Clinical Guidelines for Chiropractic Practice in Canada Chapter 2 - Record Keeping Chapter Outline I. Overview II. Definitions III. List of Subtopics IV. Literature Review V. Assessment Criteria VI. Recommendations (Guidelines) VII. Comments, Summary or Conclusions VIII. References IX. Minority Opinions I. OVERVIEW For professional and legal reasons a chiropractor is required to keep and maintain adequate patient records which clearly reflect the course of patient management. Records must be accurate, legible, and comprehensive so that a reviewer of these records can establish the essential relationship between the patient and the practitioner in terms of past, present and future health care. Records are usually the only tangible evidence of examinations, findings and treatment. The health care record has many uses. Its most important function is to assist in the immediate care and treatment of the patient. The record also permits different members of the health care team, or successive health care providers, to have access to relevant data. It is important for documenting specific services received by the patient so that the provider can be reimbursed. The health record is also helpful in peer review, in providing data for public health purposes, and may be used for the purposes of teaching and research. It is critical in a variety of legal contexts, including defensive malpractice claims. It is understood that record keeping styles may vary from practitioner to practitioner. It is not the purpose of this chapter to recommend a particular style, but rather to give guidelines on necessary elements of record keeping as supported by the reviewed literature. The health care record contains confidential information which, as a matter of law, must not be released except on the express consent of the patient or pursuant to a court order or otherwise as compelled by law. The taking and recording of informed consents, an increasingly important aspect of record keeping, is dealt with in Chapter 1. II. DEFINITIONS For definitions see the Glossary at the end of this publication. Contemporaneous External Records Health Record Patient Confidentiality Peer Review POMR Progress Notes Record Keeping SOAP III. SUB -TOPICS 1. Appointment Book 2. Patient File 3. Initial and subsequent and clinical and accounting records 4. Confidentiality of clinical records 5. Practical and technical aspects of recording clinical recordkeeping 6. Retention of clinical records IV. LITERATURE REVIEW This chapter is based upon material found in provincial laws and ethics (Quebec 1973), published textbooks, refereed journal articles, conference material and anecdotal information from lawyers, chiropractors, educators, and professional organizations. A major resource was the current American Guidelines for Chiropractic Quality Assurance and Practice Parameters (Haldeman et al. 1992). Twenty years ago Simmons (1973) prepared a concise guide to assist the practitioner in maintaining daily records and recording elements of case history and consultation. Schafer (1978 and 1987) published procedural manuals through the American Chiropractic Association which underscored the importance of documenting necessity of chiropractic care through adequate record-keeping and the support of chiropractic paraprofessionals. In a publication of the International Chiropractors' Association, Kranz (1987) provides guidance for the practitioner in the hospital environment. There have been three recent publications promoting malpractice prevention, or risk management strategies, for practitioners. Campbell, Ladenheim, Sherman and Sportelli (1990 and 1992) identify many pitfalls of lax patient chart management and failure to obtain patient consents, and offer recommendations that can be implemented in office management systems. Harrison (1991) crisply identifies shortcomings of patient records and the risks in the context of malpractice claims. The Canadian chiropractic literature has a number of recent articles in referenced journals relative to risk management, charting procedures and report writing. Authors such as Carey (1988), Cassidy (1985), Gotlib (1984), Nixdorf (1990), Vear (1992) and Vernon (1990) have contributed material that assists practitioners in management of patient records and obtaining appropriate consents. Elsewhere Reinke and Jahn (1988) provide pointed commentary correlating the importance of the patient's health record and the practitioner's "legal well-being". Other direction has been offered by Turnbull (1987) from New Zealand and Gledhill (1990). Bolton (1990) adds to the published knowledge base on informed consent. Nyiendo and Haldeman (1986) have analyzed practice activities of student interns in a chiropractic college teaching clinic, and summarize the need for standardized accountability in patient care. Recently many monographs have been establishing guidelines for the management of chiropractic cases. These include a surge in efforts to publish standards of care in a number of American state and Canadian provincial jurisdictions. Within these are position statements or "standards" on obtaining and documenting clinical information. Chiropractors in Connecticut in 1985 were among the first to provide formal practice