Basic Record Keeping FormatBasic Record Keeping Format

Basic Record Keeping FormatBasic Record Keeping Format

The chiropractic profession has come a long way and The chiropractic profession has come a long way and has made great strides. With the recognition attained has made great strides. With the recognition attained has come the responsibility to create and maintain has come the responsibility to create and maintain standards in documentation.standards in documentation.Record keeping styles vary from clinician to clinician. ItRecord keeping styles vary from clinician to clinician. It’’s s not the purpose of this course to recommend a particular not the purpose of this course to recommend a particular style, but rather to give suggestions on necessary style, but rather to give suggestions on necessary elements that are often recommended in the literature. elements that are often recommended in the literature. Having an organized, detailed format allows consistent Having an organized, detailed format allows consistent reporting and improved communication.reporting and improved communication.

Basic Record Keeping FormatBasic Record Keeping FormatSOAPSOAP

Information obtained during the initial and subsequent patient vInformation obtained during the initial and subsequent patient visits helps isits helps lay the foundation for justifying treatment, diagnostic tests anlay the foundation for justifying treatment, diagnostic tests and concurrent d concurrent care protocols. Information collected should be in an organized care protocols. Information collected should be in an organized format format (whether it(whether it’’s the classic s the classic SOAPSOAP or a modification of the SOAP format) that or a modification of the SOAP format) that allows information to be recorded in a predictable manner using allows information to be recorded in a predictable manner using specific specific headings.headings.Do not fall into the trap of believing that the level of detail Do not fall into the trap of believing that the level of detail when when documenting is directly proportional to the type of payor. For edocumenting is directly proportional to the type of payor. For example, with xample, with PI more detailed documentation is necessary vs. cashPI more detailed documentation is necessary vs. cash--paying patients. In paying patients. In the interest of the patient and from a risk management standpointhe interest of the patient and from a risk management standpoint, all files, t, all files, regardless of the source of payment, should be equally accurate regardless of the source of payment, should be equally accurate and and thoroughly documented.thoroughly documented.How you document and maintain clinical records can have a profouHow you document and maintain clinical records can have a profound nd impact at some point in the future. So if a medicalimpact at some point in the future. So if a medical--legal issue ever comes legal issue ever comes up for example relating to potential disciplinary action (sexualup for example relating to potential disciplinary action (sexual misconduct, misconduct, or negligence) your records may be all you have, so or negligence) your records may be all you have, so dondon’’t get lazyt get lazy,,document accurately and completely.document accurately and completely.

SS--OO--AA--PPAs previously mentioned, record keeping styles As previously mentioned, record keeping styles vary between clinicians. However, the most vary between clinicians. However, the most widely used format is SOAP: widely used format is SOAP:

SSubjective complaintubjective complaintOObjective findingsbjective findingsAAssessment/Diagnosisssessment/DiagnosisPPlan/Treatment protocollan/Treatment protocol

The initial SOAP notes should contain more The initial SOAP notes should contain more detail. The daily/subsequent SOAP notes should detail. The daily/subsequent SOAP notes should reflect changes in the patientreflect changes in the patient’’s condition with s condition with care on a visitcare on a visit--toto--visit basis.visit basis.

SSubjective Complaintubjective ComplaintThe The SS in in SSOAP represents the patientOAP represents the patient’’s complaint (subjective) in s complaint (subjective) in their own words. This can be gathered from forms, questionnairestheir own words. This can be gathered from forms, questionnaires, , pain drawings, and history. pain drawings, and history. Typical information gathered during the history includes: locatiTypical information gathered during the history includes: location of on of complaint, onset, duration, radiation, frequency, intensity (0 ncomplaint, onset, duration, radiation, frequency, intensity (0 no pain o pain --10 worst pain), character of pain, associated features, systems 10 worst pain), character of pain, associated features, systems review, social history, family history, meds, previous episodes,review, social history, family history, meds, previous episodes,surgeries, etcsurgeries, etc……Information obtained in this section can assist the clinician inInformation obtained in this section can assist the clinician in goal goal setting for the patient.setting for the patient.The subjective component validates that the patient has a The subjective component validates that the patient has a presenting complaint and that itpresenting complaint and that it’’s a complaint amenable to s a complaint amenable to chiropractic care. This can validate that a trial of care is warchiropractic care. This can validate that a trial of care is warranted.ranted.

