit is too expensive for a cash-paying patient, you can discount your fees 10 – 15% for a “point of service” bookkeeping savings. The CA should say: –

“The doctor has extended to you a courtesy on your x-rays. Normally these x-rays would be ______, but for you, Dr. Fernandez said your x-rays would only be ______.”



“I didn’t bring enough money with me today.”


“ That’s okay. You can bring the balance with you on your next visit. How much can you pay today?

Or… 


“If you have a charge card, we do accept them.”


“I forgot my checkbook.”


“That’s okay, here’s a blank check that will help you out this time.” 

NOTE: Call your bank to find out about the legality of counter checks in your state.

63 


“I didn’t bring any money today.”


“That’s alright. You can pay up when you come in for your next visit.”


“That seems like an awful lot of money.”


“Yes, it may seem that way, but obviously you have a lot of problems!”

The CA reserves the patient’s time with the doctor for the report-offindings. –

The CA schedules the patient and his/her spouse for the report-offindings during an opening between the doctor’s treatment clusters.

If the patient’s spouse cannot make an appointment for the report-offindings during regular office hours, the CA schedules the report for 8 am or 6 pm (before or after treatment hours). 

The doctor will give the report-of-findings at that time.

The CA then records all charges and payments.

If the doctor uses a pegboard system in conjunction with the Fernandez Consulting appointment book, the CA will simultaneously record the charges and payments on the daily control sheet, the patient’s ledger card, and a deposit slip.

The CA gives the patient the second copy of the fee slip (or pegboard receipt) as a receipt for payment of the services rendered that day.

NOTE: If your office doesn’t use a fee slip system, only give out pegboard receipts when requested.

NOTE: Never utilize a straight “pegboard” system that fills out a receipt on each patient, regardless of whether or not the patient pays or charges their services. The pegboard receipts are too expensive.

The CA closes by saying: –

“Mrs. Jones, it’s been good meeting you and I am looking forward to seeing you tomorrow. I hope Dr. Fernandez can help you.”

After the patient leaves:

64 –

The CA circles the new patient checklist items on the patient’s file when completed.

The doctor must check to make sure these items are completed.

The CA places the referrer’s name (if the new patient is a referred patient) on the referral board in the office hallway.

The CA puts the patient’s file and x-rays on the doctor’s desk for his/her review prior to the end of day.


Sometimes, a one-day procedure is divided into morning and afternoon appointments. In this case, the patient brings back all requested questionnaires on their afternoon visit.



The CA enthusiastically greets the patient and shakes his/her hand when the patient enters the office.

If the CA happens to be busy somewhere else in the office when the patient enters, she is to cease doing what she is doing, excuse herself, and immediately walk to the reception room to welcome the patient. –


“Good (morning/afternoon), Mr./Mrs. ________________.

It’s good to see you again.” 

The CA then instructs the patient how to check-in at your office: –

The patient is to sign-in on a fee slip and date it on every visit.

Offices not using a fee slip must use a patient sign-in form (PGF151.) 

Sign-in sheets are not recommended, as they may violate patient confidentiality (HIPAA).

66 The patient is to complete the upper portion of the Symptoms Update form (PGF181). 

The CA teaches the patient to use detail when answering the questions on the form, circle his/her pain areas on the pain-man drawing, and then sign and date the form.

The CA collects from the patient: –

The Cornell Health Questionnaire (Male: F116 - Female: F115).

Family Health History Questionnaire (PGF91).

Traumatically Injured Patient Questionnaire (PGF300).

Neck Pain Disability Index (PGF310).


Low Back Disability Index (PGF301).

Worker’s Compensation Treatment Authorization card (PGF81).

Urine samples.

The patient’s insurance policy.

The CA reads the patient’s insurance policy to determine if there are any limitations or exclusions that were not mentioned by the insurance company. Or…

Photocopy the pertinent portions of the patient’s insurance policy for later review.

The CA then attaches the fee slip and the Symptoms Update form (PGF181) to the patient’s file folder or travel card.

The forms, file folder/travel card, and questionnaires are then placed outside the report-of-findings room door in an appropriate holder.

NOTE: Be sure to use opaque holders and place the patient’s file in the holder so that the patient’s name faces the wall (HIPAA).

68 

The CA tidies up the report-of-findings room and places the patient’s x-rays on the unlighted view boxes.

The CA escorts the patient and their spouse to the report-of-findings room, where she seats them. –

CA: “Mrs. Jones, Dr. ____________ will be with you shortly.”


Doctors who pre-plan their report-of-findings achieve a higher acceptance percentage, and a higher office visit average.

By pre-planning the report-of-findings, the doctor avoids forgetting to address some of the corrections to be made.

REMEMBER: It is the doctor’s responsibility to tell the patient what they need to do to get well — not to tell the patient simply what he/she wants to hear.

When pre-planning for the report-of-findings, the doctor will review the following patient information: –

Application for Treatment Form (F1025A).

Fernandez Consulting C/O/N Examination form (F1557).

Family Health History Questionnaire (PGF91).

Cornell Health Questionnaire (Male: F116 - Female: F115).

Traumatically Injured Patient questionnaire (PGF300)


Fernandez Consulting Condition/Treatment Chart (PGF390) to determine the customary therapies and length of time necessary to treat the patient’s health problem.



The doctor completes a Treatment Plan Worksheet (F1055).


THE REPORT-OF-FINDINGS The Doctor Greets the Patient and Meets the Spouse: 


“Mrs. Jones, nice to see you again, and this is Mr. Jones?” (The

doctor greets the patient and her spouse, and shakes their hands.) 


“Thank you Mr. Jones, for taking time to be here today with your wife. I appreciate you coming in.”

The Doctor is Seated and Reports to the Patient: 


“Mrs. Jones, I have identified the underlying cause of your problem, and based on my experience with similar cases, I believe I can help you.”

(A new practitioner should say: “I have identified the underlying cause of your problem and I believe I can help you.)

The Doctor Reviews The Patient’s Symptoms, Cornell Health Questionnaire, Family Health History and PI Questionnaire (if used): 


“Let’s make sure we have this right. Mrs. Jones, you came in with _________ which you had for __________ which was caused by _______________ of which you had already been to ___________ which was still __________________ (getting worse).”

The Doctor Reviews the Patient’s Examination Findings (Physical, Orthopedic, Neurological, etc.): 


“Mrs. Jones, let me go over the results of your examination with you.”

71 The Doctor then illustrates the Patient’s Health Problems using Wall Charts or Neuropatholators with Patient and Spouse: 

The doctor stands and asks the patient and spouse to join him at the charts.


“Mrs. Jones, let me explain a little about the human body.”

The Doctor Identifies the Patient’s X-rays and Identifies the Patient’s Spinal Problem: 

The doctor points to the patient’s x-ray, and: –

Familiarizes the patient with the anatomy shown on the x-ray.

Reviews the good things he/she sees on the x-ray film.

Identifies the patient’s spinal problem.


“Mrs. Jones, we are looking at your body from the back. This is your right shoulder, etc. I find no signs of arthritis, no fractures, etc. Mrs. Jones, this is your problem (pinched nerves, subluxation, disc thinning, etc.).”

The Doctor Ties the Patient’s Problem Shown on the X-ray to the Gonstead Chart, Neuropatholators, Model Spine, Ciba Manual and Wall Charts: 


“Mrs. Jones, this is your problem area. Let me explain your health problem by using these charts/models so you can better understand your problem.”

The Doctor Explains the Cause of the Patient’s Health Problem — (Trauma, Congenital, Accident, etc.): 


“Mrs. Jones, this health problem is the result of the fall you had two weeks ago.”

OR 


“Mrs. Jones, in my opinion, your health problem is a result of the auto accident you had several years ago.”


72 


“Mrs. Jones, the numbness in your hand is the result of a pinched nerve in your neck.”

It is the doctor’s responsibility to make sure his/her patients understand their problems, including what may happen if they quit care prematurely.

The Doctor Explains the Predictable Progression of this Patient’s Health Problem that Will Occur Without Proper Care (Consequences): 


“Mrs. Jones, your spine is in the second phase of spinal degeneration. In the first phase, the discs between the vertebrae swell up. This has already occurred. In the second phase, the disc thins out, which you can see has already happened. Unfortunately, the spine will then progress to ____ unless proper care is give, etc.”

The Doctor Prepares the Patient for His/Her Treatment Recommendations: 


“Mrs. Jones, please be seated for my recommendations.”