guidelines, noting that there must be adequate documentation of the necessity for chiropractic care. They established recommended formats for interval reporting. The workers' compensation guidelines produced by the Washington State Chiropractic Advisory Committee (Hansen 1988) adapted an outline proposed earlier by Vear, Haldeman and West citing six primary case management objectives supported by "standards." Vear (1992) has subsequently republished these objectives and standards in a major text. Efforts by Olson (1987), LaBrot (1990) and state chiropractic organizations in Ohio (1990) Michigan (1991) and Minnesota (1991) have all produced practice guidelines that emphasize the need for better standards in record keeping. Similar efforts are underway in Manitoba, Ontario, and Quebec, and many US states including Florida, Oklahoma, Oregon, South Carolina and Texas. Chiropractic professional liability carriers have contributed to the information pool with monographs that are a part of their risk management programs. The Canadian Chiropractic Protective Association (CCPA), the OUM Group and the National Chiropractic Mutual Insurance Company (NCMIC) have produced many articles through newsletters and booklets. Chiropractic popular publications produced by the national and state associations periodically give guidance on efficient record keeping, risk management and report writing. Other popular publications that contribute articles include The American Chiropractor (Oxford 1988), Today's Chiropractic (Mootz 1989), Digest of Chiropractic Economics (Baird 1981 and 1986), and Dynamic Chiropractic. Chiropractic specialty councils have contributed white papers (Gunderson 1989) on essential elements of the patient's case file, report composition and clinical workup. Popular publications outside the chiropractic field also contribute valuable knowledge that can be used in the development of guidelines. Probably the richest technical source of information relative to documentation and patient consents is found in legal publications (e.g. MacDonald et al. 1986). The legal advice found in these publications is supported with citation of case law. Publications such as these are not easily accessed by the average practitioner in the field, nor are they available in all chiropractic college libraries. The profession must rely on its legal consultants to assist in review of such literature. Fortunately, publications such as Legal Update (formerly Chiropractic Amicus) edited by Ladenheim at al., and the Chiropractic Report edited by Chapman-Smith have emerged to fulfil this role and assist practitioners in their understanding of the legal ramifications of health care practice. V. ASSESSMENT CRITERIA Rating System 2 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) Initial Documentation and Record keeping Appointment book 2.1 The name of each patient and the date when seen shall be recorded in an appointment book. Rating: Necessary Evidence: Class II, III Consensus level: 1 Patient file 2.2 The first step in the processing of a new patient shall be the establishing of a patient file to serve as a permanent record. Information may include: name, age, gender, address, and other demographic data health insurance and other billing information occupation and employer referring practitioner case history examination special study findings imaging and laboratory findings diagnosis treatment plan Pre-printed history questionnaires that contain much of the above and other information may be used at the time of initial documentation. Rating: Necessary Evidence: Class I, II, III Consensus level: 1 2.3 The patient file shall be identified by name or number and shall be stored in hard copy form. This may be in a folder which will become part of the record if the practitioner writes patient data upon it. Outdated portions of progress notes and other documentation may be removed and stored in an archive file. However, a note should be kept in the active file identifying these additional records. Rating: Necessary Evidence: Class I, II, III Consensus level: 1 Patient history 2.4 A case history shall be kept and may include the following: demographic data including date, name, address, telephone number, gender, date of birth and guardian, if applicable patient chief complaint data relevant past and present health history family and social history, when indicated systems review (as appropriate) prior history of therapeutic and diagnostic procedures Rating: Necessary Evidence: Class I, II, III Consensus level: 1 Financial record 2.5 A financial record for each patient shall be kept. It shall include: a. date and type of professional service provided (initial visit, subsequent visit, x-ray, examination and any other services provided to the patient); b. fee for service(s); c. payment received and from which source; and d. balance of account to date. Rating: Necessary Evidence: Class I, II, III Consensus level: 1 Record of examination and diagnosis 2.6 All examination procedures performed, ordered or requisitioned must be recorded. Rating: Necessary Evidence: Class I, II, III Consensus level: 1 2.7 A diagnosis of the patient's presenting complaint(s) must be recorded. Rating: Necessary Evidence: Class I, II, III Consensus level: 