Wisconsin Chiropractic Association's Recommendations for Clinical Documentation
 
   

Chapter 1:
Wisconsin Chiropractic Association's
Recommendations for Clinical Documentation

 
   

1.   General Information

The purpose of these recommendations are:

A.   to serve as an informational source to doctors. These recommendations represent well-accepted, contemporary views on documentation issues as reported in the biomedical literature. Some of the source materials include:

  • Health Care Financing Administration documentation guidelines.
  • Record keeping standards for the National Committee on Quality Assurance.
  • chiropractic and medical textbooks.
  • peer-reviewed journal articles.
  • submissions from chiropractic colleges.
  • input from insurers.

B.   to serve as voluntary guidelines for chiropractors to use when developing documentation systems for their offices.

C.   to encourage more uniform and more understandable clinical documentation, which should serve as a benefit to patients, providers, and insurers.

The Wisconsin Chiropractic Association recognizes that the management of every individual patient is unique. Different styles of practice, or areas of clinical specialization, may prompt the doctor to vary the clinical information to be gathered and recorded.

Documentation performed within the intent of these recommendations need not be rigid and inflexible, but should be adapted to the needs of a particular case. These guidelines are intended to provide a common framework for patient records which allows for more consistent reporting and improved communication.

2.   Format

A SOAP format is regarded across the country as the most widely accepted method for keeping clinical records. This format records information about Subjective complaints, Objective findings, the doctor’s Assessment and treatment Plan in an organized manner. Used less frequently are recognized derivatives of the basic SOAP schema, such as POMR, SORE or SNOCAMP. 1-3

An organized format [whether it is classic SOAP or a modification of the SOAP format] allows information to be recorded in a predictable, repetitive manner. Proprietary or "in-office" systems of documentation are, by definition, difficult or impossible for a reviewer to understand.

Abbreviations:   The proper use of accepted abbreviations [such as those listed in these recommendations] can facilitate the documentation process by saving both record space and time. However, the use of non-standard abbreviations can lead to confusion in the interpretation of clinical records. Doctors who choose to utilize non-standard abbreviations should "translate" those abbreviations prior to the records being submitted to a third party.

Methods:   The methods used to complete clinical record keeping is a matter of preference for each practitioner. The doctor may prepare documentation by using dictation and transcription, narrative-style writing, pre-prepared forms or other methods preferred by the doctor.


Documentation of Evaluation/Management Services:   During the course of a complicated case, the chiropractor may be presented with clinical situations which require varying complexities of decision making and/or the services required. The level of detail contained in the documentation will often increase as the complexity of the decision making or the complexity of the provided services increases.

For example:

  • at the onset of the complicated case, or at other critical time periods during the patient’s treatment, the chiropractor often functions at a specialist level. When functioning at that level, a corresponding increase in the detail of documentation is typically expected to fully detail the patient’s symptoms, findings, diagnosis and treatment plan. The chiropractor will usually choose to utilize a higher level [99204, 99205, 99214, 99215] evaluation/management code when performing these specialist-level services.

  • at other times during the same case, the chiropractor may serve on a level very similar to a general practitioner. The level of documentation typically expected at this level is sufficient to tell the story of the patient, but may not include the full level of detail expected of the specialist-level documentation. The chiropractor will often use a mid-level [99202, 99203, 99212, 99213] evaluation/management code when performing these general practitioner-level services.

  • on a daily treatment basis, the doctor is applying the treatment which has been fully described in the most recent treatment plan. Therefore, the documentation for daily visits will be much more concise.


Chart organization: Clinical notes consist of three distinct elements: 1. Initial entry.   The initial entry generally includes:
  • pertinent baseline information about the patient
  • the patient’s chief complaint[s]
  • the results of initial physical examination
  • the chiropractor’s assessment
  • the recommended treatment plan


2. Daily note.   The daily note represents a concise record of pertinent changes in the patient’s condition and treatment on that day. A series of daily notes will show changes on a visit-to-visit basis. The daily note is used most often to document:

  • adjustment or manipulation
  • physical modalities


3. Progress note.   At different points in a case, a progress note is used to document additional patient services. These services may include:

  • reevaluations
  • reexaminations
  • counseling
  • coordination of care

One respected author in the field of chiropractic documentation 4 has described the initial entry as "SOAP-ing" the patient. He then explains that the progress note can be thought of as a kind of "midi-SOAP", or a somewhat abbreviated version of the original SOAP work-up. This so-called "midi-SOAP" retains the same database format, yet is not necessarily as detailed as the original evaluation. The notation for a daily or routine visit is described as a "mini-SOAP", displaying the same general organizational scheme of the of the initial evaluation, but on a significantly smaller scale.


