Have you ever read a story or a book, only to come to the end and feel like it had no ending; no cliff hanger, no idea if there will be a sequel—just nothing?
Similarly, the documentation story of your patient’s active treatment deserves an ending, too.
All too often, the story of a longstanding patient in your office is simply a run-on accounting of every time they’ve been to see you over the past 10 years. Unlike a good book, there are no chapters with great beginnings, middles and ends.
Certainly, it’s your intention as a provider to strive toward the end of crisis care and into wellness or supportive care. One of the easiest ways to make a major improvement in the story of your patient’s experience with you is to include a written discharge summary at the end of each active episode of care.
The final plateau
The term “discharge,” in this context, does not mean to kick the patient out of your office for good or to tell them they are done with chiropractic care. It only means that they have come to the end of this active episode of care, and are ready for pro re nata (PRN) care, to return as needed, or to begin a course of wellness or supportive care.
Most of the time, discharging a case is straightforward. Either the patient responded well to treatment and met all their treatment goals, or they improved but still have some residual symptomology present, or the patient did not respond positively to treatment and is being referred to another health care professional.
It can be as simple as conducting a final examination and documenting in the record that the patient has been discharged from this episode of care and what next steps have been recommended and why.
The Council on Chiropractic Guidelines and Practice Parameters offers treatment algorithms for neck and back pain that include the concept of maximum therapeutic benefit, also known as “final plateau.” Essentially, this means that the patient has reached a final degree of improvement and a complete or partial resolution of the condition has been achieved, such that the patient is unlikely to improve further.
The final exam or visit includes an assessment with the statement: “The patient has reached maximum therapeutic benefit and is discharged from this active episode of care. The patient is instructed to….” Here is where you outline the next steps, e.g., “return as needed,” “follow a maintenance schedule” or something else. Putting a “pin” into this episode allows you to show that this patient’s episode is over, so that you can effectively document a new episode should one exist in the future. This could be the same condition, a new condition, an exacerbation or a reoccurrence. Either way, it will be a clear, new beginning, like a new chapter in your patient’s story.
Continuing the story
Your patient may not be ready for full discharge. There could be new co-morbidities, new injury or re-injury. Maybe they’ve had a work condition change. At this point, you should reassess the patient, set new treatment goals within a treatment plan and include the following statement: “The patient has not reached maximum therapeutic benefit at this time because….” This is the segue that outlines why the patient is receiving more active care at this time, rather than being discharged from further treatment.
Self-dismissal and documentation
Then there are the patients who may have dismissed themselves from care prior to the completion of your recommendations for any number of reasons. They may or may not tell you about this. There may be financial or personal issues that preclude them from completing care. Or they may simply stop showing up.
What about discharging the patients who dismiss themselves? Very often, the process of self-dismissal slips through the documentation cracks. Self-dismissals can leave a gaping hole in your records, like a chapter in a good book that doesn’t just end, but leaves you hanging. The good news is that this issue is easily rectified.
The system is two-fold. First, it is critical to have a system in place to manage missed appointments. Attempting to contact the patient and documenting those attempts to reach him or her is key. For example, if the patient misses an appointment, the first phone call should be made within 15 minutes of their appointment time. If the patient provided more than one contact number, preferably call all listed numbers.
It is recommended to make a total of three phone calls in an attempt to reschedule the patient’s missed appointment.
If the patient does not return any phone calls or does not respond to messages left by team members, the next step is to get involved yourself. Your call can be as simple as stating,
I’m concerned you’re not following your prescription of care, because you missed your appointments. We’ve tried to get in touch with you and have not heard back from you as of yet. For full correction of your condition, it is critical we maintain your prescription of care. Please call us so we can get you rescheduled immediately.
Your reaching out to the patient accomplishes several things: It increases your awareness of the situation, it reinforces to the patient that their care and health goals are important to your practice, and it allows you to document ongoing attempts to reschedule the missed appointment.
In the second part of the process, once you’ve left a message, make a note in the tickler file for two weeks out from the date of the call. If the patient has not followed up in the two-week time period, this would be considered self-dismissal. You then initiate the process of administrative discharge. Note in the medical record that the patient dismissed him- or herself from treatment.
In addition to your previous phone calls to your patients, you can mail a follow-up letter. This extra step officially notifies the patient of their status in your practice, while at the same time it lets them know they are still a member of your practice and are welcome to return at any point or seek a referral if needed.
Documenting missed appointments and consistently attempting to follow up with patients is a good business practice; however, if the patient never responds to the follow-up calls to reschedule their missed appointment, this process also prevents that gaping hole in your patient’s record.
“The best defense is a good offense” is an adage that applies to many fields of endeavor—military, games and business. Strong documentation can be a game-changer for any practice. It can save you time, money and possible administrative headaches.
Be sure you have a robust discharge process to confidently document the end of each episode of care for each patient. It is a win-win, creating closure for each case and providing the proper ending to the patient’s chapter or entire story.
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P), Certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been providing chiropractors with compliance training, advice, and tools to improve the financial performance of their practices. She leads a team of 30 at KMC University and is known as a foremost expert on Medicare, documentation and CA development. She can be contacted through kmcuniversity.com.