Chapter 2:
Mechanisms of Documentation

There are many different mechanisms that a chiropractor may successfully use to keep excellent clinical documentation. Some of the most commonly used methods are discussed below:

1.   Dictation and transcription:

Dictation of clinical records remains the benchmark against which all other forms of record keeping are measured. Dictation has many obvious advantages:

• impeccable legibility

• the ability to use as much detail as may be needed

• there are no restrictions imposed by the format itself

• transcriptionist does not need special computer training

There are also minor disadvantages of the dictation/transcription method:

• labor intensive, therefore tends to be relatively costly

• dictation tapes can break or be lost

• digital dictation systems can lose data

2.   Computer-assisted record keeping [commercial programs]:

These systems are available in many different formats. Various methods of inputting information to the computer have been devised, each claiming to be the most efficient. Information may be input into the computer via voice or through the use of keyboard, light pens, scanning sheets, touch screens, bar code readers or other devices.

These systems have the advantages of:

• automating some of the repetitive aspects of patient records

• a comprehensive approach to inputting clinical data.

Disadvantages may include:

• relatively high purchase cost

• relative difficulty of editing your copy from the pre-defined format in some of the products

• lost data if the system is not "backed up" frequently.

With new technology comes intriguing new ethical questions. For example, some of the programs will automatically vary the verbiage to avoid the appearance of repetitive notes. There are computer programs which will "write" a narrative report or "calculate" a disability rating. Only the individual practitioner can decide if a particular product truly represents a time-saving tool in completing the patient’s documentation, or a clinically unacceptable "short cut".

3.   Word processing programs:

All of today’s computer word processing programs have the ability to be easily programmed by the user to perform repetitive functions. These special, user-defined commands are usually called a macro. With the use of a macro, it is possible to automate many of the repetitive tasks required in patient record keeping, such as typing the clinic name, patient name, date and other commonly required data.

In addition, a macro can generate frequently used text, often called boilerplate text. This can enable the doctor to add significant depth to records without expending much time. For example, complete instructions can be prepared for a routine of lumbar extension exercises. When a patient’s clinical condition indicates that these particular exercises are appropriate, the entire exercise routine can be added to the patient’s records with the touch of the macro button.

The advantages of this type of system are:

• low cost

• system may be adapted completely to your needs and changed at any time

The disadvantages of this type of system are:

• set-up is labor intensive

• professional assistance is seldom available

• doctors and staff must thoroughly understand the system they have devised

• data may be lost if not "backed up" frequently

4.   Hand Written Records:

It is possible to keep excellent quality patient records by hand writing each record. However, many doctors will simply not be able to utilize hand written records because they possess illegible or poor quality handwriting. In addition, the sheer volume of information required in a quality patient record often lends itself to some sort of mechanization, especially in a busy practice.

If hand written entries are to be part of clinical records:

• make sure that the handwriting is clearly legible

• be sure that the areas of the record reserved for handwriting are not cluttered with other information

• use only common, standardized abbreviations, such as those listed in these Wisconsin Chiropractic Association documentation recommendations.

5.   Proprietary or "in-office" chiropractic record keeping systems:

Over the years, many chiropractors have developed proprietary [non-SOAP] formats or shorthand systems for various aspects of their patient records. These may include the use of abbreviations or symbols which are not well recognized within the chiropractic profession.

The use of these types of devices within records can often be confusing to other parties who wish to review the patient’s records. This potential problem can often be avoided by the use of standardized abbreviations and conventions, such as those described in these recommendations.

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Since 8-08-2003