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If we want to be included on a parity basis in hospitals or in front of legislative bodies, we should be prepared to compete in competency. Our patient records must show complete attention to detail, and that sadly, is where most of us fail.
Where most physicians are concerned and certainly chiropractic physicians are no exception, the spin off of managed care has caused an intense increase in paper work. Everything from pre-certifications to post-treatment reports have been accelerated at an uncontrollable rate. Offices across the nation are faced with the issue of controlling internal office expenses while not foregoing the quality of patient care. The problem which presents itself is do I hire more staff just for the insurance and paper work or do I attempt to increase the productivity of my already overworked staff?
The solution to these questions isn’t an easy one. Most of us have found that our staff’s efficiency gravitates toward their individual areas of expertise. Those areas that seem to be their nemesis tend to be left on the back burners of the work pile until necessity dictates the paper work be finished. As a chiropractic physician who has worked for years in the field of hospitalization as well as the private office, I have been faced with a double dose of this problem. Some of my cases have included ER visits, hospital stays, post-hospitalization follow-ups and then motor vehicle accident litigation. These types of cases demand not only the continuity of patient care, but continuity of the record keeping as well. From the surgical centers where the MUAs are performed to the in-patient treatment arenas of the hospitals, dictation machines are utilized. From the history and physical to the surgical dictations and right through to the discharge summaries, notes are dictated and then typed by staff. Those records are neat, orderly and show a progressive course of treatment.
Our chiropractic offices must show that same attention to detail, and sadly for most of us this is where we fail. State Boards, peer reviewers, and the Mercy Guidelines have all delineated the data that should be minimally included in our office notes. Recently the Wisconsin Hospital Association has suggested that hospitals considering admitting DCs to their staff include in their preliminary application process a look into the quality of the DC’s private office records. Their concern was if a DC could not keep adequate records in his or her own office then how could they expect to keep the records so necessary in the acute care arena? The point should be well taken. If we expect to be included with the other physicians on a parity basis whether in the hospital, our private offices, or in front of legislative bodies, we should be prepared to compete in competency. That would include addressing the issue of records.
In my role as an educator and hospital chiropractor, I have been privileged to review the examination techniques of various types of physicians. I have observed osteopaths, medical doctors, pediatric physicians and chiropractors as they examined their patients. I have witnessed the thoroughness of complete physicals as well as the brief office examination, and I’m proud to say that I would stack up the chiropractic examination against any performed by any other discipline. When I then examine the records that are generated from those examinations, I have found that they do not convey the entirety of what was examined. In fact, most DCs are now charting by exception, which is an archaic method of charting and is discouraged by most hospitals. In this case the DC lists the positive findings and then states something such as:
“All findings not listed as positive are negative.”
This is neither a complete record nor an acceptable one. As has been proven in courts throughout the country, lawyers have been successful at reducing the charted exceptions as being not performed, therefore the record becomes incomplete.
Faced with these problems, we at our office determined there had to be a solution to this problem of time management versus costs. We decided to explore the possibility of having technology correct the problem. Our list of concerns was probably similar to those of most busy DCs. We had to control the flow of paper while not increasing our staff or overworking our existing staff. The solution needed to fit our existing office procedures and the incidence of error had to be minimal. The most important criteria to us was that the solution had to be flexible. I wasn’t interested in canned SOAP presentations where the verbiage isn’t reflective of the individual; or a note system that randomly selects verbiageas those are not reflective of the face-to-face discussions between doctor and patient. The solution also had to be complete enough to reflect both the positive and negative findings. The last of my criteria was that the system had to afford me the flexibility of working in all three treatment arenas (hospital, convalescent centers, and outpatient).
When I teach record keeping, the key components of the symptoms must include the exact location of the complaints as well as any complicating factors. The duration of the symptoms and the frequency of occurrence must be included. My records would not be complete if they didn’t address the symptomatic response following the last treatment and the present severity of the complaints. Therefore, a complete symptom record should say something such as:
“Ms. Betty Jones entered our office today complaining of right sided suboccipital headaches. These headaches worsen throughout the day and when intense last between three and six hours. Betty indicated that the pain is moderate to severe in nature and increases with activity. Ms. Jones further states that she received only temporary relief from her headaches, following her last treatment.”
