It's Negative: Everything Counts in Clinical Record-Keeping
By K. Jeffrey Miller, DC, DABCO
"Negative results are just what I want. They're just as valuable to me as positive results. I can never find the thing that does the job best until I find the ones that don't." – Thomas Edison
Most inventors consider negative results to be failures. From the quote above, it is obvious Thomas Edison thought the opposite. He considered negative results valuable, as though they were small victories. This attitude is reflected in another famous Edison quote, "I am not discouraged because every wrong attempt discarded is another step forward."
Edison's views of negative results are similar to health care's views of negative results: They are good news, victories. In health care, a negative test means the patient is fine, does not have a condition or has overcome a condition.
Fortunately, negative results are more common than positive results for most patients. However, patients occasionally consider negative results to be a bad as the positive results. Some become upset when they have paid for an expensive test that proved they were free of cancer or some other disease. They think they have "wasted" money.
Doctors can view negative results in an adverse way and seemingly downplay their importance. This is noted frequently in a doctor's record-keeping. Many doctors have the habit of only recording positive findings. Questions and tests that are negative are left blank or unmarked.
This can create several problems for the patient and the doctor. For the patient, it isn't an accurate depiction of the status of their health at the time of diagnosis or treatment. The old saying, "If it isn't written down, it did not happen or does not exist," holds true. This can prevent the patient from receiving appropriate care from another provider at a later date. The patient may have to see another provider in the same practice or a provider in another practice.
The patient may also return months or years later to see the same practitioner. Incomplete records could force the practitioner to rely solely on his/her memory of previous encounters. It is not unusual for a patient to return and say, "I want you to do the same thing you did last time, it worked great." If the doctor barely remembers the patient, much less what procedures were performed, this situation presents a problem.
Failure to record all results, both positive and negative, can also prevent the patient from receiving reimbursement from a third party due to insufficient records. This affects the patient and the doctor financially, and can create a loss of income and strained relationships.
Liability & Malpractice Issues
The doctor has an obligation to the patient to produce good records in all third-party matters. Issues of liability and injury are hard to settle with poor clinical records.
Another significant concern for the doctor is failing to record all results is malpractice liability. The doctor's primary defense in malpractice is based on the records. An incomplete record may provide an incomplete defense.
If a doctor's forms or electronic health care records have 50 tests the doctor uses for routine examinations and diagnosis, and only 12 test results are recorded (the positive findings), it appears that the doctor only performed those 12 tests. The notes appear incomplete or brief.
The doctor can claim that he/she only marks positive results, but the opposition can make a very compelling argument that the doctor performed only a small portion of the examination. This could lead to accusations of cutting corners, poor care, missed or wrong diagnoses, and inappropriate care. In other words, a doctor's actions or inactions can be made to look like malpractice, even if they were not. Thus, good notes are a smart risk-management strategy.
Damaging the Profession
Professional appearance is another issue. More than once in recent years, Medicare has reviewed chiropractic Medicare billings and the records intended to justify the billings. Each time, the published results have been embarrassing. Many of Medicare's complaints were about the quality of what was in the record, but what was missing was also a concern.
This is more than just failing to record negative test findings. A lack of history findings, treatment plans, short-term goals, long-term goals, PART notes, the regions / segments adjusted, visit schedules, progress evaluations and signatures have been noted with each Medicare review.
Conceding that Medicare is frequently unreasonable in its policies, reimbursement, communications and other areas, it is still disappointing that as a profession we cannot come close to meeting Medicare standards – especially when those standards have not changed significantly since the year 2000, with the introduction of the PART system. Medicare has added emphasis to outcomes recently with the advent of the G-codes, but this is the largest change since the year 2000.
Our poor record-keeping skills continually provide Medicare with the ability to deny claims, ammunition to justify low reimbursement and excuses for its refusal to reimburse for additional chiropractic services.
Better records will make some headway with Medicare. Research could also help with Medicare and in many other areas where chiropractic struggles. More research is needed in the profession and some of that should come from the field: the offices of chiropractors across the country.
In order for this to happen, one of the key factors to success will be the quality of the records kept; records in which all results, positive and negative, are recorded accurately.
The Bottom Line
In his book What Is Medical History, John Burnham states, "One major way of understanding a thing is to know what it is not." This is a poignant statement that returns us to Edison's views and sets the stage for a final thought. Some conditions / diseases are difficult to diagnose other than by exclusion. Negative results count here more than in other situations. If a gold-standard test does not exist for a condition / disease (and for some, it does not), exclusion through negative results can prove to be invaluable.
Diagnosis by exclusion can be a slower method of diagnosis, but if another way does not exist, then it is a valid method. It is a method that should not be discounted or forgotten.
Everything counts in clinical record-keeping. It isn't a task forced on doctors for no legitimate reason. It is something that is best for the patient, the practitioner and the health care professions involved. There are ethical and legal standards for it. In short, it is part of your job.
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