3.   Legibility

Clinical documentation should always be legible. If patient records are hand written, it is especially important that the handwriting is legible to the reviewer. If the handwriting is not legible to the reviewer, the provider should be informed and given the opportunity to transcribe the information.


4.   Documentation of Patient Consent

Doctors should review with their legal counsel their responsibilities 5 to obtain written proof of the patient’s consent in the following critical areas:

  • general consent to examine and treat:   Many doctors will have the patient complete this written consent as part of their initial patient questionnaire.



  • informed consent:   if any proposed treatment procedure poses a meaningful risk to the patient, the doctor is expected to disclose that risk to the patient and to document that the patient has consented to proceed with the proposed treatment. [In some cases in which the patient has significant difficulties communicating, such as Alzheimer’s disease, stroke victims or the mentally impaired, the informed consent should be obtained from a family member.]



  • parent’s consent to examine and treat minor children:   generally recommended before evaluating or treating any child under the age of 18.



5.   The Initial Patient Entry

The initial entry generally includes pertinent baseline information about the patient, the patient’s chief complaint[s], the results of physical examination, the chiropractor’s assessment, the recommended treatment plan. An initial patient entry may be made anytime a patient presents with a new chief complaint.


A   Subjective: Initial New Patient History

This section forms the subjective area of the documentation. HCFA has recently defined elements which may be included in the subjective portion of the patient records. 6

The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of the these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

These elements of the subjective portion of clinical record keeping include the following:

History of the present illness: [HPI] HCFA has defined the following factors to constitute a complete history of the present illness:

  • history of trauma
  • description of the chief complaint[s]
  • onset of symptomatology
  • palliative factors
  • provocative factors
  • quality of pain (burning, numbness, tingling)
  • radiation of pain
  • severity of pain (scale of 1-10)
  • frequency or timing of complaint
  • previous episodes of chief complaint.


As an alternative, the elements of the history of the present illness can be represented by the use of the mnemonic "O, P, Q, R, S, T". 7

O = onset of symptoms
P = provocative or palliative factors
Q = quality of pain
R = radiation
S = severity of pain
T = timingof pain
When using this mnemonic, many doctors add an additional element to indicate whether the patient has experienced prior episodes of the chief complaint:

U = previous episodes [have you ever had this problem before?]

Past history:

  • prior major illnesses and injuries
  • prior operations
  • prior hospitalizations
  • current medications
  • allergies (food or drug)
  • age appropriate immunization status
  • age appropriate feeding/dietary status.


Social history:

  • current employment
  • occupational history (discretionary)
  • use of drugs, alcohol, and/or tobacco
  • other relevant social factors.


Family history:
Significant health factors which may be congenital or familial in nature should be noted.


Review of systems: [ROS]

HCFA has defined the following fourteen areas for review of systems:

  • constitutional symptoms [fever, weight gain or loss, fatigue, etc.]
  • eyes
  • ears, nose and throat
  • cardiovascular
  • respiratory
  • gastrointestinal
  • genitourinary
  • musculoskeletal
  • integumentary [skin/breast]
  • neurologic
  • psychiatric
  • endocrine
  • hematologic/lymphatic
  • allergic/immunologic


Appendix A   includes the requirements from HCFA for the proper coding of evaluation and management codes by the number of included elements from the elements of the history above.

B   Objective: Initial New Patient Physical Examination

This section forms the objective area of clinical documentation. The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

The elements of the objective portion of the patient records may include the following:

C   Assessment: Initial New Patient Assessment

  • Diagnostic impression in a narrative or descriptive format.


  • Assessment of risk factors, if applicable.


D   Plan: Initial New Patient Treatment Plan

The complexity of the patient’s health problem will determine which of the following elements a chiropractor will choose to include in the patient’s record. It is not necessary to include all of these elements in the records of patients with less severe health problems. The elements of the treatment plan may include the following:

  • Diagnostic treatment plan: describes the need for further tests, including reexamination, etc.


  • Therapeutic treatment plan: describes the frequency and duration of adjustments and in-office therapies and modalities.


  • Educational treatment plan: home exercises, modification of daily or work activities.


  • Short and long term goals.


  • Referral for other necessary services.


  • Coordination of care with other health professionals, if applicable


6   Daily Notes:

The daily note represents a concise record of pertinent changes in the patient’s condition and treatment on that day. A series of daily notes will show the significant changes in the patient’s condition and treatment which occur over a period of time. The daily note is used most often to document ongoing treatment, such as adjustments/manipulation or physical modalities.