OR 


“Mrs. Jones, if you’re looking for temporary relief, pain pills or relaxants may help. However, if you’re sincerely interested in getting this health problem under control, then I can help as your health problem is within my area of specialty.”


“My objective, Mrs. Jones, is to relieve your pain and to stop and reverse your disc damage, or, to control and stabilize your health problem.”

The Doctor Makes Treatment Recommendations: 

As the doctor makes his/her recommendations, he/she writes them down on the patient’s file folder or adjusting card.


“Considering the duration and intensity of your health

73 problem, I am recommending a 90 day (6 weeks, 3 months, or whatever the doctor deems necessary) treatment program. I will be treating you daily for two weeks in the beginning, tapering off as quickly as possible.” The Doctor Gets The Patient To Commit: If the patient is in severe pain, 


“Is there any reason why you can’t come in every day this week and next?”

Or… 


“Mrs. Jones, is there any reason why you can’t come in three times a week for the next four weeks?”

Or… 


“Mrs. Jones, is there any reason why you will not be able to come in for all the visits I have outlined for you?”

Or… 




“Good, because that is my recommended treatment schedule to get the maximum results with your (health) problem.”

The doctor designs the patient’s multiple appointment schedule and the initial frequency of treatment with the goal of doing the most good for the patient, as quickly as possible. –

This usually means intensive daily care during the initial phase of treatment, and a decrease in frequency of treatment as determined by on-going re-evaluations.

The Doctor Explains the Therapy the Patient will Receive: 


“Let me explain what’s going to happen when you come to my office each visit. First of all, you’ll spend a few minutes with me as I find and fix your subluxations (misalignments). But, you’ll be

74 here longer than a few minutes because after you are treated (adjusted) by me, you’ll receive therapy (exercise instructions) etc., that will take at least 30 minutes. So please plan on 30 to 40 minutes of care each time you come in.” 


“You’ll also be receiving... Nutritional care (if necessary). Cervical collars, supports, etc. (if necessary). Comparative exams and x-rays. And, you must attend the Spinal Care class that my CA will register you for when you check out today.”

Explain Progress Examinations: 


“I will be making periodic Progress examinations to determine any necessary adjustments to your treatments or scheduling in order to achieve maximum results.”

Explain the Spinal Care Class: 


“Do you want to know how to get the most benefits from your care?”




“Good! I have a Spinal Care class to teach my patients what they need to know in order for them to get better as quickly as possible and to maintain their spinal health after their treatment program is finished.”

Invite the Spouse: 


“I expect both you and your husband/wife be there because I’m going to show him/her special treatment techniques to do for you at home that will help relieve your pain and get you well faster. I’m also going to show you how to painlessly get out of

75 bed and out of a chair, and I’ll need your husband/wife to help you with these procedures. In order for you and your husband/wife to learn exactly how to perform these procedures, I need both of you to attend this class. OK?” Financial Close, If Medicare: 


“Oh, I see you have Medicare insurance. I want you to know that Medicare is very good, inexpensive insurance. You can expect it to pay about 40% of your bill, with you being responsible for the rest.”


“Oh no, doctor, Medicare pays 80%.”


“No, let me explain. Medicare pays 80% of the services they want to pay for at prices that were charged back in the 70's. Realistically, they are only going to pay about 40% of your bill.”

Put the Blame Where It’s Due: 


“I don’t know why they treat our senior citizens this way. You have been putting money into the Medicare system your entire life, so that when you retired your healthcare needs would be taken care of. But every year, Medicare seems to pay less and less of patients’ bills. I don’t know why they treat our mothers and fathers this way. You deserve to have at least 80% of your bill paid. But, unfortunately, the government will only pay about 40%. Please don’t be shocked when they only pay 40%.”

If you do not follow this procedure, when Medicare only pays 40% of their bill and places nasty comments on their rejection slip (EOB) like, “doctor is overutilizing,” “doctor is over-treating,” your patient will be upset with you, and you will lose your patient and their referrals.

The patient needs to understand that Medicare is extremely good, inexpensive insurance, however, it is not designed to take care of non-life

76 threatening problems. It is designed to take care of catastrophic problems, i.e., kidney transplants, heart surgery, extensive hospitalizations, etc. Unfortunately, patients have to pay a larger portion of their bill for less serious problems. Financial Close By the Doctor If the Patient Doesn’t Have Insurance – Case Fee Presentation Only: 


“You may pay 50% now, 25% in 30 days and the balance in 60 days. If you wish to pay for these services at this time, you will receive a 10% (or 15%) bookkeeping savings of $225 — and we pass this savings on to you, leaving the amount due of 1275.”

Financial Close by the Receptionist, if the Patient Doesn’t have Insurance Coverage: 


“Mrs./Mr. __________, in your case, the doctor has recommended a 90 day total care program. The fee quoted will include all services from this time to the end of the 90 day period. This will include all therapies, adjustments, examinations, comparative X-rays, supplements, etc. The fee for these services is (have the figures completed before the report and use rounded figures for less confusion): 1500 for which you may pay 50% now, 25% in 30 days and the balance in 60 days. If you wish to pay for these services at this time, you will receive a (10-15%) bookkeeping savings of 225 – and we pass this savings on to you, leaving the amount due of 1275.”

Financial Close by the Receptionist or the Doctor, if the Patient has Insurance Coverage: 

DR or CA:

“I see you have insurance coverage. You have paid for your initial diagnostic visits, so from this point forward you will only need to pay 30% of each office visit. We will bill

77 your insurance company and if there is a balance due after they pay us, we will bill you for the remainder. If they pay us more than your balance due, the overage will be credited to your account or refunded to you. Fair enough?” If the patient has a HMO or PPO Insurance Plan: 


“I see you have insurance coverage. From this point forward, you will only have to pay your $20 (or whatever) co-pay each visit.”

Financial Close, by the Doctor or CA, if the Patient Doesn’t have Insurance and Wants to Pay by the Visit: 


DR or CA:

“Can I pay as I go along?” “Mrs. Jones, if you prefer, you may pay for our services as they are rendered on a daily basis. Fair enough?”

Recap of Money Options for the Cash Paying Patient: 

Do not confuse the patient by offering too many options at once.

Offer the two most favorable options first - prepay and receive a bookkeeping savings, or pay the full amount in 3 payments (50/25/25). –

If the patient cannot do either of the first 2 payment options, the CA will offer the by-the-visit plan.

If the patient appears destitute and asks for a discount, the CA should ask them how much they can afford to pay per week and then discuss the patient’s financial situation with the doctor.

The CA will note the financial agreement in the financial box in the upper right hand corner of the Fernandez Consulting Patient File Folder (Regular: F1195 - Lateral: F1205). 

The CA does this in full view of the patient.

78 Additional Payment Options: 

Bank loan for the patient.

Credit cards.

Pay each visit.

Assistance from family, friends, church, etc.

The doctor should not begin treating a patient until all financial arrangements have been made.

Pre-Payment Rules: 

If the patient pays in advance” or the “50%, 25%, 25%” plan, the doctor should open a separate checking account, a trust account, for those payments.

At the end of each month, the doctor withdraws the amount of money to pay for his/her services provided to those patients for that month.



“I know I need the treatments, but I can’t afford them.”


“Mrs. Jones, you have two problems, one is your health problem, and I can help you with that because this is my specialty. Your second problem Mrs. Jones is a financial problem. I cannot help you with that. However, we have several options that our patients can take advantage of to help them pay for their care.”


“Doctor, that seems like an awful lot of money!”


“Mrs. Jones, you have a lot of problems. I can assure you of one thing, it will never cost less than it does right now. Had you come in sooner, it may have required less treatment, but if it is ignored for any longer period of time, it could cost much more.”

79 


“Do you think all this treatment is necessary?”


“Mrs. Jones, the treatment I’ve recommended is what you need in order to get as well as possible, as soon as possible. If you do not receive this care as prescribed, your problem could take much longer to improve, could get worse or even reach a state of permanent impairment.”


“Can’t you give me just a few adjustments and see how it goes?”


“If you are looking for temporary relief, I can do that for you. However, I believe your condition is much too severe to be treated that way. What would you like to do Mrs. Jones?”


“Doctor, I’ve had x-rays recently. Why didn’t my family doctor find this problem?”


“Because I have examined your case using a very specialized approach. I am a spinal structural specialist and your condition falls under my specialty.”