“Ms. Jones also suffered from right sided neck pain and associated stiffness. This pain also worsens as the day progresses and would increase with cervical function. The pain was moderate in nature, and Betty indicated that the more active she was, the worse the neck pain became. Ms. Jones indicated that her neck pain was reduced following her last treatment.”
Every chiropractor I associate with asks those questions of every patient who enters their office and yet very few doctors chart the symptoms as thoroughly as this. Yet if we are going to be accurate, we should be charting this completely on each visit. The term “symptoms, unchanged” or “no response” is no longer adequate.
The evaluation aspect of the record should include the palpation of the joints being examined both from a motion and static basis and each should be listed individually. Further palpation should include the soft tissues either surrounding the joints or affected by the involved joints. These are findings utilized by most DCs on their daily visits with their patients. An example of how that might be charted is as follows:
“Ms. Betty Jones: The palpation of the following osseous structures were in aberrant position when Betty was in a relaxed posture: C6, C7, T1 and T4. Additionally palpation of the following structures as they moved through various planes of motion indicated that they move in an aberrant fashion: C6, and T1.”
It should be noted that this is a minimum of osseous palpation which each DC routinely performs on each visit in their office. Yet many of these findings are never charted.
“Soft tissue palpation of Betty Jones. Palpation of the soft tissues revealed the following findings: The right side of the upper cervical spine was determined to be hypertonic with spasms. It was also determined to be tender to touch. The right upper division of the trapezius muscle was in spasm and was determined to have trigger points. The right deltoid muscle was determined to be hypertonic. The upper thoracic spinal areas were tender upon palpation and edema was present on the right side.”
Again this does not make the note complete but as far as palpation is concerned, this note is representative of findings typical in a DC’s office. If instrumentation is utilized, there needs to be a section on instrumentation which would say something such as:
“A dermathermagraph was utilized on the patient’s cervical and thoracic spinal areas today, and revealed the following findings: a deviation from the normal graph was identified at the level of the C6 dermatome on the right side.”
If treatment other than adjustments are utilized in your office, it is important to indicate what those treatments were and where they were applied. An example of those might be:
“Ultrasonic therapy was applied to the left and right sides of the cervical spinal areas, including the upper division of the trapezius muscle bilaterally. Micro-current was then applied to the area of the upper cervical spine bilaterally.”
(If your treatment plan is complete, then the rationale for this treatment has been included in your records which affords a third party the flexibility of reviewing your plan as well as the rationale of treatment).
Your daily note should also include a section for the adjustment. This section should identify which segment is being adjusted, how it is being adjusted and why. A statement such as:
“The following structures were provided a specific adjustment to correct static malposition and right sided aberrant motion dynamics: C6 and T1. The adjustment was accomplished by the utilization of diversified technique.”
Finally, the last section should include a statement indicating where the patient is in the treatment plan. If the patient is 20% improved then this should be stated in the note. Not all notes require this statement but it should be included every ten or fifteen visits. It clarifies the direction of treatment and assists the doctor in determining exacerbations from lingering care.
Obviously when creating a note this involved, time becomes the issue. While it is easy to ask these questions, writing down the responses can be quite involved. Our office was at this point when we decided to explore the possibility of computer generated notes. There were several different types from which to choose, but each had their limitations. Some were too simplistic while others were too time intensive. Most were simply not complete enough for our office. We run a group practice in which we have a certified chiropractic sports physician, a chiropractic acupuncturist and a pain manager. We work together for the common good of the patient, yet we each have differing needs from a note system. Therefore completeness was paramount to our success.
After testing nearly twenty different systems we selected an automated clinical notes software system that utilized hi-speed scanning technology. The system comes with an entire suite of scannable forms that can be completed while the doctor discusses with the patient how they were feeling. The scannable Daily Notes form acted as a travel card and was utilized in billing as well as note generation. This reduced the need for a second form and everything could be accomplished by one staff member. We required no additional staff and the training was simple, fast and effective.
Ben C. Eubank DC, DACPM is the former Department Chief at Scottsdale Community Hospital in Scottsdale, Arizona. He currently is in private practice and is an Associate Professor at Bridgeport University in Connecticut.