Recordkeeping for risk management
By Marty Kotlar, DC, CHCC, CBCS

I just opened a new chiropractic office and want to make sure that my documentation is accurate, especially when it comes to risk management. Please point me in the right direction.

There is a saying in medical circles, "If it isn't written down, it didn't happen." In today's healthcare environment, this statement has more relevance than ever before. Malpractice insurance carriers, Medicare, managed-care organizations, and other entities have all increased their demands for extensive and thorough clinical documentation.

Your patient documentation must accurately reflect your clinical thought processes. Specifically, it must tell how the patient has progressed since care was initiated, and how you measured the progress. The documentation starts with SOAP notes (subjective findings, objective findings, assessment, and plan):

• Subjective findings. During the initial session, while taking the patient's history, collect information about the patient's own perception of his or her condition. This part of the clinical database is subjective.

• Objective findings. The medical history, physical examination, and x-rays (when clinically indicated) are considered the objective components of the clinical database.

• Assessment. Integrate the information you collect about the patient and develop a diagnosis or impression of the patient's current status. This is termed the assessment.

• Plan. Based on what you determine to be the patient's problem, now plan your course of action.

Your plan will include such things as chiropractic adjustments, passive modalities, active therapeutic procedures, and, if necessary, further diagnostic procedures.

Include in your written plan patient goals that include feasible timelines. For example: If you set a goal of improving range of motion, document that you would like to see the patient transition from severe restriction in forward bending and needing assistance putting on a pair of socks to not needing assistance within two weeks.
If the patient lives alone, clearly explain why you chose this goal and how achieving it will increase independence and improve quality of life.

SUBSEQUENT DOCUMENTATION

Each time a patient returns, briefly recheck the patient's subjective status (what he or she has experienced since the last visit), examine objective chiropractic indicators (such as palpation findings, levels of articular dysfunction or subluxation, location of asymmetry, muscle tightness), make an assessment, and modify the treatment plan.

Update your documentation by relating the patient's current condition to initial goals. For example: Instead of simply writing "Initial goals continue to be realistic," state, "Goals will be met in ___ more visits" or "Treatment will be extended for ___ more weeks."

Also, if applicable, add information, such as, "The prescribed low-back exercises were too painful and had to be eliminated," and go on to explain the activities you will do with the patient.

RE-EVALUATIONS

Re-evaluations are typically a required part of any prolonged course of treatment, or after a prolonged period of a patient's absence from care. Re-evaluations assure that the course of treatment is providing the anticipated, desired results. They also represent a method to demonstrate to the patient the progress being made.

It's essential to re-evaluate patients who have had a lapse in between visits or when they present with new or different symptoms or whenever the course of treatment elicits an unexpected or negative response.

In addition, consider a re-evaluation any time the patient fails to respond within a reasonable period of time.

Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, Inc., is offering continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, at drkotlar@targetcoding.com, or through the Web site www.TargetCoding.com.