“Doctor, I can’t really afford this treatment program.”


“Mrs. Jones, is it really a problem of money, or not wanting the care?” If it is really a money problem, try to work out financial options with the patient. If it is not a money problem, the patient did not understand the seriousness of their problem or did not believe the doctor. Re-report the patient.


“Doctor, will you guarantee your care will correct my problem?”


“Mrs. Jones, I guarantee I’ll do my very best job to get you well. Now, will you guarantee me that you’ll follow my recommendations and do exactly as I advise?” (Wait for the patient’s response.)

80 


“Doctor, can I pay as I go?”


“Yes, Mrs. Jones, you can. However, that is not what I recommend, let me explain why. So many times when patients say they want to pay as they go, as soon as they start feeling better they stop coming in for treatment, making it impossible for me to take care of their health problem the way it should be. Now, is that what you have in mind Mrs. Jones?” (Wait for response.)


“No, not at all doctor. I just can’t come up with $1000 all at once, or even 50% of it. But I could pay for each office visit.”


“I believe you’re serious about getting well Mrs. Jones, so I will tell Mary at the front desk you will pay for your service as it’s rendered.”


“Doctor, I’d like to get another opinion.”


“Mrs. Jones, according to your case history, you told me you were seen by your family physician, he in turn referred you to an orthopedist, and I believe you were then seen and x-rayed by a neurologist. Mrs. Jones, that’s a lot of opinions. Don’t you think it’s time for you to get serious about fixing your (health problem)?” If the patient has not been seen by other doctors: “Mrs. Jones, I would happy to refer you to a qualified chiropractic orthopedist, as this is a chiropractic problem.”


“Doctor, I’d like to go home and think about it. Would that be all right?”


“Mrs. Jones, what is there to think about?” (The doctor may need to give a mini-report.)

81 


“Doctor, I can’t come in Monday, Wednesday and Friday. I work for the airlines and I’m out of town four days in a row.”


“In your case, we will intensify your treatment program. We will treat you each day you’re in town until we have your (health problem) under control.”

Once the doctor recommends a treatment frequency and the doctor or CA discusses financial arrangements with the patient, he/she records the treatment frequency for the initial ten (10) visits and the financial arrangements, on the patient’s file/treatment card.

Doctors Post Report-of-Findings Procedure 

The doctor dictates a report to the patient’s family doctor, describing the patient’s symptoms, exam findings, diagnosis and treatment plan, and asks the doctor if he/she has any input that he/she feels may be helpful in getting his or her patient well, faster.


The CA escorts the patient to the “jump seats” outside of the adjusting room.


“Mrs. Jones, please have a seat right here. As soon as Dr. Fernandez treats Mrs. Brown (the patient in the adjusting room), he’ll be with you.”


A number of chairs (jump seats) are lined up along the wall immediately outside an adjusting room.

Patients are escorted to these chairs and asked to sit in the next available seat closest to the adjusting room door.

82 

The doctor ushers the patient from the chair closest to the door, into the adjusting room while telling the next patient in line: –


“Mrs. Jones, I’ll be with you shortly or I’ll be with you as soon as I adjust Mrs. Brown.”

The doctor will say this loud enough for Mrs. Brown to hear, so that she knows there is another patient waiting.

When the doctor has finished adjusting Mrs. Brown and is leaving the adjusting room, he/she will say to Mrs. Jones (the next patient in line), and loud enough for Mrs. Brown to hear: –


“Mrs. Jones you can step into the adjusting room as soon as Mrs. Brown comes out.”

Mrs. Brown (the patient in the adjusting room) will not waste time getting changed and getting out.

As soon as the CA sees an empty chair, she calls the next patient to fill the “jump seat.”

Jump Seats: –

Speeds up office visits.

Maximizes productivity of the doctor’s time.

Allows the doctor to never have to “wait” for his/her next patient because the next patient is ready and waiting at the door.

Spreads waiting patients throughout the office.


Makes a good “storage spot” for patients who receive one service and then have to wait for another.


Do not hurt a patient when giving an adjustment.

If you have a choice of taking three visits to relieve a patient’s pain, or to give the patient one potentially painful adjustment (even if slight) to relieve their pain, choose the three-days.

83 

Patients come to you to get rid of their pain, not to be placed in additional pain.


It is important that the doctor explain: –

The sensations the patient might feel during an adjustment.

The sensations or soreness the patient might notice following their first adjustment.

After the adjustment, the patient is taken to the therapy suite for therapy and placed in a jump seat outside the therapy suite.


The therapy suite should have an open area for treating fully dressed patients using unattended therapies, i.e., diathermy.

It should have an area for providing patients with therapies requiring privacy, i.e., ultrasound, interferential, ice, moist heat, galvanic, etc. –

Use ceiling hung hospital curtains to section this area off from the rest of the therapy suite and to also separate the individual patients within the private therapy area.

When the private therapy area is not in use, the curtains should be pulled back to make the therapy suite appear larger.

Only have a patient undress in a private therapy area.

The therapy suite is to always be attended by a qualified therapist.

A patient’s modesty should be considered at all times. –

Always cover female patient’s legs with a towel when she is receiving traction.

The therapist is to initial the service he/she provides.


It’s a great storage spot for patients.

Strange as it may seem, patients that state they are in a big hurry to get in and out of your office will gladly spend an hour talking in the therapy suite.

It keeps the cost of therapy equipment to a minimum, i.e., –

One intersegmental traction machine can treat 40 patients per day in a therapy suite, whereas only 20 patients a day can be treated by that same therapy if used in an adjusting room.

Less staff is needed. –

One CA can care for 50 patients a day in a therapy suite, whereas one CA can only care for 30 patients per day when therapy is used in adjusting/therapy rooms.

Costs less cost to construct.

Increases referrals.


The CA, after the report-of-findings and after each 10 visits, sets up a schedule (both day and time) for a predetermined number of appointments in the future (minimum of 10).

The advantages to advance multiple appointment scheduling are: –

It makes it clear to the patient that his/his problem cannot be fixed overnight.

It allows the doctor to pre-plan when the patient should be reexamined.

It allows the patient to pre-plan their schedule.

85 –

Prevents drastic and potentially crippling fluctuations in a doctor’s practice.

The patient’s first multiple visit schedule is given to the CA by the doctor immediately following the report-of-findings.

The doctor confirms the next office visit with the patient and then escorts the patient from the adjusting room or therapy room to the front desk.

The doctor carries the patient’s file and attached fee slip, hands them to the CA and tells the CA (in front of the patient) the treatment frequency and agreed upon financial arrangements.


The doctor asks the CA to make an appointment for the patient to attend the next Spinal Care Class.

The doctor says to the patient: –


“Mrs. Jones, I’ll see you again tomorrow (or whenever the patient’s next appointment is).”

The CA schedules the patient for the next Spinal Care Class.


The CA tells the patient that the doctor wants the patient to reserve time for his/her appointments. –


“Mrs. Jones, Dr. Fernandez wants to reserve time for your appointments. Would you prefer morning or afternoon?


“Mornings work best for me.”


“The doctor has time available at ______ or ______. Which would you prefer?”

Always give the patient a choice of two options when scheduling appointments, i.e., morning or afternoon, early or late, 3 p.m. or 4 p.m., etc.

The CA only schedules the patient’s next appointment, writes it on an appointment card and gives it to the patient.

86 When the CA gets a break in her patient schedule, she completes a Multiple Appointment Card (F010A) for the remaining 9 appointments.

When the CA has a break in her schedule, she enters these appointments in the appointment book and schedules a Progress examination for the patient’s 10th visit.

Two days after a patient’s report-of-findings, the doctor is to ask the CA to show him the patient’s 10th visit Progress examination in the appointment book. –

By doing so, the doctor is assured that this procedure is being conscientiously followed.

Once the CA has completed the patient’s Multiple Appointment card and scheduled the appointments, she staples the top NCR copy of the Multiple Appointment card to the inside of the patient’s file folder or to the patient’s travel card.

The patient will be given the hard copy of the Multiple Appointment card on his/her next visit.


The CA then reviews the financial arrangements with the patient.

