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Chiropractic News

November 2005

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Guidelines, protocols, and flow sheets: Tools for your practice

Do you “shoot from the hip” — use your own methodology — in managing your patients’ cases? If you do, you will find that things are changing. Guidelines, protocols, and flow sheets are becoming the norm in case management.

If you are skeptical of their usefulness, think of guidelines, protocols, and flow sheets as tools to help you treat your patients more efficiently and effectively.


A highly significant trend in healthcare has been the development of utilization guidelines. Evidence-based healthcare is driving the need for guidelines, and increasingly, the evidence exists to support (or refute) the use of various treatments for commonly encountered conditions. Guidelines are framed as recommendations for best practices in prevention, diagnosis, and the treatment of common conditions.

Essentially, utilization guidelines recommend initial treatment for anticipated clinical situations and then attempt to answer the question “what next?” if a patient doesn’t respond as expected.

Guidelines are not meant to replace your judgment or expertise. Rather, they provide a ready reference as you manage your patients’ cases. Guidelines also benefit patients by letting them know where they stand in the treatment process and why.

Despite their shortcomings, utilization guidelines represent a welcome new era of rationality to what has traditionally been perceived as the least scientific of disciplines — manual medicine. In the future, they may serve to displace the HMO-imposed six or less visit “screens” that dominate case management today, although they have gone largely unchallenged from a scientific standpoint.

Ultimately, guidelines may reduce the lack of standardization in case management between individual practitioners and may standardize the outcomes expected from therapeutic intervention.


Treatment protocols are care paths, based upon accepted utilization guidelines and a consensus among the healthcare delivery team, that organize the diagnostic and therapeutic services appropriate to a patient’s condition. They also indicate how often each service should be performed.

Essentially, treatment protocols map out case-management decisions and are individualized according to each patient’s specific complicating or attenuating factors. They summarize what is to be done, how often, and for how long.

Treatment protocols consist of three basic components:

  • Diagnostic procedures,
  • Passive interventions that may be provided by the practitioner, and
  • Active interventions that patients may perform on their own.

All treatment protocols, centered on a plan of intervention and monitoring, map the processes and chronology that practitioners go through in making their clinical decisions.

Treatment protocols do not provide “one size fits all” care. But, they do offer a more efficient approach to case management. They give you a base that you can modify, depending upon an individual patient’s needs. By using and modifying a protocol, you do not have to create one from “scratch” (or memory) each time you provide care.

Treatment protocols provide a concise methodology for the application of care over the duration of the case, whether the care is brief and episodic or long-term. Each patient responds uniquely to the care he or she receives. Through regular reassessment of the clinical progress, you can change treatment protocols to reflect the level of patient progress.

Treatment protocols also make possible the retrospective reconstruction of the clinical decision-making process. Well-organized treatment protocols capture the details of the courses

of action that were performed throughout care.

Without the benefit of a treatment protocol, it may be difficult for you to remember exactly why you approached a specific situation in the way that you did. Treatment protocols help to coordinate care and keep everyone on the healthcare delivery team on track. Everyone knows what is going on all the time.


Managed care, multi-provider practices, and increased medicolegal regulation require thorough clinical documentation. At the same time, the realities of business and reimbursement constraints necessitate that this documentation be as efficient as possible.

Case-management flow sheets are an effective means to template patient evaluation, care, and the procedural approach that a practitioner would ordinarily use in case management. With a minimal amount of time, some consistent practice, and well-designed flow sheets, practitioners can maintain high-quality case management within the time constraints inherent in contemporary practice.

Flow sheets are “case-at-a glance” documents that indicate the stage at which particular diagnostic, therapeutic, and evaluative services may be recommended. This methodology allows you to map and monitor changes in the patient’s condition, which then documentis the effectiveness of treatment.

The documents lay out the major events in patients’ care on a visit-by-visit basis. As procedures are performed, they are checked off. This maximizes the efficacy of care delivery and ensures that necessary procedures are not inadvertently overlooked.

An advantage of case-management flow sheets is that they serve as an ongoing reminder to include an entry for each dimension of the clinical management process.

If you use flow sheets:

• Use standard abbreviations. Because of space constraints on the forms, flow sheet use abbreviations. These abbreviations must be standardized and used consistently by all clinic personnel. It is essential to have a key of abbreviations used in the practice that can be referred to or supplied for third-party review. Some jurisdictions even have laws or policies requiring this.

• Select a flow sheet based on appropriate protocol. Guidelines suggest treatment protocols. The protocols dictate which flow sheet should be used. All depend upon the patient’s condition.

A good type of flow sheet is the reverse-process type which lists every procedure in the protocol. Each one is performed, unless you consider it unnecessary and exclude it by striking through the procedure with a single line.

• Establish office procedures concerning the use of flow sheets. Train your records-personnel staff to place a case-management flow sheet in each patient’s chart for review, on each occasion the patient presents to the practice.

• Perform chart audits regularly — at least once per quarter. The goal of these audits is to assess the appropriate use of the flow sheets. Audits should show new flow sheets in each patient’s chart whenever a patient presents with a new condition, recurrence, or exacerbation of a current condition. The original flow sheet should be left in the chart for purposes of documentation.

The application of utilization guidelines, treatment protocols, and flow sheets to case manage-ment ensures consistent, high-quality care and simplifies the assessment of patient progress and practice compliance. Most importantly, it keeps your focus centered on your patients.

Headshot Mark SannaMark Sanna is the CEO of Breakthrough Coaching, a practice-management consulting firm. He can be contacted through his Web site, or by telephone at 800-723-8423.

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