SSubjective Complaintubjective Complaint

This example shows an initial patient visit that contains almost all of the recommended aspects of history takingfrom the previous page. It contains: Location of complaintLocation of complaint, , onsetonset, , durationduration, , radiationradiation, , frequencyfrequency,,intensityintensity (0 no pain (0 no pain --10 worst pain), 10 worst pain), character of paincharacter of pain, associated features, systems review, , associated features, systems review, social history, meds, and previous episodes.social history, meds, and previous episodes.

OObjective Findingsbjective FindingsThe The OO in Sin SOOAP represents the objective (clinicianAP represents the objective (clinician’’s) s) examination findings relevant to the patientexamination findings relevant to the patient’’s complaint.s complaint.Typical information gathered in this section include: vital Typical information gathered in this section include: vital signs, postural exam, physical/orthopedic exam, motion signs, postural exam, physical/orthopedic exam, motion palpation to identify fixated segments or subluxations, palpation to identify fixated segments or subluxations, neurological exam, and inspection.neurological exam, and inspection.The objective findings of examination can support the The objective findings of examination can support the clinicianclinician’’s initial impression from the history taking s initial impression from the history taking (subjective component) and lead the clinician to a (subjective component) and lead the clinician to a diagnosis or a list of differential diagnosis. The objective diagnosis or a list of differential diagnosis. The objective findings can also help the clinician decide if treatment is findings can also help the clinician decide if treatment is warranted, if additional diagnostic tests are warranted or warranted, if additional diagnostic tests are warranted or if a referral is necessary.if a referral is necessary.

OObjective Findingsbjective Findings

This objective findings in this case contain the majority of the suggested information to gather from the previousslide. These include: Vital signs, physical/orthopedic exam, motion palpation to identVital signs, physical/orthopedic exam, motion palpation to identify fixated segments or ify fixated segments or subluxations, neurological exam, and inspection. Missing is the subluxations, neurological exam, and inspection. Missing is the postural examination.postural examination.

AAssessment/Diagnosisssessment/DiagnosisThe The AA in SOin SOAAP represents the clinicianP represents the clinician’’s diagnostic s diagnostic impression (narrative or descriptive, with potential impression (narrative or descriptive, with potential differentials).differentials).The clinical assessment or diagnosis is reached once a The clinical assessment or diagnosis is reached once a history is collected, the examination performed and if history is collected, the examination performed and if necessary any other diagnostic tests performed.necessary any other diagnostic tests performed.The diagnosis should be clearly marked in the patient The diagnosis should be clearly marked in the patient record. The diagnosis assists in developing an record. The diagnosis assists in developing an appropriate treatment plan, communication with the appropriate treatment plan, communication with the patient, employers, insurers, attorneys, and other health patient, employers, insurers, attorneys, and other health care professionals.care professionals.

PPlan/Treatment Protocollan/Treatment ProtocolThe The PP in in SOASOAPP represents the treatment plan. This should record any need represents the treatment plan. This should record any need for additional tests, refor additional tests, re--exams, followexams, follow--ups, exercises, modification of ups, exercises, modification of activities of daily living (ADL), short/long term goals, referraactivities of daily living (ADL), short/long term goals, referrals and/or cols and/or co--management.management.Other basic information that should be reflected in this sectionOther basic information that should be reflected in this section include:include:

If the patient was adjusted, and if so, where? For example; maniIf the patient was adjusted, and if so, where? For example; manipulation was pulation was performed to the following levels; L2performed to the following levels; L2--3 left, C33 left, C3--4 right.4 right.If therapies were performed, which therapies were used, at what If therapies were performed, which therapies were used, at what setting, and setting, and intensity.intensity.What was the response to manipulation or therapies? Often the paWhat was the response to manipulation or therapies? Often the patient may state tient may state that they felt improvement after the adjustment or therapy. A nethat they felt improvement after the adjustment or therapy. A negative response gative response to either should suggest a possible alternative treatment approato either should suggest a possible alternative treatment approach.ch.