1 2.8 A plan of management shall be recorded, and may include: a. therapeutic approach; b. additional testing or referral to another health care provider when indicated; c. proposed frequency and duration of treatments; d. any complicating factors should also be included. Rating: Necessary Evidence: Class I, II, III Consensus level: 1 2.9 A prognosis may be recorded. Rating: Recommended Evidence: Class I, II, III Consensus level: 1 2.10 Relevant clinical findings, both positive and negative, should be recorded. Rating: Recommended Evidence: Class II Consensus level: 1 Consent 2.11 Patient consent to treatment may be oral, written, or implied, depending upon the circumstances, and it is not necessary in most cases to record the giving of consent in the patient file. It may be wise to make a record in some circumstances, such as: oral consent following explanation of a material risk of treatment - consent for treatment of a minor when circumstances suggest that consent may later be challenged consent for treatment of a legally incompetent patient The best record of any consent is one that is objectively documented and signed by the patient. Rating: Recommended Evidence: Class I,II,III Consensus level: 1 Special studies 2.12 Documented results of special studies when received become a component part of the file. If an outside facility is used, there should be a record of the date of the study, and the names of the interpreting practitioner and facility. Rating: Necessary Evidence: Class I,II,III Consensus level: 1 Progress notes 2.13 Progress notes shall be recorded and dated at each patient visit or communication. Rating: Necessary Evidence: Class I,II,III Consensus level: 1 2.14 Progress notes should reflect the patient's subjective and objective findings, changes in the clinical presentation, specifics of the treatment(s) or recommendation(s). Rating: Necessary Evidence: Class I,II,III Consensus level: 1 External documentation 2.15 Relevant documentation to and from external sources becomes part of the patient file. Examples may include: correspondence to or from a referring practitioner - general correspondence from lawyers, third party payors, and others Rating: Necessary Evidence: Class II,III Consensus level: 1 Record of discharge 2.16 When the patient is discharged there should be a record made of the reason and the patient's current health status. Rating: Discretionary Evidence: Class II,III Consensus level: 1 Confidentiality of patient records 2.17 Patient records are confidential and no part of them shall be examined by or released either verbally or in writing to anyone without the written consent of the patient or where legally required. Rating: Necessary Evidence: Class I Consensus level: 1 Retention of records 2.18 A chiropractor shall retain a patient's records. Rating: Necessary (for such periods as prescribed by law) Evidence: Class I,II,III Consensus level: 1 Rating: Recommended to be stored indefinitely Evidence: Class III Consensus level: 1 Attributes of records: 2.19 Records should be: a. legible b. clear and unambiguous c. concise with an emphasis on essential clinical information d. chronological e. recorded contemporaneously Rating: Recommended Evidence: Class II,III Consensus level: 1 Method of recording 2.20 Notes must be recorded in ink or other permanently retrievable method. Rating: Recommended Evidence: Class II,III Consensus level: 1 Use of abbreviations and terminology 2.21 Recorded abbreviations and terminology should be internally consistent and a key for these abbreviations must be available. Rating: Recommended Evidence: Class II,III Consensus level: 1 Amendment of records 2.22 Errors in the record should be corrected observing the following: a. when an entry is to be deleted or amended it should be crossed out in such a manner that it can be read if necessary. Rating: Necessary Evidence: Class II,III Consensus level: 1 b. record date and sign corrected entry; Rating: Recommended Evidence: Class II,III Consensus level: 1 Transfer of records 2.23 Health care records, excluding data and reports from external sources, that are requested by another health professional currently treating a present or former patient should be forwarded promptly, following receipt of an appropriate request and patient consent. Rating: Necessary Evidence: Class I,II,III Consensus level: 1 Office staff: 2.24 The practitioner has the responsibility to ensure that staff members involved in record keeping are properly instructed on all relevant guidelines including the confidentiality of patient records. Rating: Necessary Evidence: Class II,III Consensus level: 1 VII. COMMENTS, SUMMARY OR CONCLUSION This chapter has provided guidelines to be used by chiropractors through documentation of patient records. It is suggested in the literature that optimum patient care is enhanced by maintaining such records. The principles outlined in this chapter should be taught in chiropractic undergraduate programs and then re-enforced at the postgraduate level and at risk management seminars. VIII. REFERENCES Baird R. Health record documentation: charting guidelines. Dig Chir Econ 1981; 24(1):32-33. Baird R. Confidentiality statements. Dig Chir Econ 1986; 29(1)60. Baird R. Obtaining health record