| Clinical Guidelines for Chiropractic Practice in Canada
Chapter 3 - Initial Clinical Examination
Chapter Outline
I. OVERVIEW
The main objective in practice is to find a solution to the patient's problem. To accomplish this goal the nature and cause of the problem must be known before appropriate management can be instituted.
Initially, this requires data collection and interpretation. The patient interview represents an important opportunity to obtain the information necessary to make a correct diagnosis. A careful examination is then necessary to verify that diagnosis. Responses to pertinent historical queries suggest how the examination should be planned, what course it should take, and what areas may require special consideration. Several methods of examination exist and from the choices made during the examination a management plan is finally formulated.
It is the initial patient contact that establishes the nature of the doctor/patient relationship and determines the degree of confidence and trust developed.
II. DEFINITIONS
For definitions see the Glossary at the end of this publication.
III. SUB-TOPICS
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IV. LITERATURE REVIEW
Specific literature on the appropriate history and examination techniques for chiropractic practice can be found in numerous texts and journals. Apart from general texts, one should consider texts dealing with specific areas such as interviewing skills and history taking. The reader is directed to those texts listed in the references. The initial clinical examination has three goals:
1. To establish a satisfactory relationship with the individual seeking care. This relationship will be enhanced by identifying and addressing specific concerns of the patient, and by explaining the nature and purpose of the physical examination before this commences.
2. To complete a thorough examination, and determine whether or not the patient needs to be referred for additional diagnostic procedures.
3. To arrive at a provisional diagnosis or clinical impression.
Each initial clinical examination should be carefully planned making allowance for the unique circumstances of each patient. Several methods of examination exist. The following algorithm describes one accepted method.
V. ASSESSMENT CRITERIA
Rating System 1 assessment criteria are used in this chapter. For an explanation of this system see the Introduction and Guide to Use (p. xxiii).
VI. RECOMMENDATIONS (GUIDELINES)
3.1 The initial clinical examination is an extension of the previously gathered historical data. The chief complaint should provide the major focus for this examination. Attention, based on clinical significance should be given to other complaints. As well, the general health of the patient should be investigated.
Rating: Necessary
Evidence: Class I,II, III
Consensus level: 1
3.2 The initial clinical examination shall include those elements of a general and focused physical examination that are pertinent to the investigation of the presenting complaint(s).
Rating: Established
Evidence: Class I, II, III
Consensus level: 1
3.3 Special procedures, particularly those involving the genitalia, should be explained to the patient in advance of the examination, and consent obtained. Whenever possible, these procedures should be witnessed by an appropriate member of the office professional staff.
Rating: Established
Evidence: Class I,II,III
Consensus level: 1
3.4 The record of the initial clinical examination should include all significant clinical conclusions. Data from questionnaire forms should not be the sole basis for treatment. Further investigation may be required based on clinical judgement.
Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1
Financial record
3.5 The material findings on initial clinical examination should be recorded utilizing current and accepted terminology.
Rating: Necessary
Evidence: Class II, III
Consensus level: 1 VII. COMMENTS, SUMMARY OR CONCLUSION
The basis of a good initial clinical examination is the ability to take and record accurate and reliable information. One must always remember that one's clinical notes may have to be interpreted by another person, or subpoenaed for use in a court of law. Sketchy and unreadable notes are worthless. The S.O.A.P. (Subjective findings, Objective findings, Assessment and Plan) method of collecting and recording notes is extremely useful. A master file in the office should contain a code to all abbreviations used. There are now many validated patient survey instruments or questionnaires that measure pain and/or function (e.g. visual analogue scale, Oswestry Index, Neck Pain Index, etc.). The practitioner should consider increased use of these, both for reliable data at entry level and as a base line to assess outcome of care.
VIII. REFERENCES
Bates B. A guide to physical examination and history taking. 5th ed. Philadelphia: J.B. Lippincott, 1990.
Burnside JW. Physical diagnosis. 17th ed. Baltimore: Williams & Wilkins, 1986.
DeGowin EL, DeGowin RL. Bedside diagnostic examination. New York: MacMillian Pub., 1976.
Gatterman MI. Chiropractic management of spine related disorders. Baltimore: Williams & Wilkins, 1990.
Guckian J. The clinical interview and physical examination. Philadelphia: JB Lippincott, 1987.
Lawrence DJ. Chiropractic technique: principles and procedures. New York: Churchill Livingstone, 1993.
Lawrence DJ. Fundamentals of chiropractic diagnosis and management. Baltimore: Williams & Wilkins, 1991.
Magee DJ. Orthopaedic physical assessment. Philadelphia: Saunders Pub., 1987.
Oregon Board of Examiners. Oregon Chiropractic Practice & Utilization Guidelines, Volume 1. Oregon Chiropractic Practice Committee, 1991.
Schafer RC. Physical diagnosis: Procedures and methodology in chiropractic practice. Arlington, Virginia: Amer Chiropr Assoc, 1988.
IX. MINORITY OPINIONS
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