I have written several articles now on the topic of documentation and discussed a whole list of reasons to keep good records.
It becomes very tedious to lay out the logical discussion of how you arrived at your treatment plan. Arguably, your conclusions should be self-evident, but to an insurance reviewer or legal nurse unfamiliar with chiropractic procedure, the thought process must be spelled out - line by line. It is also likely that very few people will even read a particular report you generate. You never know. The standard of care requires that we completely document records in SOAP format. More recently, the question is being raised about response to care: "If the patient is not responding to care, then care is not reasonable and should not be covered."
The next detail that should be included in each of your narratives is how the patient responded to your treatment and how your care plan has changed. For example: If you are treating a patient for lower back spasm, you might start with EMS, ice and myofascial release. It is reasonable to expect that the spasm would resolve within a few weeks, and your care should evolve to include manipulation and an active therapeutic exercise program. Your follow-up notes should document that: "The patient's pain is decreased, range of motion is improved, discontinue passive therapies and instruct in a home stretching protocol." You have now been able to show that the patient has responded to your care plan, and that your plan has been modified to meet the changing needs of the patient.
To continue doing EMS and ice for weeks on end is of little value. It will not help the patient improve, and it suggests that your care is ineffective. If there is a reason to continue on with passive modalities, your rationale for care must be clearly explained in your documentation.
At a recent state society meeting, I made the comment that care should be focused on the complaints of the patient. If a patient has a lower back complaint, then treat the lower back. One doctor in the room made the comment that he was a full-spine practitioner, and he would treat full spine "because that's what he does." That is a great practice philosophy, but we have to treat the patient, not a philosophy. "Just because" is not acceptable. "That's my philosophy" is equally invalid. You must be able to justify your treatment of that specific patient.
It may be entirely reasonable to treat the neck when the patient has a primary complaint of a lower back pain, but you must be able to document why you chose to treat the neck at that time. Were there positive orthopedic findings? Palpation findings? Postural compensation? You must be able to show a thought process for the care you render - anything less may be construed as reckless and negligent.
There is no one single modality that will meet the needs of every patient. Given your personal experiences, you may have developed strong preferences. You may or may not like this or that technique; you may not wish to pursue some specialized therapy. Make sure you are open-minded enough to recognize when a patient may not be responding to your plan of care, and when you should be referring for co-management with a competent para-practitioner.
Recognizing that patients are different and individual patient needs are thus different, every patient should be evaluated and treated on the grounds of what is best for them. You should recommend what you feel to be the most appropriate care plan - regardless of what the insurance coverage is. If your care is limited by a plan contract or by a patient's choice to only receive services covered by their plan, you are still obligated to share with them your recommendations and document why those treatments are not being pursued.
Make sure you know and understand the benefits and limitations of the procedures you offer. Make sure your patients know that you are working to meet their needs. Be known for offering the highest level of patient care; don't settle for anything less.
- "Meeting Medicare's Documentation Requirements." ACAnews, September 2009.
- "Chiropractic Compliance Programs." ACAnews, June 2009.
- "Research and the Bottom Line." ACAnews, May 2009.
Click here for more information about Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT.