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Dynamic Chiropractic – October 12, 2006, Vol. 24, Issue 21
Dynamic Chiropractic
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Dynamic Chiropractic

Standardizing the Process of Chiropractic Care, Part 3

By Nancy Martin-Molina, DC, QME, MBA, CCSP

The first two articles in this series ("Documentation and Standardized Care Plans," and "Standardizing the Process of Chiropractic Care,") provided information geared toward the chiropractic clinician and included components of a chiropractic management system and the development of individualized patient-database required intake forms, such as a patient registration form (e.g., the reason for the patient's visit, medications, past medical history, surgical history), family history intake, review-of-systems intake, and baseline outcome assessment intake.

The next step for the treating chiropractor is to initiate obtaining a history, performing a physical examination, identifying the problem, and formulating an initial plan of action, aka the chiropractic care plan.

The follow-up office visit is generally a report of findings or what is known today as a "counseling session," during which the plan of action is discussed and patient consent is obtained. Once the patient enters into the care plan (subsequent visits), documentation occurs that may be handwritten in the form of progress notes/chart notes.

In this era of cost-conscious medicine, chiropractic interventions that place an emphasis on today's chiropractic education and knowledge base should be emphasized not only to our patients, but also to our medical physician providers. Hence, the purpose of this article is to illustrate suggestions for chiropractic clinicians to utilize when writing reports, and thus to optimize chiropractic clinical and economic success. At the end of this article, I have included a sample format of what entails a 99245 or specialty office (comprehensive) consultation report. This is utilized once a medical referral is generated and your opinion is requested. No treatment is preformed at the time of the specialty consult examination; however, the care plan may include the patient returning for chiropractic care. I leave it to the chiropractor to learn the required reporting elements of each level of examination, established or new, as this template is interchangeable.

First, here is an example of the required elements of a 99243 to enhance your understanding: "A requested specialty office consultation, identified as 99243, was performed, consisting of approximately 40 minutes face-to-face, including six minutes in counseling; hence, the basis for today's report." The following elements are required: chief complaint, history (extended) of the present illness, extended ROS (musculoskeletal only), pertinent past medical history, social history, pertinent family history, physical examination (affected and related organ systems). Include one paragraph on NMS and extremity findings. Finally, include a diagnosis of moderate complexity (example: piriformis syndrome, aka sciatic neuritis). Conclude your report with one brief paragraph under the subheading, "Discussion (Recommendations in Management)." The 99243 should only be about two pages in length. Vital signs are required on all new patients.

The following example of a comprehensive specialty consultation 99245 can be used as a template (when tailoring for a specific patient, omit fields that are not needed; data included is for illustrative purposes only).

TEMPLATE for Chiropractic Physical Medicine Consultation

Patient Name: ____________________________________________

Date of Service: __________________________________________

Referring Physician: _______________________________________

      Thank you very much for your confidence and for allowing me the opportunity to consult on your patient.

History of Present Illness:

      The patient is a pleasant __ year-old woman/man with a history of a ruptured disc. The patient's symptoms started in _____ when she/he began to _________. The patient's complaint is [bilateral/unilateral cervical/thoracic/lumbar/extremity pain]. The pain level was rated as an 8/10 on a scale of 1-10, with 10 being severe pain with moderate interference in activities of daily living. The quality of the pain is burning, aching, stabbing, pins and needles. Provocative: side-bending activity, straightening up, lying lateral recumbent, lying prone, lying supine. Palliative: analgesics/ heat/ice/ rest. There is radiation of pain into the [right/left upper/lower] extremity.

Past Medical History:

      Operations or Injuries:

      Medications:

      Allergies:

Review of Systems:

      General: There is no history of fever, chills, night sweats or weight loss.

      Head and Neck: There are no frequent of severe headaches; no history of blurred vision, double vision, tinnitus; no hoarseness, sinus trouble, hay fever or glaucoma.

      Cardiopulmonary: There is no history of cough, chest pain, pleurisy, palpitations, cold, hemoptysis, wheezing, sleep apnea or ankle edema.

      Gastrointestinal: There is no history of hematemesis, frequent or severe abdominal pain, dysphagia, dyspepsia, nausea, vomiting, diarrhea, chronic constipation, peptic ulcer disease, gallbladder attacks, jaundice; no history of hepatitis, changing caliber of stools or hemorrhoidal complaints.

      Genitourinary: There is no history of kidney stones, urinary tract infection, any hematuria, pyuria, urinary frequency, no loss of urine with coughing or sneezing, no hernia.

      Gynecological: Last pap smear, LMP date; number of pregnancies.

      Musculoskeletal: No history of varicose veins, phlebitis, claudication, frequent joint pain, swelling in joints, morning stiffness, back pain, degenerative or inflammatory arthritis.

      Neuro/Psychiatric: No history of anxiety, depression, or mental illness; no history of headaches, seizures or epilepsy, dizziness or fainting episodes; no recent lightheadedness; no history of vertigo; no recent gait difficulties; no tingling, numbness, or recent paraesthesias.

      Endocrine: There is no history of thyroid disease, changes in hair growth, no history of diabetes, recent marked tiredness, or marked muscle weakness.