If the doctor has already made the financial arrangements with the patient, the CA will say:

Insurance Patients: 


“Dr. Fernandez and you have agreed that you will pay for your care in the following manner. You have paid for your initial diagnostic visits (deductible, etc.), so from this point forward you will pay 30% (or the co-pay) of each office visit. We will bill your insurance company and if there is a balance due after they pay us, we will bill you for the remainder. If they pay us more than

87 your balance due, the overage will be credited to your account or refunded to you. Fair enough?” Cash Patients: 


“Dr. Fernandez and you have agreed that you will pre-pay for your entire recommended care and receive a 15% bookkeeping savings.”


“Dr. Fernandez and you have agreed that you will pay for your recommended care in three payments - 50% now, 25% in 30 days and 25% in 60 days.”


Dr. Fernandez and you have agreed that you will pay for your recommended care on each visit. Payment is due at the time services are rendered.”

If the patient has a balance due, the CA will address it now. –


“Mr. Jones, all fees for your services are due the day your services are rendered. Your fee for today is 45, and you have a previous balance of 15 for a total of 60. Will you take care of that by cash or check? Or, you can put it on your Master Card.”


Never let cash patients run up large balances. 

A patient faced with a large balance builds resentment towards the doctor quits care, doesn’t refer and spreads his/her resentment to others.

A significant percentage of malpractice cases stem from doctors trying to collect patient balances.


The CA totals the patient’s fee slip and transfers this total to the: –

Charge column of the Fernandez Consulting Appointment Book (X157, X257, X357, X457).

The Fernandez Consulting File Folder (Regular: F1195 - Lateral: F1205).

The patient’s account ledger.

The patient’s new balance due is determined.

The CA writes the next appointment date on the fee slip and in the appointment book.

The CA distributes the copies of the fee slip: –

The top copy (the original and most legible) going to the insurance department.

The second copy going to: 

The cash-paying patient when payment has been made.

The patient who has paid for a treatment plan.

The insurance CA enters the data from the top copy of the fee slip into the office computer.

The fee slips are stapled together with the date marked boldly on the back of the last copy with a felt marker.

The fee slips are then put in storage and kept as part of the office’s permanent records.



“I’ll see you tomorrow, Mrs. Jones.”


The CA sends out: –

A “Welcome to Our Office” letter to the patient.

89 –

A “Thank You For Referring” letter to the person who referred the patient.

The CA places: –

A post-it note on the referrer’s travel card or File Folder (Regular: F1195 - Lateral: F1205) to remind the doctor to personally thank the referrer. 

The post-it note would simply say, “Mr. Smith referred Mrs. Jones.”

The patient’s name and telephone number on the PIP sheet for the doctor to call and find out how the patient is doing after their first adjustment.

The referrer’s name and telephone number on the PIP (Patient In Pain) telephone call sheet (PGF420) for the doctor to call the referrer with a personal thank you.

The referrer’s name on the Referral Board.


If the doctor forgets to schedule multiple appointments: –

The CA should ask the doctor for the patient’s treatment schedule.

If a patient does not want to schedule multiple appointments: –

The CA impresses upon the patient the importance of selecting a schedule that they can commit to, as the doctor has asked that the time be reserved for them.

If a patient does not commit to a financial arrangement:

Let him/her consider the options and let you know what they have decided on his/her next visit. –

Every patient must commit to a financial arrangement by his/her third visit.



The CA collects for visit #2.

The CA gives the patient the second copy of the fee slip as a payment receipt. The first copy goes to the insurance CA for posting and to be filed in permanent records.

The CA makes one appointment for visit #3, which is the report-of-findings visit of the three-day procedure.

Multiple appointments will be prescribed at the end of the third visit.

Free Exam and Test Adjustment Procedures 

Follow the same procedures as described.


Have an “Appointment Only” office.

If a patient arrives on time for his/her appointment but an unscheduled patient, or a patient with a later time has arrived just before him/her, be sure to take care of your patients according to their scheduled time.

Do not take patients on a first-come, first-serve basis, and take care of your drop-in patients in a manner that does not interfere with your scheduled patient’s time.

An office that respects a patient’s appointment time, earns the patient’s respect for their appointment time in return. –

This greatly reduces the number of missed appointments.

Typical Daily Visit Procedures: –

The CA enthusiastically greets the patient as the patient enters the office, and shakes the patient’s hand.

91 –

The CA then has the patient sign in on a fee slip and date it. 

Or, the patient signs a Sign-In Form (PGF151.)

Patient signatures and dates are needed to verify the patient’s visit(s) to your office.

The CA instructs the patient to complete the patient section of a Symptoms Update Form (PGF181), circle the pain areas on the painman drawing, sign and date the form. 

The CA explains to the patient that it is important for him/her to describe his/her symptoms in detail and not use answers like “fine” or “ok”.

The more specific the information the doctor has, the quicker the doctor can get the patient well.

NOTE: If the patient writes “OK” or “fine”, the insurance company can immediately de-authorize care.

The CA asks the patient to have a seat, then transfers the following information to the patient’s fee slip: 

Diagnostic Codes.

The next scheduled appointment (as recorded on the file copy of the patient’s Multiple Appointment Card).

The CA attaches the fee slip/super bill (PGF350) and the Symptoms Update form (PGF181) to the patient’s file folder or travel card.

The CA makes sure the Diagnosis Code List is in the patient’s file folder.

The CA then places the patient’s file folder/travel card in the spot at the front desk that has been designated for files/travel cards of patients currently waiting in the reception room. 

These files/cards are in order of the patient’s appointment times.

92 

NOTE: This designated area must be located where patients will NOT be able to read another patient(s) name on a file folder or travel card.

The doctor picks up the patient file/travel card from this area when he/she is ready to see the next patient. 

Or, the CA places the patient’s file folder/travel card in a holder outside the treatment/exam room door in which the patient is placed.

The CA escorts the patient to the adjusting room in smaller practices, and directs patients to the adjusting room in larger practices.


The doctor enters the adjusting room, smiles, looks the patient in the eye, and says: –


“Mrs. Jones, good to see you today.”

STEP #2: 

The doctor glances at the fee slip, noting his previous diagnosis and the next scheduled appointment.

STEP #3: 

The doctor uses the following script to cover all pertinent points of an office visit in an orderly and efficient manner. –


“How is your (health problem) today?”



STEP #4: 


“Let’s find it.”

93 The doctor performs range-of-motion and palpation examinations, etc. to find the subluxation(s).

STEP #5: 


“I found it.”

STEP #6: 

The doctor reaffirms the patient’s pain. –

The doctor gently presses on the area of complaint to verify that the patient’s problem area is still painful.


“Your (neck/back) is better, however, your problem is still there. Can you feel it (as the doctor gently palpates the pain part)?

The doctor reaffirms the pinched nerve. –


“Remember, when I showed you your x-rays and told you about your pinched nerve? The nerve is getting better, but it’s still sore, isn’t it? You can feel it, can’t you?”

STEP #7: 


“Let’s fix it.”

The doctor adjusts the patient.

STEP #8: 

DR: “I fixed it.” –

The doctor tells the patient he/she has set the vertebra back in place.

STEP #9: 

The doctor performs a regimen. –


“This bone was out of place pinching the nerve to….”

94 STEP #10: 

The doctor tells the patient how they will respond to his/her adjustment. –


Here’s what you can expect ......”

STEP #11: 

The doctor explains the changes the patient should make in his/her activities of daily living, in order for the patient to get well as quickly as possible. –


“Here’s what you can do to help me get you well ......”

STEP #12: 

The doctor writes his daily visit notes on the top portion of the Symptoms Update form (PGF181) and fills in the rest of the form.

If a new health problem arises for one visit only, the doctor will determine the diagnosis and note it in the “New Diagnosis” space on the fee slip.

If a new health problem arises and will require on-going treatment, the new diagnosis is circled or otherwise noted to tell the CA that this is a new and permanent diagnosis, and should be used along with the previous diagnosis from that point forward.

STEP #13: 

The doctor re-affirms the patient’s next office visit.

The doctor looks the patient in the eye and says: –


“Don’t forget, you need to see me on (the next

appointment).” –

If the patient’s eyes waiver, he/she does not intend to keep the next appointment.

The doctor impresses upon the patient how important it is to follow his/her prescribed plan of treatment, and to get the patient to understand the potential, and possibly permanent health risks if he/she chooses not to.


STEP #14: 

The doctor checks off the services listed on the fee slip that he/she has performed, and: –

Gives the fee slip and file folder/travel card to the patient to take to the front desk.

Or… –

Carries it to the front desk and picks up the next patient’s file folder/travel card.

