Documentation for the Pediatric Practice

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By Claudia Anrig, DC

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Over the years, each chiropractic office usually develops its own style of documentation for rendering care to the pediatric patient. The intent of this article is not to set a standard that should be universal, but rather to provide an opportunity for family chiropractors to re-evaluate their documentation protocols and to possibly invite new ideas to their procedures.

Forms

First, review your current case history form. An adult case history form does not cover the necessary information for the young child. Does the form include the necessary questions to understand the new child patient? For instance, does it include pregnancy and labor history, developmental milestones, and history of medication, trauma and childhood disorders? If your current form does not meet these criteria, you might want to consider contacting the ICA Council of Pediatrics or one of several other chiropractic pediatric resources and requesting a sample of one of their forms for review.

The doctor should also have an intake form that asks and/or reviews pertinent questions regarding the pediatric population. Questions concerning pregnancy, delivery/birth, childhood trauma, medical and present history may be important in developing a plan for the evaluation and care of the patient.

A consultation should inquire thoroughly about the history of micro/macro trauma as a part of the assessment process. The past and current history of the child may assist in understanding the cause of any trauma to the pediatric spine and the vertebral subluxation complex. This may also help the doctor understand if this is an acute or chronic condition.

Examination forms should also give the doctor the opportunity to evaluate the newborn-to-child patient. If the newborn has birth trauma, for example, does your exam form allow for neurological, orthopedic and chiropractic evaluation?

If there are sections of the pediatric evaluation you choose not to perform, note why on the examination form. For example, if you are not going to perform an orthopedic or X-ray exam on the infant, you

should record, "Omit due to age"; if you do not want to perform a physical, you should note, "Last visit to pediatrician was [insert date] and all was WNL per mother."

Chiropractic Visits

During the chiropractic visit, the doctor, depending on his or her technique, should remain objective when evaluating the child. The age of the child and the doctor's technique will determine the protocol of evaluation. The chiropractic evaluation might include one, if not several, of the following objective procedures: posture, gait, static and motion palpation, and instrumentation. It should be noted that in its earliest stages, the vertebral subluxation may not manifest as a clinically symptomatic disorder. Objective findings, not necessarily a symptomatic picture alone, should be the criteria for its identification.

During the visit, the doctor should inquire if there have been any new falls, tumbles or minor trauma since the last visit. This should be recorded. Instructions provided by the doctor for the patient (ice, rest, changing a behavior, etc.) should also be recorded.

Re-Examinations

Not unlike the adult patient, the nature of the child's condition will determine the frequency of re-examinations in the doctor's office. An auto injury usually is re-evaluation every 30 days. I personally recommend that the parent fill out a form regarding the status of his or her child's progress at every re-evaluation. Participation from the parent regarding the progress of his or her child is very helpful. Further, with respect to caring for children in auto injuries, doctors should review Dr. Dan Murphy's chapter, "Children in Motor Vehicle Collisions," from the textbook Pediatric Chiropractic. This is a great reference tool for the field doctor.

For a child free from injury, depending on the age and clinical picture, re-evaluating between 45-60 days should be sufficient; however, each doctor should investigate what is the considered the normal standard in his or her community or state. The pediatric re-evaluation may include additional tests that are not performed during a normal chiropractic visit. For example, at each chiropractic visit, the doctor performs a postural and static palpation and may include the cervical or lumbar range of motion at the re-evaluation. The EMG is also an excellent tool for a re-evaluation visit. Having parents fill out an update form, or recording your questions, may be helpful down the line, should you be required to furnish additional information to an insurance carrier.

Claudia Anrig, DC
Clovis, California

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Since 6-20-2006