This is also the section where the clinician can decrease the riThis is also the section where the clinician can decrease the risk of sk of malpractice by documenting the alignment of clinician and patienmalpractice by documenting the alignment of clinician and patient goals and t goals and expectations. It helps show twoexpectations. It helps show two--way communication between the patient way communication between the patient and clinician, patient participation, informed consent to treatmand clinician, patient participation, informed consent to treatment, and ent, and records the patientrecords the patient’’s acceptance of responsibility for following through with s acceptance of responsibility for following through with the treatment plan and being an active participant in their carethe treatment plan and being an active participant in their care..

Treatment Treatment PPlan Progress Noteslan Progress Notes

Now letNow let’’s look at a few sample treatment s look at a few sample treatment progress notes. They represent daily notes and progress notes. They represent daily notes and are less detailed than the initial SOAP notes but, are less detailed than the initial SOAP notes but, should follow a similar SOAPshould follow a similar SOAP--like format that like format that shows patient progress to care. The following shows patient progress to care. The following are examples of the are examples of the GoodGood, the , the BadBad, and the , and the UglyUgly when it comes to documentation.when it comes to documentation.

Treatment Treatment PPlan Progress Noteslan Progress NotesThe The GoodGood!!

This example contains most of the necessarycomponents of a progress note:

patient name at top of page(blacked out for confidentiality)treating Dr. identified(blacked out for confidentiality)SOAP formatsubjective informationobjective findingsspecific levels adjusted

The notes are not perfect but they arereasonable, clear and concise. Iwould add the diagnosis to the “A” portionof the SOAP note.

Treatment Treatment PPlan Progress Noteslan Progress NotesThe The BadBad!!

These notes do not contain the These notes do not contain the minimum amount of minimum amount of information based on information based on professional standards and professional standards and have many problems:have many problems:

They are only partially legible. They are only partially legible. Some entries have spinal Some entries have spinal segments that can be identified.segments that can be identified.No clear SOAPNo clear SOAP--like formatlike formatItIt’’s unclear if the patient is s unclear if the patient is improving.improving.WhatWhat’’s the diagnosis?s the diagnosis?WhatWhat’’s the treatment plan?s the treatment plan?

Treatment Treatment PPlan Progress Noteslan Progress NotesThe The UglyUgly!!

This is the worst it can get next to having no This is the worst it can get next to having no documentation at all. Look at the progress documentation at all. Look at the progress notes to the right. This is just a sample of notes to the right. This is just a sample of the notes, the remainder appeared the the notes, the remainder appeared the same. Each visit is just stamped with a date. same. Each visit is just stamped with a date. In fact there were a total of 61 visits over 5 In fact there were a total of 61 visits over 5 months. Can you tell:months. Can you tell:

What is being performed?What is being performed?Patient response to care?Patient response to care?Effectiveness of care?Effectiveness of care?Justification for ongoing care?Justification for ongoing care?

These notes do not support the treatment These notes do not support the treatment given to this patient.given to this patient.

There is a total lack of any SOAPThere is a total lack of any SOAP--like like format.format.

Ask yourself: If this were a malpractice suit Ask yourself: If this were a malpractice suit could the chiropractor be defended with could the chiropractor be defended with these notes?these notes?

In todayIn today’’s health care environment a s health care environment a clinician may be judged more by the quality clinician may be judged more by the quality

of the records they keep than their skills. of the records they keep than their skills.