Or… 

The doctor directs the patient to the therapy suite. –

The doctor gives the file folder/travel card to the patient for them to take it to the therapy suite “jump seats.”


The CA totals the fee slip, and transfers this total to the charge column of the file folder and appointment book.

The CA collects for that visit, and for any previous balance due from cash paying patients or amounts due from insurance patients when an insurance claim has been denied, or the insurance company has paid all it will pay.

The CA determines the patient’s new account balance and records it on the patient’s file and account ledger.

If the doctor’s office uses a pegboard system, the CA will post the daily control sheet, the deposit slip, the ledger card, and the receipt (if the patient wants one) at the same time.

The CA reviews the patient’s fee slip for any changes the doctor may have noted in diagnosis, treatment schedule, and looks for doctor’s notations.

96 

If the patient does not have a multiple appointment schedule, the CA will place the next appointment date on the patient’s fee slip and in the appointment book.

The CA then distributes the copies of the fee slip: –

The top copy (the original and most legible copy) going to the insurance department.

The cash-paying patient is given the second copy of the fee slip as receipt for payment. 

A patient who insists on billing his/her own insurance is a cashpaying patient. –

Only give them a receipt/fee slip when they have paid for their service.

If the patient is on a payment plan, the second copy is released to him/her when he/she has paid for their plan.

The CA puts the patient’s Symptom Update form (PGF181) inside the patient’s file.


The insurance CA posts the pertinent billing information from the fee slip for that visit.

At the end of the day, the insurance CA bundles the fee slips for that day and staples them together, notes the date on the back of the last slip (where it can easily be seen without unbundling the slips) using a bold felt tip marker.

The insurance CA stores these bundles as part of the office’s permanent records.



The CA will pull the patients’ file folders/travel cards the evening before for those patients to be seen the next morning, and just before noon for those patients to be seen that afternoon.

The Doctor will be on time, or ahead of time for each office visit. –

Never keep patients waiting.


The CA will record the name and telephone number on the PIP Telephone Call Sheet (PGF420) of any patient receiving their first adjustment or that is in pain.

The Doctor will write a note (i.e., Call Mr. Jim Jones) on the patient’s fee slip when he/she wants to call a patient that evening. –

The CA will look up the telephone numbers for the patient(s) the doctor wants to call and adds their name(s) and telephone number(s) to the PIP list.

The Doctor or CA (if the doctor requests the CA to do so) is to call a patient as soon as the patient’s x-ray, blood, or urine test results are received.

If the Doctor is to call, the CA is to: –

Place the patient’s name on the PIP list.

Attach a copy of the blood/urine/x-ray results to the PIP list.

DR or CA:

“Great news! We just received your blood (urine, x-ray) results and you don’t have any cancer. There are some other problems we have to deal with (if true), but you sure don’t have any indications of cancer.

98 It is cruel and unacceptable not to call your patients immediately upon learning that their tests do not indicate any signs of cancer.


The CA places a sticky note on a patient’s file folder/travel card, to remind the doctor to speak to a patient regarding his/her previously missed appointment. –

“Mrs. Jones missed her office visit on July 2nd.”

The CA will use sticky notes to remind the doctor of the patient’s birthdays, anniversaries, special services to be performed, etc.


The purpose of a Progress Examination is to re-evaluate the patient's “Objective Findings” to determine what progress, if any, has been made.

The doctor’s goal is to get his/her patients as well as possible, as soon as possible, and the only way to accomplish this is to regularly evaluate patient progress and make changes in treatment as soon as they are indicated.

If the patient is progressing as anticipated, great! –

In this case, the doctor encourages the patient to continue following the already established treatment plan because it is working marvelously.

If the patient is not progressing at an acceptable rate or is getting worse, the doctor must determine why and make the necessary treatment adjustments, or counsel the patient more on the necessary changes in their activities of daily living.

99 

If the patient has plateaued, the treatment plan should be changed to increase the patient’s response, or reduced for longer term corrective care.

In addition, Progress Exams rekindle a patient’s interest in their care.


Never change the frequency of adjustments, type of

adjustments or therapies without a Progress Examination. –

Never agree to reduce your patient’s frequency of care because that’s what the patient wants

Only do so after a Progress Examination.

If you do so, you’re sending your patient the message that you have over-prescribed their care in the first place.


A Progress examination is conducted on a patient every ten (10) office visits. –

There is no magic to the number ten (10).

A doctor may use a different re-exam time interval depending on his/her preferences or individual case, i.e., every nine (9) visits, every twelve (12) visits, etc.

Never postpone re-examining a patient any longer than the number of visits it would reasonably take to determine if the patient’s problem is responding as anticipated to the prescribed treatment plan.

Rule #2: 

Always compare the patient’s Progress Examination objective findings to the objective findings of the patient’s previous exam to determine if and how much the patient has progressed.

If you are not happy with the patient’s progress, or the patient’s condition has worsened, something is wrong and you must determine what that is, i.e.: –

Your diagnosis is not correct.

Your prescribed treatment plan is not adequate.

100 –

The patient is ignoring your activity of daily living advice.

Or, the individual is not a chiropractic patient.

Rule #3: 

Reduce the frequency of the patient’s care when you determine through a Progress examination that the patient’s quick results period is over.

Grind-it-out care is now necessary to resolve the remainder of the patient's objective findings, and to preserve the progress that has already been made.

Rule #4: 

Progress examinations should be conducted every ten (10) visits until all objective findings are eliminated, or until one (1) or two (2) objective findings remain over a period of three (3) consecutive re-examinations. –

At this point, it can be concluded that the patient has reached Maximum Medical Improvement (MMI), and is as well, as they are going to get.

Not everyone gets one hundred percent (100%) well.

Some people get ninety percent (90%) well and need ongoing supportive care to keep the pain of their permanent injury at a minimum, and to help prevent their percentage of permanent impairment from increasing.

Rule #5: 

A common practice is to, "Only Re-examine Positive Findings."

This definitely is not the common practice of a highly competent doctor.

The doctor must determine if the patient’s condition is progressive, and to be able to measure the existing progression.

By only re-examining positive findings, the doctor is effectively closing his/her eyes to any new and otherwise detectable, objective findings. –

This is a major disservice to the patient and malpractice.

101 Never limit Progress Examinations to only re-examining the previous positive findings.

Rule #6: 

Is there anything wrong with prescribing an extended plan of treatment.

Yes, and plenty!

No matter how good the doctor is, or how much experience he/she may have, every case will have its own uniqueness, making it impossible to accurately determine what a patient will need beyond the next ten (10) to twelve (12) visits.

Rule #7: 

The doctor should always perform a Progress examination at the time he/she feels the patient is ready to be dismissed from care.

This procedure: –

Justifies the doctor’s decision to release the patient.

Reveals that the patient is not yet ready, if true ... (has not yet reached MMI).

Documents the patient’s condition at the time of release, saving the doctor from: 

Bogus claims of patient abandonment.

Saves insurance companies from having to pay claims for injuries not received as a result of a covered incident.

Properly performed Progress exams result in: –

Better control of your treatment plans.

Brings faster relief for your patients.

Gets your patients well quicker.

Provides professional validation of your choice of treatment plans when needed.

In other words, Progress examinations make you a much better doctor.


Patients should not be scheduled for Progress x-rays unless the doctor deems it chiropractically/medically necessary.

Under no circumstances should Progress x-rays be routinely scheduled, i.e., every tenth (10th) office visit.

Patients should be re-x-rayed: –

As soon as the doctor suspects a late appearing pathology, i.e., fracture not appearing on initial x-rays.

Whenever the doctor feels it is necessary to evaluate osseous correction, i.e., Grostic, AO, NUCCA, Gonstead, CBP, Pettibon, Logan post x-rays, etc.

At the end of the patient’s active treatment program, to confirm osseous correction and that no late appearing pathology has occurred, i.e., compression fractures.


Progress reports let your patients know how their health problem is responding to care, what to expect next, and are reminded that their getting well is very important to the doctor.

Progress reports keep the patient actively interested in his/her care and mindful of his/her responsibility to help himself/herself get well.

Progress reports keep the patient under recommended care, which will help him/her get as well as possible … as soon as possible.

Progress reports turn the patient into a firm supporter and great referrer of the doctor.

When a doctor doesn’t re-report a patient and the patient asks how he/she is doing, all the doctor can give is a quick, somewhat generic response. –

Understandably, these patients: 

Lose interest in their care.