      Integumentary/Skin: There is no history of skin disease, skin cancer, history of hives, or abnormal pigmentation.

      Hematologic/Lymphatic: No history of anemia, easy bruisability or prolonged bleeding, or history of other blood disease.

Physical Examination:

      Vital Signs: B/P, P, RR, T

      Height (inches):

      Weight (pounds):

      Chiropractic General Postural Inspection & Gait:

      Chiropractic Motion Palpation: paraspinous myospasm, spinal listings:

      Percussion: negative spinous testing

      HEENT: PERRLA, EOM intact, lids/conjunctivae without masses or ulcerations. No lesions, masses in ears or nose. Ear canals and tympanic membrane are normal. Oropharynx - without exudate.

      Neck: trachea midline. No masses.

      Thyroid: there is no enlargement or tenderness. No lymph node enlargement.

      Heart: normal sinus rhythm at apical. No extra sounds.

      Lungs: clear to auscultation.

      Abdomen: no masses, tenderness or hernia. Liver and spleen nontender. Bowel sounds normal.

      Neurological and Orthopedic: II-XII cranial nerves intact. No nystagmus or vertigo. General Cerebral Function: intact. Coordination Disturbance (cerebellum vs. posterior columns): intact. Vibratory senses intact. Lower extremities, no pedal edema, no calf tenderness on squeeze test, distal pulses are equal. Seated deep tendon reflexes: +2/4 symmetrically using the Wexler Grading Scale.

Myotone or Motor Tests (normal: 5, good: 4, fair: 3, poor: 2, trace: 1):

  Right Left
C5 Shoulder Abduction 5/5 5/5
C6 Wrist Extension 5/5 5/5
C7 Wrist Flexion 5/5 5/5
C8 Finger Flexion 5/5 5/5
T1 Finger Abduction 5/5 5/5
Myotone or Motor Tests Right Left
Flexed Thigh (L1-3) 5/5 5/5
Extended Leg (L2-L4) 5/5 5/5
Foot (Inversion & Dorsiflexion L4) 5/5 5/5
Foot (Great toe Dorsiflexion L5) 5/5 5/5
Foot (Eversion & Planter flexion S1) 5/5 5/5
     
Circumferential Measurements Left Right

Bicep

   

Forearm

   

Thigh-3"

   

Thigh-7"

   
Calf    
     

Cervical Spine Range of Motion

Actual/Normal

Extension

45/45

Flexion

55/55

Right bending

40/40

Left bending

40/40
Right rotation 80/80
Left rotation 80/80
     
Thoracolumbar Range of Motion Actual/Normal
Extension 30/30
Flexion 90/90
Right bending 30/30
Left bending 30/30
Right rotation 30/30
Left rotation 30/30
     
Hip Range of Motion Normal Right Left
Flexion 120 110 120
Extension 30 30 30
Abduction 50 45 50
Adduction 30 30 30
Internal rotation 35 35 35
External Rotation 50 50 50
       
Knee Range of Motion Normal Right Left
Flexion 135 135 135
Extension 180 180 180
       
Ankle Range of Motion Normal Right Left
Plantar Extension 50 50 50
Dorsiflexion Flexion 15 15 15
Subtalar Eversion 20 20 20
Subtalar Inversion 35 35 35
Hallux Extension 40 40 40
Hallux Flexion 40 40 40
       
Shoulder Range of Motion Right Left
Flexion 180/180 180/180
Extension 30/30 30/30
Abduction 180/180 180/180
Adduction 45/45 45/45
Internal rotation 6060 60/60
External rotation 80/80 80/80
       
Elbow/Forearm Range of Motion Right Left
Flexion 140/140 140/140
     

Radiological Findings:

      The bone density and remaining soft-tissue structures are unremarkable. There is no further evidence of any further gross pathology, congenital findings or obvious fracture.

Radiographic interpretation:

      Diagnostic Impression: lumbar HNP displacement, lumbar sprain/strain.

Discussion:

      The focus of care is to reduce the radicular effect of the lumbar spinal nerve roots and centralize the pain. Emphasis on patient education is required. Special diagnostics are necessary to determine extent of pathology if pain fails to respond to conservative care. (The spinal facet joint subluxations can be a source of low back pain, and may become partially inflamed from the insult of repeated minor injuries, due to marked aberrant biomechanical movements, to include torque and rotations.)

Recommendations:

      Lumbar brace instructions and ice/heat; recommend natural NSAIDs such as Boswellic acids.

      Limited lumbar radiographs and palliative intervention with physical therapy modalities; very good response noted. Instructions on prices and off-duty status.

      Instructed in immediate follow-up for: orthopedist referral, prescription control, lumbar MRI to determine extent of pathology and clinical correlation. Chiropractic technique procedures: Activator method, diversified, flexion/distraction (Cox, Leander), McKenzie.

      Instructed that should symptoms worsen, or experience increased pain when sneezing or coughing, or incontinence of stool or urine, to contact 911 and proceed to the emergency room for evaluation.Treatment frequency: three to four times per week for two weeks, and then reassess for additional care.

      Thank you again for allowing me the opportunity to participate in the care of your patient.

 


Click here for more information about Nancy Martin-Molina, DC, QME, MBA, CCSP.

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