Documentation has been an ongoing concern for years. Some states, Texas, for example, require chiropractors to take 4 hours per year of continuing education in record keeping, documentation and ethics. Medicare and other carriers continue to deny chiropractic claims or perform post care audits where refunds are being asked based on lack of supporting documentation. CMS and every major insurance carrier has a guideline concerning requirements of documentation. Yet, we continue to struggle.
For many years, I have performed preauthorization requests, peer reviews and file reviews. I routinely see patient records with illegible, hand-written notes or computer generated “canned” notes. Neither of which allow for me to make an informed decision concerning the care given or request being made. Our patients have entrusted us with their health care needs and deserve the best care we can give them. As doctors, we must clearly document why the care is necessary, exactly what care was performed, how the patient benefitted from the care, or how he/she is expected to progress with the care. Our documentation must be clearly written and legible. The goals of clearly written, legible documentation include the following:
- Provide ease of reading and understanding of care/treatment/diagnosis/prognosis
- End medical necessity denials
- Pass post review audits
- Get paid for your services
- Protection against malpractice
- Continuity of care (locum tenens doctor)
Simply following the CC, Hx, OPQRST on the first visit, and the SOAP format for subsequent visits, is a great starting place. The use of travel cards and check off boxes are no longer enough to protect ourselves from denials and requests for refunds. If you choose to hand write your notes, they must be legible. Basic EHR systems are now very affordable for most offices. The use of EHR systems makes documenting our encounter much easier and most come with the following format:
- CC: Chief complaint. Why is the patient seeking care?
- Hx: Relevant health history, past health history. Past providers seen. Past care received.
- O: Onset. When, how, did the symptoms start?
- P: Provocative/Palliative. What makes the symptoms better or worse?
- Q: Quality of the pain. Sharp, dull, burning, aching, stabbing, etc…
- R: Radiating. Is the pain radiating. Related areas?
- S: Severity of pain. Use a number scale or similar system.
- T: Time. When do the symptoms appear? How long? Has it changed? Previous episodes?
Document constitutional findings, vital signs, positive and negative orthopedic and neurological findings, vascular testing, subluxation levels, tenderness, hypertonicity, motion, strength, observations.
Subsequent dates of service (SOAP) format:
S: Subjective. What is the patient’s complaint? Give details. “He complains of neck pain that is rated 7/10, described as sharp and stabbing and worse with motion.”
O: Objective. What you, the doctor, has seen or found on examination. “The patient is noted as rotating from the waist and not his head and neck. He has palpable hypertonicity of the paracervical muscles, trapezius muscles and suboccipital muscles on the left. There is restriction of motion and subluxation of C5-C7 on the left. There are no positive nerve root tension signs. Cervical compression test increases the cervical pain locally with no radiation of pain.”
A: Assessment. What your thoughts are concerning the patient and progress? “The patient is progressing as expected and I do not see need for advanced diagnostic studies at this time.” List how the patient responded to the care on this visit. List the goals being met.
P: Plan. What is your plan of care? List home care given, anticipated progress, how you will grade the progress. List Oswestry scales, pain scales, ADL’s. List the levels adjusted and what techniques were used. List all therapy modalities used and time the patient was on the modality or in therapy. Short-term and long-term goals should be discussed in this section.
Here are some helpful tips for proper documentation:
The areas treated must match the areas of complaint or be related to the areas of complaint. The diagnosis must be supported by the examination findings. The care being given must be appropriate for the diagnosis. Outcome assessments should be used to support your care or need for ongoing care. Activities of daily living (ADL), neck and back pain index forms should be used to support care and chart progress.
The specific levels adjusted should be listed and not just the general region treated. The placement of the electrodes and ice/hot packs or other passive modalities should also be noted on the body part treated. Active modalities should be documented as to what activity and what body part, how the patient responded, any correction to patient posture or technique made, and time in and out for each modality used.
Proper coding for our care and office visits will be another topic covered in the future.
Remember, someone, besides yourself, is going to read your notes. A detailed explanation of patient complaints, examination, medical reasoning, treatment and prognosis will help get you the care you are asking for, paid for the care performed, defend you against any possible malpractice claims and keep you from paying back the carrier in a post audit.
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