The "Great Opportunity" for Chiropractic: Expanded Scope of Practice
Your Report of My Findings, "Medicine Presents: A Great Opportunity" [May 15 issue], was interesting, but I was disappointed by your conclusion and left feeling empty.
I think the reason chiropractors are not mentioned is the fact that medicine does not think about our profession whatsoever, except possibly when an occasional patient mentions it as a concurrent part of their medical care.
Our scope of practice, as defined and strictly limited by Medicare / Medicaid, is of little consideration, use and certainly not appreciated by medicine and upwards of 95 percent of the population.
Furthermore, I feel that the profession is barking up the wrong tree in merely trying to figure out how to be paid by Medicare for providing just one single aspect of our licensed services: "correction of subluxation." I think we need to tackle Medicare and regain our full scope of practice (exam, diagnosis, ancillary therapies, imaging, etc.).
We need to be recognized for what we do, and then perhaps we would be paid for what we do. I do not like Medicare limiting my scope of practice against what my license says I can do. I also support expansion of license to allow advanced-practice certificates to be issued to those who desire and are willing to take additional training.
I believe that with an expansion of our scope of practice, so will follow the "great opportunity" you speak of. We won't get there by avoiding the question / topic. We won't get there by doing the same thing over and over, expecting different results. We won't get there by offering cash-paid alternative therapies such as lipo laser, diet / weight-loss programs, hypnotism, etc. (nothing wrong with those) to make up the difference because we aren't fairly paid for our standard and limited chiropractic adjustment.
I hope you get on board with expansion of our scope of practice. If we don't do it, other less qualified professions certainly will.
Michael Lynn, DC
The SOAP Note: An Effective Tool for Documentation
In a recent article, Dr. James Edwards stated that the established SOAP note medical record-keeping protocols are "wrong" for practicing chiropractic physicians ["SOAP Notes: It's Time for a Cleaning," May 15, 2013 issue]. He references a recent previous article authored by Dr. Ronald Short, who also claims SOAP documentation protocols do not meet the needs of the practicing chiropractor, to further support his position ["SOAP: A Chiropractic Perspective," March 1 DC].
Edwards was quite vague regarding his concerns. He stated his displeasure with the ACA committee, particularly an "ACA officer" with whom he was interacting, either directly or indirectly; and that, to his chagrin, he was overruled on a medical documentation issue I assume involved documentation standards.
Both Edwards and Short either do not understand the SOAP process or do not understand the importance of medical records that are an accurate reflection of the actual patient encounter. With this said, I am grateful the ACA committee, and the officer in question, stood their ground on this issue and that their action hopefully prevented one more chiropractic outlier system.
The dominant medical documentation model is SOAP. The SNOCAMP expanded model is also available and provides an expanded opportunity to organize data and make the information more accessible.
Like most health care professions, the chiropractic profession provides vital and important services to the public. It is gratifying to see the chiropractic profession now gaining some recognition for the contribution we provide to the public good. And while our share of the current health care pie is small compared to others, when we consider incidence of nonsurgical musculoskeletal disorders as a public health issue, we are establishing ourselves as a viable option in this domain.
These advances have not been easy. We as a profession had made contributions that will point us in the right direction and as the chiropractic profession matures, we will become an increasingly an active player within the health care community. That said, we are not there yet.
The strength of our educational institutions and the admission standards to those institutions must be constantly improved upon. The research contributions to the core of knowledge particularly in musculoskeletal disorders is essential, and as the profession matures so must the research sphere of investigation expand. Self-regulation and standards of care to include "best practices initiatives" are essential for us to establish the moral high ground as a profession focused on the public good.
Medical record-keeping is just another part of this equation. The chiropractic profession has traditionally been a poor player in the area of medical record documentation. As a participating member of the health care community, we have the responsibility to provide medical records that permit different members of the health care team, or successive HCPs, to have access to relevant data concerning the patient to see what procedures have been performed and with what results.
Historically, this has not been the case, as we have (and many still do) relied on abbreviated "check the box" office records to document the events of the patient encounter. Even among our own profession, peer to peer, we often find ourselves struggling to understand another chiropractor's records. With the advent of EMR, this mindset still persists, as many electronically generated daily notes produce canned and voluminous notes that often do not reflect the doctor-patient event in useful terms.
To generate useful medical records that meet the established standards of documentation requires time, but "who gets paid to write notes?" Well, actually we do! As a case in point, consider the 9894 CPT series for chiropractic manipulation: there are three sections to this code series: the assessment component, the work required for delivery of the procedure, and documenting the details relating to the service provided.
It is doubtful that "check-off format" progress notes will provide the details to meet necessary documentation standards required of a responsible member of the health care community. Canned EMR SOAPs create a lot of paper in the folder, but typically poorly reflect the details and interaction of the doctor-patient encounter. Many chiropractic electronic progress notes programs generate medical records that produce volume and lack substance. We must demand more of ourselves and those vendors who sell their EMR products to us.
Fortunately, there is a format available to use that addresses all these stated shortcomings – the SOAP note. So, what does the SOAP note do and why is it an effective medical record-keeping format for health care practitioners including chiropractors? The subject of effective medical record-keeping is too voluminous to address in this brief letter, but for those committed to quality, I would suggest a resource text on the subject would be a worthy addition to one's medial library. While there are many other resources equally of value, as a suggestion to the reader a practical text to consider might be: Writing SOAP Notes, by Ginge Kettenback, MS, PT (clinical education coordinator, Christian Hospital Northeast-Northwest and adjunct asst. professor, St. Louis University.] Publisher: F. A. Davis Company.
Ronald O. Williams, DC
Treating Patients Goes Beyond Following Established Protocol
Reading the letter from Dr. Strasser in the April 15, 2013 issue ["Big Problems With Disc Article"], I was really surprised when I got to the part where he states, "We can't address this crisis if we can't follow established protocols in treating spinal conditions, the core of our current acceptance in the health care arena ...
Hopefully this article will not end up in a neurosurgeon's hands as a summary of the chiropractic approach to disc injuries. I think most of us would be embarrassed if it did."
Poor fellow, he has a DC after his name and he wanted an MD, ND or possibly a CNA. Doesn't he realize that we are the neurosurgeons' competition and as long as we get results even after they have failed, we are taking food out of their families' mouths along with boats, expensive cars etc.?
At least half of what I do to my patients does not follow established protocol. They come and refer to me because of results. This includes MDs, nurses and druggists.
To Dr. Todd Turnbull [whose Feb. 1 article in DC, "Protocols for Managing Lumbar Disc Injuries," spawned Dr. Strasser's letter], I have one thing to say: Hang in there. We would no longer be a profession if all we did was follow established protocol. We would still be using HIO technique on a side-posture table, waiting for more deaf black men to come in.
Worrying about what a neurosurgeon might think if perchance, he should have his attention drawn to this article, is like the optometrist who fell onto his grinding machine and made a spectacle out of himself. Figure that one out.
E.M. Whitman, DC
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