Docs, Documents and Integrated Care: The Cooperative Formula
By Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM
None of us works in a vacuum. At some point, we find ourselves having to interact with other medical professionals, whether it is in a hospital setting, with the referring medical doctor or another health care provider such as a physical therapist or an acupuncturist.
Integrative care, the treatment of conditions that require a team of health care practitioners, requires a cooperative approach that is heavily dependent on high-quality, in-depth documentation. Without it, patient care suffers, perhaps disastrously. Accuracy and clear records benefit the patient, you and the entire chiropractic profession.
Recently, I consulted with a neurologist on a mutual patient. I like to consider her one of my miracle cases. Not only had her post-CVA symptoms responded well to care, but she was now also able to be up and about without the use of a wheelchair. The problem was, without my notes, the neurologist would have never known that.
In fact, the patient had returned to his office, in the wheelchair, stating her need for more narcotics. After reviewing my notes, he was able to be more accurate in his care of the patient. He called and thanked me for keeping him informed of the patients' condition.
I have known chiropractors who prefer to save up data and offer a summary after eight, 12 or 20 visits of care. This approach is reckless and unprofessional. I have also seen chiropractors use computerized note systems that generate a pre-formatted note for every visit; leading to weeks and months of redundant treatment notes that show no progress in patient care. This type of record-keeping is sloppy and only serves to show how ineffective chiropractic is.
There is a standard of patient care in this country that is clearly defined. It is dangerous to think that because we are chiropractors, we do not need to keep records to the same degree as medical doctors. We must learn to think outside the chiropractic bubble in terms of health care in general. Ultimately it is the patient that we take care of, not the insurance companies, attorneys or other doctors. Whether or not you feel obligated to document your case, responsible patient care mandates it. Chiropractic deserves every bit of respect that any other health profession does, but that respect comes with a level of responsibility. Yes, it is a pain, yes, it takes more time, but like it or not, documentation paperwork is part of professional health care.
It Begins At First Contact
Whenever you encounter a patient, there should be some level of documentation. The classic way of keeping daily notes is in the "SOAP" (Subjective, Objective, Assessment, Plan) format. This is the outline for the information you need to keep on every patient encounter on every visit. Using this format makes it simple for any other practitioner to follow along and understand the care you have given the patient, thus allowing for a seamless treatment regimen.
Subjective - This is commonly where you note how the patient is feeling at this encounter. Information in this section of your notes should also include any changes in how the patient feels or functions since the last treatment. Did the patient see any other practitioners (medical, acupuncture, massage)? What diagnoses or treatment plans were given? Was any other care given? How did these treatments affect the patient's level of complaint?
Objective - What were your findings today? This does not have to be a full, complete, formal exam report on every visit, but you should be able to note some degree of quantitative findings on every visit. The comment "unchanged" is not acceptable because this only serves to show your care is ineffective. Is there any change in muscle spasm? Is there any change in motion or function? These should be noted even if they are only minor changes. Other non-tangible changes should be noted such as a decrease in medication or increase in work function. These types of findings give a daily record of how your patient feels with progressive care. This section should also include any discussion of other diagnostic studies or evaluation reports you have received since the last patient encounter such as radiographic reports, functional capacity exams, EMG summaries, etc. These should all be referenced in your daily notes.
Assessment - Your interpretation of the patient's subjective complaints, the objective findings, the current diagnoses and your perception of their overall condition today. This is also where you should note your thought process. Why did you take x-rays? For what purpose? Or: Why did you choose to not refer for an MRI? Why are you doing a particular therapy? You must give a thought process and rationale for your care plan and treatments.
Plan - This is not only the treatment you provide today, but also your plan for future visits. The standard of care dictates that you clearly define what you did. There are a number of clinical forms that provide you the ability to "check off" what you did, but this gives no detail. To what areas did you do muscle stimulation? For how long? What regions of the spine did you adjust? What rehab exercises were done? How many repetitions? At what level of resistance? These questions are all tedious, but this is clinically relevant data that you are responsible for in the care of your patient. You must provide clear, accurate, information contemporaneous to the visit.