““You are what you writeYou are what you write””Robert Mootz, DCRobert Mootz, DC

Methods of DocumentationMethods of Documentation

Methods of DocumentationMethods of Documentation

There are numerous methods used in record keeping. There are numerous methods used in record keeping. The one you choose is a matter of preference. Each has The one you choose is a matter of preference. Each has its strengths and weaknesses. We will review:its strengths and weaknesses. We will review:

Dictation & TranscriptionDictation & TranscriptionComputerComputer--Assisted ProgramsAssisted ProgramsWord Processing ProgramsWord Processing ProgramsHand Written/PreHand Written/Pre--prepared Formsprepared Forms

Wisconsin Chiropractic Association’s Recommendation for Clinical Documentation

Methods of Documentation Methods of Documentation Dictation & TranscriptionDictation & Transcription

Dictation of clinical records remains the most Dictation of clinical records remains the most common method of documentation.common method of documentation.AdvantagesAdvantages

legibilitylegibilityNo restrictions imposed by the formatNo restrictions imposed by the formatNo special computer trainingNo special computer trainingCan use as much detail as neededCan use as much detail as needed

DisadvantagesDisadvantagesLabor intensive, hence costlyLabor intensive, hence costlyTapes can break or be lostTapes can break or be lostDictation systems can lose dataDictation systems can lose data

Methods of Documentation Methods of Documentation ComputerComputer--Assisted ProgramsAssisted Programs

Computer programs come in many formats with various methods of Computer programs come in many formats with various methods of inputting information into the computer. Information can be captinputting information into the computer. Information can be captured via ured via voice, through keyboard, light pens, scanning sheets, touch screvoice, through keyboard, light pens, scanning sheets, touch screens, bar ens, bar code readers, etccode readers, etc……AdvantagesAdvantages

Automates repetitive aspects of records keepingAutomates repetitive aspects of records keepingComprehensive approach to inputting clinical dataComprehensive approach to inputting clinical data

DisadvantagesDisadvantagesCan have a high initial costCan have a high initial costDifficult to edit your copy from the preDifficult to edit your copy from the pre--defined format in some productsdefined format in some productsCan lose data if the system is not backed upCan lose data if the system is not backed upRepetitive daily notations that suggest the patient is not respoRepetitive daily notations that suggest the patient is not responding to nding to care.care.

Methods of Documentation Methods of Documentation Word Processing ProgramsWord Processing Programs

Can be programmed to perform repetitive functions. These are basCan be programmed to perform repetitive functions. These are basically ically programs that use macros. Automates many of the repetitive tasksprograms that use macros. Automates many of the repetitive tasks such as such as typing the clinic name, patient name, data, etctyping the clinic name, patient name, data, etc…… Macros can also generate Macros can also generate frequently used text blocks, e.g. lumbar exercise routines.frequently used text blocks, e.g. lumbar exercise routines.

AdvantagesAdvantagesLow costLow costUses macrosUses macrosCan be easily adapted to meet needsCan be easily adapted to meet needs

DisadvantagesDisadvantagesSetSet--up is labor intensiveup is labor intensiveCan lose data if the system is not backed upCan lose data if the system is not backed up

Methods of Documentation Methods of Documentation Hand written/PreHand written/Pre--prepared formsprepared forms

If you are using hand written or preIf you are using hand written or pre--prepared forms ensure the prepared forms ensure the writing is legible. Often hand written notes contain abbreviatiowriting is legible. Often hand written notes contain abbreviations. If ns. If nonnon--standard abbreviations are used, supply a key. Also, itstandard abbreviations are used, supply a key. Also, it’’s s extremely important to document the information gathered from thextremely important to document the information gathered from the e patient at the time of visit to prevent any recall bias.patient at the time of visit to prevent any recall bias.

AdvantagesAdvantagesLow costLow costCan use abbreviationsCan use abbreviationsNo special technical/computer training No special technical/computer training requiredrequired

DisadvantagesDisadvantagesMay have legibility problemsMay have legibility problems

““Hope for the best, plan for Hope for the best, plan for the worst, expect the the worst, expect the

unexpectedunexpected””

Document, Document, Document!

Today in health care, as physicians we can reduce our risk for malpractice allegations by adhering and updating to appropriate standards of care in documentation and changing our view of documentation from a necessary chore to an opportunity to credit and validate the excellent care we provide.