103 

Miss appointments.

Do not follow the doctor’s prescribed treatment plan.

Blame the doctor when they don’t get well or don’t get well quickly enough.


A Progress report should not take any longer than five (5) to seven (7) minutes.

A solo practitioner will give a Progress report to the patient immediately after the Progress examination.

A practitioner who has an exam doctor or physician’s assistant, will give a Progress report to the patient on the visit immediately following the Progress examination visit, i.e., if you give a Progress examination on the tenth (10th) visit, you will give a Progress report on the eleventh (11th) office visit.

Use the “Progress Examination Complaints & Symptoms Update” form (F1037).

“Neck Pain Disability Index (PGF310) and Low Back Disability (PGF301) Questionnaires are to be used at this time.

The doctor first tells the patient the “good” news, re: the objective findings that have been corrected.

The doctor then congratulates the patient on his/her cooperation that resulted in his/her positive response up to the date of the Progress examination.

Typically, the patient will try to refuse the credit and give it back to the doctor. –

At this point, the doctor will emphasize that no doctor can help a patient get well unless the patient helps himself/herself by coming in for the treatments prescribed, and by following his/her doctor’s athome/work instructions.

The doctor then emphasizes the importance of continuing care until all objective findings are eliminated, or until maximum wellness is achieved.

104 At the end of the Progress report, the doctor prescribes the next ten (10) visits treatment schedule.

PROGRESS REPORT SCRIPT Good News:  DR: “Mrs. Jones, I have some really good news for you. There is a great deal of improvement in your examination test results. You are not totally well yet, but you’re definitely a lot better. Let’s go over what I found. 


“First, in comparing the results of yesterday’s orthopedic and neurological examination to the results of your previous examination, I found that your previous examination showed you had a diminished knee reflex, which indicated you had pressure on the nerves in your lower back. Yesterday’s exam results show that we have been successful in returning the reflex to normal, which means we have been able to relieve the pressure on the nerves in your lower back enough to allow the flow of nerve energy to return to normal.”


“Do you remember the test where I tilted your head back and to the side, and then pushed down on top of your head? That test is called a nerve opening (foramen) compression test. When I performed that test on you the first time, you had severe pain on the right side of your lower neck area, which indicated you had pinched nerves in that area.”


“You also felt a tightness or tension in the neck and across the shoulders. Left untreated or not treated properly, it could eventually cause numbness in the arm and hand, and loss of strength of your right hand. On examining you yesterday, the nerve opening test was completely normal on the right -- there wasn't any pain or discomfort at all. This is excellent improvement and it indicates that we have been successful in

105 stopping the advancement of your condition and in reversing some of it.” 

Continue to tell the patient how he/she was (the previous exam’s positive objective findings) and how he/she is now.

Thank the Patient: 

Then proceed to thank the patient for his/her cooperation. –


“I want to thank you for your cooperation in keeping your office visit schedule. Because of your cooperation you are doing much better.”


“Thanks, Dr. Fernandez, but you’re the one who’s getting me better.”


“Well, thank you Mrs. Jones, but even the greatest doctor cannot get a patient well if the patient refuses to cooperate. I know it’s not easy at times, but you are doing a marvelous job and getting well as a result of it.

However: –


“You’re not completely well, yet. So, let’s see how quickly we can get rid of your remaining problems of (doctor will itemize the patient’s remaining objective findings), so they don’t cause the problems we’ve helped from returning. Because the body is made up of parts that depend on and respond to the functioning condition of other parts, it’s important that we eliminate all your objective findings as quickly as possible.”

Illustrate: –


“Mrs. Jones, when you first came in to see me you were going downhill (gesture with your hands). We have been able to stop the advancement of your problem and even

106 reversed part of it (if you have). You are now on your way back up hill (indicate uphill trend with your hand motions). You’re not at the top yet, but are much closer and much better than you were before. I want to see you often enough to keep you moving uphill and not slipping back down. “ 

Consequences: –


“Your (condition) is half well (or percentage well). If I stop treating you at this time, your (health problem) will get worse, and it will return to the way it was when you first came in (if true).

Give an analogy. –


“It's like pushing a car uphill (gesture with your hands). At this point, I've pushed the car half way up the hill. If I stop pushing now the car will roll down the hill to where it started or even farther. We don't want your condition to slide back to where it was when you first came in.”

New schedule. –


“So I need to treat your spine (number) a week to finish correcting the (objective findings) and keep the problems we’ve fixed from returning (if true).”


“I will re-examine you in ten (10) visits to determine how many of your (objective) problems remain, if any, and what treatment may be necessary at that time.

The CA prepares and gives the patient a new ten (10) visit multiple appointment card, and schedules the next Progress examination.



It’s an easy portal of entry for newcomers.

Patients who know more, refer more.

Helps patients to understand and accept the necessity of spinal correction. –

Too often when the patient’s pain is gone, so is the patient.

A great opportunity to recommend a preventative approach to health care.

Establishes the doctor’s professional credibility.

Saves the doctor valuable office visit time.


Tuesday evenings at 6:15 p.m. every two weeks.

For those patients who can’t or won’t come in the evening, a Saturday morning Spinal Care class is recommended.


All new patients and their spouses or guests because one person is going to check (examine) the other.

Re-activated patients.

Non-responding patients.

Referring (bird dog) patients.

Anyone and everyone, including lawyers, other doctors, important people in your community, political people in your community and business owners.


CPT code 99078, Physical Education Services in a Group: $45

The Spinal Care class tickets state $45.

108 –

Anyone who is not a patient receives this $45 class free as an introduction to your office.


Spinal Care classes should be conducted in your office.

If your classes become too large, move the classes to a public meeting room in a library, hotel, school, etc., close to your office.


All New Patients: Tell your new patients about the Spinal Care class during their report-of-findings when they are the most motivated and enthusiastic about taking care of their health problem. –


“Do you want to know how to get the most benefits from your care?”




“Good! I have a Spinal Care class that will teach you what you can do to help yourself get better as quickly as possible, and how to stay well once you’ve completed treatment.”

Spouse of New Patients: During the report-of-findings, the patient’s personalized Spinal Care Folder is on the doctor’s desk. –


“Mr. Patient, I have a folder here that was made up

109 especially for you. It contains information about your (health problem), as well as self-care instructions that you can do at home to help you get better faster. I have scheduled a Spinal Care class for next Tuesday at 6:00pm so that I can go over all of this and show you exactly how to help yourself get well.” –


“Your husband/wife will need to be there because I’m going to teach him/her some special treatment techniques that he/she can do to you at home to help relieve your pain and get you well faster. I’m also going to show you how to painlessly get out of bed or out of a chair, and I’ll need your husband/wife to help you with these techniques. So please make sure your husband/wife will attend the class with you. OK?”

If the spouse is present at the report-of-findings, the doctor should turn to the spouse and say: –


“Of course I expect you to be there. Your husband/wife cannot do these special treatment techniques to him/herself, so I need you there in order to show you how to help your husband/wife get well quicker.”

If there is any hesitation on the patient’s part, the doctor should put the folder to the side, and make it clear that the Spinal Care class is a must for patients who come to him/her for care.

The doctor explains that his/her care and treatment is of little value to a patient who, through a lack of knowledge, continues to ruin his/her spine with damaging habits.

The doctor further states: –


“Your attendance is necessary as you cannot get this information anywhere else.”

110 

Friends of New Patients and Current Patients: The doctor tells the new patients and his/her current patients to bring a friend to learn how to: –

Check each other’s spine for indications of spinal problems.

Help the patient with certain pain relieving techniques.


“You are invited to bring any of your friends who have

back/neck problems. I can teach them how to take care of their back/neck at the same time I teach you.” 

Present Patients and Referring Patients: Always invite your present patients and referring patients to these classes.

Reserving Space: The doctor states that the class is usually very well attended and he/she reserves space for the patient, and their relatives/guests. –


“I’ve reserved a seat for you and your wife (friend, etc.). It’s important that no one misses anything, so we do not start the class until everyone has arrived. If an emergency comes up and you can’t make it or you’re going to be a little late, please call and let us know right away. That way we’ll know whether to keep everyone waiting or to go ahead and start.”


After the patient’s adjustment and therapy has been given, the doctor escorts the patient to the Front Desk CA and instructs the CA (in front of the patient) to: –

Give the patient the multiple appointment schedule that he/she has recommended.

