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Dynamic Chiropractic – April 12, 1991, Vol. 09, Issue 08

The Problem with Progress Notes

By Brad McKechnie, DC, DACAN
Quantifying a patient's pain is one of the more difficult and time consuming tasks that the chiropractic physician must perform during each office visit. Most institutions and risk management experts agree that effective progress notes should include the subjective assessment of the patient's progress, an objective assessment, an assessment based on the subjective and objective findings, and detailed notes as to the type or types of treatment rendered at each office visit.

Most of us come to the realization that this becomes incredibly time consuming and unwieldy as the practice grows. I found most of my time was occupied during the office visit with the subjective portion of the daily progress notes. It seemed that in an effort to accurately interpret and write down the patient's subjective findings for the day there was no time left to treat the patient and record the objective and treatment data for that office visit.

The outcome of this scenario is the production of inaccurate and scanty progress notes. Another problem presented by this format for daily progress notes is the potential of malpractice. A typical course of events resulting in a lawsuit against a doctor would start by the patient claiming that he or she was injured by the doctor. The doctor would counter this claim by producing the daily progress notes where the statement, "Patient feeling better," or a close equivalent, would be found. The plaintiff's response to the doctor's progress notes is, "I never got better," or "He hurt me ... I don't know why he wrote that I was doing better ... because I didn't get better." At this point in the proceedings the legal system has to decide which party is telling the truth.

After review of several malpractice cases, I decided to change my office procedure for daily progress notes in order to close this potential loophole by having the patient fill out his or own subjective progress notes at each daily visit. While in the waiting room, the patient is required to fill out the entire front side of the daily progress note sheet. After they fill in their name, date, and time (A), they proceed to fill out a pain drawing corresponding to their symptoms for that day. The patient is instructed to indicate the origin, the quality, and the radiation of the pain (B).

The patient then proceeds to the analog scale (C) and rates his pain for the day. Following this, the patient is asked to complete the "dollar's worth of pain" portion of the daily notes. In this section, the patient is told to list his level of pain for the day, based on the premise that their pain level at the first office visit was at the $1 level (D). This figure lends some idea as to the percentage level of improvement that the patient has experienced. Lastly, the patient is required to fill out the bottom section of the page (E) which pertains to changes in the patient's condition.

Once the patient has filled out the front portion of the sheet, I make use of the back side of the sheet. There is a spot (F) for additional history updates. The objective portion of the assessment is performed in section (G). This section may also be used for re-examinations. Physiological therapeutic modalities employed at that office visit are charted in section (H) and detailed notes on manipulative procedures are charted in section (I). The bottom of the page (J) is used to list recommendations given to the patient, the time of the next office visit, or other pertinent data.

When I switched over to this format, I found that my time in the treatment room actually decreased and my progress note accuracy increased because the patient performed the bulk of the time consuming subjective assessment in the waiting room. The strength of this system lies in the fact that patients record their subjective findings. Thus, the doctor is relieved of the duty of trying to interpret the patient's symptoms and a possible breeding ground for a malpractice proceeding is alleviated.

Recently, a prominent malpractice attorney was visiting Texas Chiropractic College and I had the opportunity to visit with this attorney during her campus visit. I showed her this progress note format and asked her what kind of effect this system would have on her business. She replied that she would probably see a 95 percent reduction in the number of malpractice cases if doctors were to use this format for their daily progress notes.

Brad McKechnie, D.C., D.A.C.A.N.
Webster, Texas

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