information. Dig Chir Econ 1981; 24(3):137-8. Bolton SP. Informed consent revisited. J Aust Chiro Assoc 1990; 20(4):135-38. Campbell LK, Ladenheim CJ, Sherman RP, Sportelli L. Risk management in chiropractic. Fincastle, Virginia: Health Services Publications Ltd, 1990 Carey P. Informed consent - the new reality. J Can Chiropr Assoc 1989; 32(2):91-94. Cassidy JD et al. Medical-chiropractic correspondence: when and how to write effectively. J Can Chiropr Assoc 1985; 29(1):29-31 Coulehan JL, Block MR. The medical interview: a primer for students of the art. F.A. Davis Co., Philadelphia, 1987. Gatterman MI. Chiropractic management of spine related disorders. Baltimore: Williams & Wilkins, 1990. Gatterman MI. Standards of practice relative to complications of and contraindications to spinal manipulative therapy. J Can Chiropr Assoc 1991; 35(4):232-236. Gledhil SJ. Expert opinion and legal basis of standards of care determination. J Chiro Technique 1990; 2(3):94-97. Gotlib AC. The nature of the informed consent doctrine and the chiropractor. J Can Chiropr Assoc 1984; 28(2):272-274. Gotlib AC. The chiropractor and third party access to confidential patient health records. J Can Chiropr Assoc 1984; 28(3):327. Gunderson BV. The Case History. Orthopaedic Brief. Council on Chiropractic Orthopaedics of the American Chiropractic Association, 1989. Haldeman S, Chapman-Smith D, Peterson (Jr.) DM: Guidelines for Chiropractic Quality Assurance and Practice Parameters The Mercy Conference ~ Major Recommendations Gaithersburg, Md: Aspen Publishers Inc; 1993. Haldeman S. Importance of record keeping in the evaluation of chiropractic results. J Chiro 1975. Hansen DT. Chiropractic standards and utilization guidelines in the care and treatment of injured workers. Chiropractic Advisory Committee, Department of Labor & Industries. State of Washington, 1988. Hansen DT, Sollecito PC. Standard chart abbreviations in chiropractic practice. J Chiropr Technique 1991; 3(2):96-103. Harrison JD. Chiropractic practice liability: a practical guide to successful risk management. Arlington, VA. International Chiropractic Association, 1991. Harrison JD. Standards of practice. ICA Review 1989; 45(6):11-13. Huffman EK. Medical Records Management. Berwyn: Physician's Record Company, 1972. Hug PR. General consideration of "consent". J Chiropr 1985; 22(12):52-53. Kranz KC. Chiropractic and hospital privileges protocol. International Chiropractors Association. Arlington, Virginia, 1987. LaBrot TM. A standard of care for the chiropractic practice. Self-published. Phoenix, Arizona. 1990. Lewkovich GN. Progress notes made easier. Calif Chir J. 1989; July:32-35. Loi sur la Chiropratique du Québec et son Code de deontolojie, 1973. MacDonald MG, Meyer DC, Essig B. Health care law: a practical guide. New York: Matthew Bender & Co. 1986. Michigan Chiropractic Society. Chiropractic care and utilization review guidelines. Lansing, Michigan. 1991. Minnesota Chiropractic Association. Standard of Practice. Roseville, MN. 1991. Mootz RD. Chiropractic clinical management and record-keeping. ICA Review. 1988; 3:56-59. Mootz RD. Interprofessional referral protocol. Today's Chir. 1989; 16(4):37-39. Murkowski K, Semlow GD. Doctor's guidebook to risk management. Self-published. Associated Practice Library Consultants. Jackson, Michigan, 1986. Nixdorf D. Current standards of material risk. J Can Chiropr Assoc 1990; 34(2):87-89. Nyiendo JA, Haldeman S. A critical study of the student interns' practice activities in a chiropractic college teaching clinic. J Manipulative Physiol Ther 1986; 9(3):197-207. Ohio State Chiropractic Association. The Chiropractic manual for insurance claims personnel. Columbus, OH. 1990. Olson RE. Chiropractic/physical therapy treatment standards: a reference guide. Data Management Ventures, Inc. Atlanta, GA. 1987. Oxford G. Progress notes: Keeping track of patients. Am Chir. 1988; March:26-33. Peyser MD (ed): Chiropractic and the HMO environment in Connecticut. Connecticut Chiropractic Association. 1985. Polit DF, Hungler BP. Nursing research principles and methods. Philadelphia: J.B. Lippincott. Reinke T, Jahn W. Commentary: Preventing legal suicide with medical records. J Manipulative Physiol Ther. 1988; 11(6):511-513. Rothman EH. Manual of narrative report writing. Chiropractic on paper: recordkeeping and the narrative report. Western States Chiropractic College. Portland, OR. St. Paul Fire and Marine Ins. Co. Defensible Documentation. Physical Therapy Today. 1991; Spring:62-63. Schafer RC (ed): Basic Chiropractic Procedural Manual. American Chiropractic Association. Des Moines, IA. 1978; (4):10. Schafer RC. Chiropractic physicians guide: clinical malpractice. National Chiropractic Mutual Insurance Company, Des Moines, IA. 1983. Schafer RC. Chiropractic paraprofessional manual. American Chiropractic Association. Des Moines, IA. 1987. Simmons DF. The chiropracto-legal story. Self-published. Tacoma, WA. 1973. Strachan G. Chiropractic physician records: essential for defense and new practice areas. DC TRACTS 1990; 2(6):315-321. Thomas MM. Chiropractic research and the I.R.B. J Chiropractic. 1987; 6:60-63. Turnbull G. Peer Review: an outline. NZ Chir J. IX. MINORITY OPINIONS None

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