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Dynamic Chiropractic – March 15, 2013, Vol. 31, Issue 06
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Dynamic Chiropractic

Simplifying Documentation and the Physician Quality Reporting System

By Ronald Feise, DC and J. Michael Menke, MA, DC, PhD

Consistent, current and complete health care documentation is an essential component of quality patient care. Practitioners are required to maintain uniform, organized records containing patient demographics, history and treatment information.

To facilitate communication and promote efficient and effective treatment, Medicare has implemented the Physician Quality Reporting System (PQRS). This program will be mandatory beginning in 2015. For the 2013 PQRS reporting period, two measures are required for chiropractors: Pain Assessment and Functional Outcome Assessment.

Pain Assessment

Although there are numerous pain measures practitioners can use to assess pain, the Numeric Rating Scale (0-10) is a good choice. It provides a reliable and valid method of measuring the patient's perception and report of pain.2,6,8-9 Patients find the scale intuitive and easy to use, and practitioners find it easy to score compared to the Analog Scale, which patients do not like and practitioners need a ruler to measure. Medicare requires a pain scale report on every Medicare patient for most visits.

Functional Outcome Assessment

The need to measure the function of the spine and to demonstrate clinical effectiveness has resulted in many reliable and valid patient report instruments in the past 20 years. Yet most self-reporting instruments measuring spinal function are underutilized in daily practice, because they require too much time for patients to answer (5-10 minutes per instrument) and health care workers to score (1-5 minutes per instrument).4 Patients become overwhelmed when they have too many time-consuming forms to fill out. The fact that many patients have symptoms in multiple anatomical regions compounds the problem by necessitating the completion of multiple forms. Consider the following scenarios:

Scenario #1: Your new patient has neck and low back pain from two distinct events. To document the patient's condition appropriately, you should use two outcome measures: one for the cervical spine and one for the lumbar spine. Overall, no instruments are shown better than Oswestry for the low back or Neck Disability Index for the neck, both which have been widely researched and validated.3,10 Each of these instruments requires 3-5 minutes for a patient to complete.1,8,10

Scenario #2: An established patient has a new episode of upper back pain with no neck or low back issues. What outcome measure should you use? Neck Disability Index is primarily for cervical pain and related complaints, and Oswestry is primarily for lumbar pain and related complaints. Neither of these measures is for the thoracic spine, per se.

One validated measure for the thoracic spine is the Patient Specific Functional Scale. This scale can be used to measure activity limitations and to compare progress from the baseline measurement in patients with thoracic spine pain.11 It has demonstrated reasonable reliability, validity, and responsiveness, but the estimated time for a patient to complete this instrument is 5 to 10 minutes.7,11

The Burden of Multiple Forms and a More Effective Choice

Medicare requires a functional scale score to be utilized at least every 30 days. To comply with Medicare's PQRS requirement, you can use three separate measures (i.e., Neck Disability Index for cervical conditions, Patient-Specific Functional Scale for thoracic conditions and Oswestry for lumbar conditions); but the administrative burden of using three measures is substantial.

A practical alternative to using multiple forms is to use one instrument, the Functional Rating Index (FRI). This instrument can be used with cervical, thoracic or lumbar conditions – eliminating the need for multiple instruments for spine-related conditions.

The FRI has been tested, and the initial results published in Spine.4 Multiple independent research teams have verified that the FRI demonstrates excellent reliability, validity and responsiveness, and significantly reduces administrative burden.5 Moreover, the FRI requires only about one minute for a patient to complete, and about 20 seconds for a health care worker to score – a fraction of the time required for any of the above three measures.


  1. Beurskens AJ, de Vet HC, Koke AJ, et al. Measuring the functional status of patients with low back pain: Assessment of the quality of four disease-specific questionnaires. Spine, 1995;20:1017-28.
  2. Brunelli C, Zecca E, Martini C, Campa T, Fagnoni E, Bagnasco M, Lanata L, Caraceni A. Comparison of numerical and verbal rating scales to measure pain exacerbations in patients with chronic cancer pain. Health Qual Life Outcomes, 2010;8:42.
  3. Fairbank JC, Couper J, Davies JB, et al. The Oswestry low back pain disability questionnaire. Physiother, 1980;66:271-3.
  4. Feise RJ, Menke JM. Functional Rating Index: A new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. Spine, 2001;26:78-87.
  5. Feise RJ, Menke JM. Functional Rating Index: literature review. Med Sci Monit, 2010;16:RA25-36.
  6. Jensen MP, Karoly P: Self-report scales and procedures for assessing pain in adults. Handbook of Pain Assessment, 2001;2:15-34.
  7. Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther, 2012;42:30-42.
  8. Ruta DA, Garratt AM, Wardlaw D, et al. Developing a valid and reliable measure of health outcome for patients with low back pain. Spine, 1994;19:1887-96.
  9. Turk DC, Dworkin RH, Burke LB, Gershon, et al. Initiative on Methods Measurement and Pain Assessment in Clinical Trials: developing patient-reported outcome measures for pain clinical trials: IMMPACT recommendations. Pain, 2006;125:208-215.
  10. Vernon H, Mior S. The neck disability index: A study of reliability and validity. J Manip Physiol Ther, 1991;14:409-18.
  11. Yelland M, Hooper A, Faris P. Minimum clinically important changes in disability in a prospective case series with chronic thoracic and lumbar spinal pain. Int Musculoskel Med, 2011;33:49-53.

Ron Feise, DC, is the president of the Institute of Evidence-Based Chiropractic, an organization that helps chiropractors achieve optimal patient outcomes through the use of evidence-based strategies.

Click here for more information about J. Michael Menke, MA, DC, PhD.

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