After the initial entry, each subsequent office visit will usually be documented by a daily note, until the next specified reevaluation. If the initial entry clearly states the assessment and plan, it is not usually necessary to reevaluate the patient on a daily basis or to reiterate the assessment or the treatment plan. Any significant modification of the treatment plan should be recorded in the daily note. 9

Because of its brevity, the daily note will list only the most important changes in the daily presentation of the patient, and the management of the case. Therefore, the treating chiropractor is best qualified to decide which objective and subjective elements of the case should be recorded via the daily note.


7   Progress Notes:

At many different points in a case, a progress note is often used to document additional patient services. These services may include:



A   Re-examination frequency:

Periodic reexaminations of the patient are an important element of case management, and are used to assess the effectiveness of treatment. It may be appropriate to reexamine a patient or reevaluate a patient’s condition anytime there is a significant change in the patient’s symptoms or response to treatment.

Reexaminations are especially important when a patient exacerbates their injury or if the clinical condition of the patient changes, which may indicate the need for the doctor to reassess the treatment plan. The following chart which describes typical frequency of re-examinations for established patients:


Patient Type Definition Typically, a reexamination is performed within:
Acute
  • Symptomatology is present less than six weeks.

  • Acute exacerbation of a chronic or recurring condition.
30 days or 12 visits or as clinically indicated
Chronic
  • Symptomatology present more than 18 weeks
 3 months or 18 visits or as clinically indicated
Supportive
  • Symptomatology is present due to a known, permanent deficit; a full recovery is not expected.
Six months to one year or as clinically indicated
Maintenance or preventative
  • No active symptomatology.
As clinically indicated


A re-examination for an established patient is particularly appropriate in the following circumstances:

  • a patient who presents with a new chief compliant.
  • a patient who presents with a new, distinct episode of a recurring condition.
  • a patient who presents with symptoms, and has not received treatment for 90 days or more


8   Documentation of X-ray Findings

X-ray documentation is usually produced on the day the film was read and/or billed. These x-ray findings may be in the form of a separate report, or may condensed to the major findings, and included with the objective portion of the patient’s documentation.

Just as the "SOAP" format is used to methodically prepare patient records, formal x-ray reports often follow a repeatable format. When preparing formal x-ray reports, the following format has been advocated by Yochum and Rowe 10

Introductory Information

Letterhead Information

  • Name of physician
  • Clinic name and address


Patient Information

  • Full name and address
  • Date of birth
  • File identification


Radiographic information

  • Views submitted
  • Dates and location of films taken
  • Technique factors [optional]



Report

Clinical Information

  • Chief complaint
  • Key clinical findings
  • Reason for study
  • Numbered summary of pertinent findings


Radiologic Findings

  • Descriptive narrative of findings
  • Findings are usually listed in the order of alignment, bone, cartilage, soft tissue, which can be easily remembered by the mnemonic "ABCs".
  • Conclusions


Recommendations

  • Indications or contraindications to treatment
  • Follow-up procedures indicated


Signature and qualifications



References:


1.   Journal of Family Practice 1995 (Oct):   41:   4

2.   Jordan E.   St. Anthony’s guide to E/M coding and documentation. St. Anthony’s Publishing, Reston, VA 1995

3.   Vernon H.   Clinical note: S-O-R-E, a record keeping system for chiropractic treatment visits. Can Chir Assoc J. 1990;   34:   93

4.   Mootz RD.   Maximizing the effectiveness of clinical documentation. In: Top Clin Chiropractic 1994;   1 (1):   60-65  Aspen Publishers, Gaithersburg, MD.

5.   Campbell L, Ladenheim CJ, Sherman R, Sportelli L.   Informed consent: a search for protection.   Top Clin Chiropractic 1994;  1 (30):   55-63

6.   Reported in: St. Anthony’s Physician’s Claims and Billing Manager.   St. Anthony’s Publishing, Reston, VA Vol. 3, No. 6, March 1995

7.   Foreman S, Croft A.   Whiplash injuries; the cervical acceleration/deceleration syndrome. 2nd ed.   Williams and Wilkins, Baltimore, 1995

8.   Legg AT.   Physical therapy in infantile paralysis. In: Mock. Principles and practice of physical therapy. Vol. II. Hagerstown, MD: WF Prior, 1932:45

9.   Bronston LJ.   Record Maintenance and Narrative Writing.   In: Ferezy JS. The Chiropractic Neurological Examination. Aspen, Gaithersburg MD, 1992, p. 153

10   Yochum TR, Rowe, LJ.   Essentials of Skeletal Radiology, 2nd Ed.   Williams and Wilkins, Baltimore, 1996, p.1371-1396

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