Give the patient the financial plan the patient has agreed upon.

Schedule the patient and his/her spouse or friend for the next Spinal Care class.

111 The CA places the patient’s name and telephone number on the Spinal Care class appointment sheet (PGF434), and writes the patient’s name on two Spinal Care class tickets (PGF432) and gives them to the patient.

The CA then asks for the guest’s telephone number so his/her attendance at the Spinal Care class can be confirmed by phone.

The CA reaffirms the doctor’s prescription of the Spinal Care class: –


“We expect your wife/husband to be there. The doctor has special treatment procedures to teach him/her how to help your health problem get well.”

The CA then asks the patient if he/she would like to bring 1 or 2 additional guests, and gives the patient 2 more tickets to encourage him/her to do so.

NOTE: The Spinal Care class must be important to you if it is going to be important to your patients. If you or your staff has an indifferent or hesitant attitude, you will have a very poor attendance.


One week prior to the spinal care class, place Spinal Care class (PGF438) posters in your reception room, bathrooms, changing rooms, adjusting rooms, and therapy suite.

The posters should state, “Spinal Care Class - Date and Time - Learn How You Can Self-Treat Your Back and Neck Pain – A brief informative talk about your spine and how to take care of it. Bring a friend - everyone is invited. Pre-register with (CA’s name) at the front desk.”

The CA and doctor should personally hand out two 8-1/2" x 11" Spinal Care class flyers (PGF442) to everyone they meet and to all patients (one for the patient and one for their friend). –

The flyer is simply a smaller version of the poster.

The Spinal Care class flyer is a “hand out”, not a “take-one.”


The key to success here is for each person to bring someone they know.

The doctor and CAs must “talk it up” and encourage patients to bring others.

113 For those patients with an appointment prior to their scheduled Spinal Care class, the CA writes, “Spinal Care Class” on a post-it note and sticks it on the patient’s travel card/file folder.

Both the doctor and CA, should remind these patients about their reserved seat at the Spinal Care class and to bring their relatives or friends so they can check (examine) each other, and learn the special treatment techniques that will help the patient get well faster.


The CA calls the patients and friends the afternoon of the day before the Spinal Care class, or the morning of the night of the Spinal Care class, to confirm their attendance.

The CA also calls the “referring patients” that the doctor has invited to the class. –

This is a must for a good Spinal Care class.


The CA compiles a list of patients with cervical problems that will be attending the class.

A separate list of patients with lumbar problems will also be made.

The CA neatly prints the attendees’ names on name tags.

A Spinal Care class folder is made up for each person who is to attend.

The folder has the individual names written across the front and will include: –

A sheet on home exercises of the cervical and lumbar spines.

General health hints.

Folders on mattresses and pillows that are chiropractically sound.

Pamphlets on the health problems of the people attending the class.

Your office brochure.

Free spinal examination gift certificate.


The doctor reviews the case histories of all patients attending the class and their Family Health History Questionnaires (PGF91) in order to tailor his/her explanation of chiropractic to the patient’s or their relative’s/friend’s health problems. –

The doctor should only choose 4 or 5 health problems to emphasize.


The patients and guests sign in on the “Spinal Care Class” Sign-in Sheet (PGF430).

Each person receives a clinic notepad and a pen.

Give the guests/relatives of the doctor’s patients a tour of your office.


The CA introduces himself/herself and welcomes everyone.

The CA says a few words about her experience with chiropractic, how long he/she has been in the profession, and how much he/she loves his/her job.

Then the CA says: –


“I would like to welcome you to our Spinal Care class. The purpose of this class is to give all of you a better understanding of your health problems, how your body works, and how to take care of your spine. But before, Dr. Fernandez starts teaching you , I’d like to tell you a little about his/her qualifications ...............”

The doctor then steps up and says: –


“Thank you, (CA’s name), and welcome to all of you. I congratulate you for taking time out of your busy schedules to learn about your bodies, your spine and our care. For many of you, chiropractic is a new experience,

115 therefore it is necessary to explain what we will do to help you return to good health.” –


“I will show you how to take better care of your (back and neck problems) and how to not undo what we are trying to accomplish during your program of spinal correction. There’s an old adage that says, “If you give a man a fish, you can feed him for a day, but if you teach him how to fish, you will feed him for a lifetime.” That’s the purpose of this class, to teach you how to take better care of yourselves to avoid the (back and neck problems) that brought you to our office.”


The sperm and egg form a mass. –

Draw the sperm, egg and mass on the flip chart.

Filaments come out of the mass and forms body parts. –

The body parts conform to the health problems that the patients have in your audience.

– 

The mass is your brain, and it produces 100% energy. –

Draw the filaments on a flip chart. It’s like the power plant outside of your town producing electricity.

The filaments are nerves. –

The nerves are like the electric wires going from the power plant to your house.

When there is 100% energy flowing from the brain over the filaments (nerves) to the body parts, the body is healthy. –

It’s like the electricity going from the power plant, over the electric wires to your house, lighting your light bulbs.

116 Draw on the flip chart the body parts that match the audience’s health problems.

The parts of your body, like the light bulbs in your house, are supposed to burn bright until they burn out, not flicker, etc.

The brain and the main trunk of nerves (the spinal cord), are protected by bones that can slip out of alignment. –

These bones are called vertebrae.

When a vertebra slips out of alignment, this is called a subluxation. It decreases the flow of energy from your brain to the body part by as much as 50 to 60%. –

Place a < on the flip chart. Show the results of a decrease in nerve flow.

This results in a slowly progressing disease process.

Use the plant analogy: 

“Stepping on a garden hose will cut off the water supply to the plant, but the plant doesn’t immediately fall over when this happens.

It takes time for damage to occur before the symptoms of wilting starts.

To restore the plant to life, you need to get the pressure off of the water hose.”

When the misaligned vertebra is fixed, 100% energy again flows from the brain over the nerves to the body parts.

Health is the result.

Demonstrate on the flip chart the organs/parts now getting 100% energy.

Demonstrate a pinched nerve using a dry spine.

Show pre and post full spine x-rays of other patients (their names or identities hidden) with conditions similar to those of the people in your class.

117 –

Turn on the view box with the PRE x-ray on it.

Point out the main anatomical landmarks: –

“You are looking at this person from the back.”

“This is their right shoulder.”

“This is their left shoulder.”

“This is their right hip.”

“This is their left hip.”

“This is their head and the white structure going up the middle of the film is their spine.”

Use the Fernandez “red dot” and “black line” x-ray marking system on the pre and post full spine x-rays.

The doctor explains what the red dots and black line mean: –

“The red dots are the center of the vertebrae.”

“The black line is the center of the body.”

“All the red dots belong on the black line.”

“The objective of chiropractic care is to balance your spine, bringing the red dots closer to the black line.”


Explain the obvious signs of subluxation: high ears, high shoulders, low hips, rotated pelvis (which causes the feet to rotate inward or outward).

Red and black lines can also be used on lateral x-rays. –

Discuss the negative effects of a straightened or reversed curve, i.e., premature arthritis, etc.

Turn on the view box with the POST x-ray on it.

Show the audience the difference between the pre and post x-ray.

Tell the audience how the patient responded to chiropractic.

Tell the story of a patient who was told he/she needed surgery, and how chiropractic cured the patient without it.

Then relate a story of another patient who didn’t get chiropractic care but chose surgery instead. –

One surgery after the other.

NOTE: Patient stories must be factual. –

The doctor can use the story of one of his/her patients or those of another DC.

End the Spinal Care class with patient testimonials. –


“At the beginning of our talk, you learned about the

119 nervous system and the surprisingly number of health problems that are successfully treated here at our clinic. I want to share with you a first hand example of the results that people receive in our office. We have (Mrs. Bird Dog) with us this evening whom has consented for us to show you her x-rays, after which she will tell you what our care has done for her. If you would like to ask her any questions, you are welcome to do so. She will be happy to answer them. 

The doctor shows the patient’s x-rays and then has him/her testify. –


“Thank you, (Mrs. Bird Dog). We’re happy you’re doing so well and appreciate you taking the time to share with us today. I would also like to ask some of my other patients why they came to my office and the results they have experienced through chiropractic care.

The doctor asks 2 or 3 referring patients for their testimonials.



“Thank you for coming and sharing. We hope we have in some way helped you understand your spine and the importance of its care. But, before our class is officially over, I have two things I am going to do.


“I am going to conduct a Free Postural Examination on each of the non-patients attending this class.”


“Then I am going to instruct you and your partner on the special treatment techniques that will help relieve your pain and get you well quicker.”

The CA will then invite the attendees to have refreshments and talk with each other while they wait their turn for the doctor’s examination.

The doctor will then examine the spouse/friends of the patients.

120 –


“I will examine each person here using a Posture Pro Analyzer. This test will take a total of 3 to 5 minutes. If the test indicates you need care, I will offer you a Free Spinal Examination at no charge because I don’t want you to suffer if you don’t have to.”

The doctor will take an AP & lateral Posture Pro pictures of each person, and note the findings on the corresponding person’s pictures.

The doctor then reviews the findings with each person.

At this point, if indicated, the doctor will recommend a Free Spinal Examination.

The doctor directs the patient to the CA to make an appointment.


The CA explains to the patient’s spouse/friends how to: –

Massage the patient’s injured area with ice.

Strip the patient’s muscles of toxins.

The CA cautions the patients about moving too fast, doing too much, etc.

He/she hands out the “Oh, My Aching Back” brochure (P7576) to all patients on her lumbar list, and the “After a Neck Injury, Do Not...” brochure (P2576) to all patients on her cervical list.

121 

The CA proceeds to teach the back pain patients how to get out of bed and out of a chair.

The CA then teaches the neck pain patients how to take care of their necks, i.e., proper sleeping positions, the use of cervical pillows, etc.

Then the CA will explain the difference between the Free Postural Examination they received and the Free Spinal Examination they can make an appointment for. –


“The Free Spinal Examination gift certificate (PGF445) you will be receiving when you pick up their Spinal Care class folder at the end of this class, entitles you, one of your friends, or a member of your family, to a Free Spinal Examination at our office, and at no cost. This gift certificate is a $45 value and must be used within the next 12 days.”


“This is your opportunity to helps you, your friends or relatives find out if the doctor can help their health problems at no obligation or cost to them.”

CA: “We have a limited number of appointments available for these exams, and they are granted on a first-come, firstserved basis.”


“If you have any other friends with health problems that might benefit from chiropractic care, please pick up a gift certificate for them too.”


“You are welcome to take as many of these Free Spinal Examination gift certificates (PGF445) as you’d like. The more people you share these with, the more people you could help.”


“Since these gift certificates are only valid for 12 days,

122 please call your friends/relatives to let them know that chiropractic might be able to fix their health problem, and ask them to give me a call for an appointment.” –


“If you would like, Dr. Fernandez will be happy to call your friends/relatives for you. He/she welcomes the opportunity to review your friends’/relatives’ health problems and provide them with a Free Spinal Examination. Simply call your friends/relatives first and ask their permission for the doctor to call them. When the doctor gets permission, he/she will call.”


“To those of you who have received a Free Postural Examination today. If you would like to start care with Dr. Fernandez, I will be happy to make an appointment for you when you pick up your Spinal Care class folder at the end of the class.”

NOTE: Some D.C.s prefer to add free x-rays to their offer of a free examination. In this case, the free exam/x-ray visit would have a $195 value (or whatever fees the doctor would charge for these procedures). However, in order to get the free exam and x-rays, the prospective patient will have to be examined and x-rayed within 12 days of the Spinal Care class.

The doctor finishes the Spinal Care class with a “question and answer” session.

After the question and answer period, the CA directs the guests to pick up their Spinal Care Class folder from her.

As each guest comes up for their folder, the CA asks them if they would like an appointment with Dr. Fernandez.

The appointment book will be there in front of the CA.

The CA records the appointments in the appointment book, and fills out an appointment card (PGF460) with the day and time and hands it to the individual.

123 

Having completed the appointment process, the CA proceeds with the following referral procedure. –


“Would you like Dr. Fernandez to call one of your friends or relatives with neck or back problems?”


“Yes, that would be nice.”


“Please call your friend or relative and get permission for Dr. Fernandez to call him/her. Then contact me and I’ll have Dr. Fernandez call him/her.”

OR… –


“No, I’ll have him/her call you.”


“Why not bring your friend/relative with you on your next visit? We would love to meet him/her. Then, we will give him/her a Free Spinal Examination.”

The CA gives the person a pamphlet that relates to the friend’s/relative’s health problems, after writing the prospective patient’s name on it.

The CA elicits a promise from the guest that they will make sure their friend/relative receives the pamphlet.

The CA writes down the friend/relative prospective patient’s name, plus their symptoms. –

Later on, she will transfer this information to the referring patient’s file folder/travel card.

The CA hands the attendee his/her personalized Spinal Care class folder(PGF436).

The CA says: –


“It’s been good meeting you Mr./Mrs. _____. If you ever need us, please give us a call.”

Or… 

If the guest made an appointment: –


“We’re so happy you came. We’ll see you on (day and date

124 of appointment) and remember you are always welcome to bring your spouse/friend/relative with you, we’d love to meet him/her.” Or… –


“We’re so happy you came. We’ll see you on (day and date of appointment) and thank you for making sure your friend/relative gets this pamphlet. We look forward to meeting him/her and hope we can help him/her feel better.”

If a patient is asked three times to come to your Spinal Care class and they don't come, don't irritate them by continuing to ask him/her. –

Don't get an otherwise good patient and potential referrer upset with you.

The doctor should conduct special patient education classes on the weeks the Spinal Care classes are not held. –

Neck Care Relief class.

Back Care Relief class.

Headache class.

Nutrition class.


6:00 - 6:15: Attendees arrive.


Attendees are taken into the lecture room/office by the CA and asked to sign the sign-in sheet, given a name tag, pen and clinic notepad.


CA begins with welcome.


Doctor teaches class.




Free Exams and Special Treatment Technique classes are performed.


Question and answer session.

125 


Guests receive their personalized Spinal Care class folders.


Guests depart with a positive attitude towards chiropractic and enough new information to refer sick people to your clinic.


Length of time ---- Never over 1½ hours.

Clean and lock up.


Spinal Care Class Sign-in Sheets (PGF430).


Special Spinal Care Instruction Forms (PGF440).


Appointment Book and a Couple of Pens.


List of Patients with Cervical Pain scheduled to attend.


List of Patients with Lumbar Pain scheduled to attend.


Prepared Name Tags.


Notepads and Pens for Each Attendee.


Postural Check List (PGF450).


Appointment Card (PGF460).


Spinal Care Class Tickets (PGF432).


Spinal Care Class Appointment Sheet (PGF434).


Personalized Spinal Care Class Folders (PGF436).


Spinal Care Class Poster (PGF438).


Spinal Care Class Flyer (PGF442).


Free Spinal Examination Gift Certificates (PGF445).


Free Spinal Examination and X-ray Gift Certificates (PGF447).


Special Treatment Techniques sheets (PGF439).


Yellow Paper from Full Spine X-ray Film or a Flip Chart.

126 Appropriate Pamphlets: !

When an Automobile Accident Occurs (P0002).


Disc Problems (P0014).


Arm & Shoulder Pain (P0017).


Pinched Nerves — The Great Pretender (P0018).


I Yelled for Help but You Didn’t Listen (P0020).


Restricted Material: Only for Patients Desiring a Speedy Recovery (P0021).


Whiplash Injuries of the Neck (P0038).


Headache (P0045).


Migraine Headache (P0055).


Head & Neck Pain (P0056).


After the Accident (P0060).


Low Back Pain and Backache (P0061).


Nerve Problems (P0065).


Sciatic Nerve Pain (P0085).


Scoliosis (P0095).


After a Neck Injury, Do Not .... (P2576).


Oh My Aching Back (P7576).


Exercises For The Lower Back (PGF305).


Exercises For The Neck (PGF315).

Refreshments: !

Coffee and Tea.


Cream and Sugar.


Donuts or Cookies.


Soft Drinks - Diet & Regular.


Disposable Cups.


Paper Napkins.

127 Technical Products: !

White Background Screen.




Flip Chart and Markers.


Posture Pro.


Dry Spine.


Gonstead Chart.


Two 14 x 36 View Boxes.


2 or 3 sets of Pre & Post Full Spine X-rays


Red & Black Grease Pencils.


Measuring Stick (Yard or Meter).


Nerve Charts (Neuropatholator optional).

New patient walk through procedures  
New patient walk through procedures