The American Chiropractic Association reports that “more than 50 percent of chiropractic care denials [are] made on the basis of insufficient or non-specific clinical documentation” when billing for third party reimbursement.
Continuing with this observation, the ACA cautions its members: “Remember, poor clinical documentation hurts your patients, your practice and the profession.”
We echo the ACA’s position with regard to the importance and necessity for solid, substantive documentation, but with a slightly different perspective: Documentation is still the best means by which to demonstrate comprehensive critical thinking that supports sound judgment and treatment plan development. And it becomes the primary weapon in your defense arsenal should you be challenged with an allegation of malpractice.
How do your documentation habits align with ACA guidelines and New Jersey licensure regulations? It is not uncommon for us at Princeton to take phone calls from chiropractors asking about documentation. Inquiries typically include: “How much is too much?” and “How can I be confident that I write a sufficient (and proper) note for each patient encounter?”
Warp back in time to the 1950s and the television show Dragnet (those of us who are “mature” enough to remember or those of you who watch reruns decades later) … recall Sergeant Joe Friday’s admonition to someone he is interviewing: “All we want are the facts …” This caveat remains a fundamental principle for any provider of services in the healthcare sector today. Keep your entries objective (factual) and relevant (on point and germane to the patient’s concern).
Let’s take a brief look at some of the guidelines promulgated by the New Jersey State Board of Chiropractors (NJSBC) with regard to record maintenance and documentation in order to promote patient safety and best practices.
The initial consultation, according to the NJSBC, is for the purpose of assessing and documenting the clinical condition necessitating chiropractic care.
Like all medical and allied healthcare providers, the chiropractor is expected to maintain a patient record in which patient information is stored. The data entered is to be contemporaneous – that is, a complete note is entered into the record as soon after the patient encounter as is possible, but usually no later than the end of the business day.
There are rare occasions where you may find yourself needing to make a late entry. Before doing so, ask yourself these questions:
· Why is a late entry necessary?
· Is there a fact (or facts) that are relevant and important to the patient encounter that you failed to note when making your last entry?
Be circumspect and deliberate when making a later entry. Again, ask yourself:
· What is my primary motivation for doing this?
· Did I fail to mention a substantive fact or facts (which certainly supports good clinical practice and keeps patient safety foremost)?
· Or am I concerned that the note does not accurately and completely reflect the patient encounter?
Avoid the temptation to make a late entry if you discover or are informed of an unexpected or untoward outcome resulting from a patient visit with you. It is almost impossible to justify the intentions of a clinician when it appears that a late entry is nothing more than self-serving or an attempt to justify one’s actions or decisions after learning of a negative patient-related outcome. Avoid giving any appearance that you are putting your professional self-preservation before the best interest of your patient, which is a difficult – if not impossible - impression to overcome.
Other elements of a chiropractic patient record as set forth by the State Board of Chiropractic Examiners (13:44E-2.2) include:
- Maintain key patient identifying information such as name, address, date of birth. For those of your patients who are minors or may be deemed incompetent, the contact information for the parent or guardian who possesses legal authority to approve treatment rendered by you is also important to note in the record.
- Why has the patient come to see you? Your note should reflect the patient’s primary complaint or other reason for the appointment. Make it a routine or custom to record the complaint in the patient’s own words wherever possible, placing quotation marks around the patient’s response.
- New Jersey regulation also requires “a pertinent case history.” Pertinent may be defined as “relevant to the matter being considered.” Often, a patient seeking chiropractic intervention will come to you because of a recently-acquired injury. Document the source and nature of the injury as presented and described to you by your patient.
- Be certain to document your findings based upon an appropriate and thorough examination of the patient. Do this for the initial visit and any subsequent visit that suggests or necessitates an additional patient examination. Findings will assist you with developing a working diagnosis and a care or treatment plan or to revamp the plan based upon recent developments.
- Does the diagnosis and plan accurately and completely reflect your clinical thinking and impression?
- Does it demonstrate your consideration of all potential treatment options and does the documentation reflect why you chose one course of action to the exclusion of all others that may be considered as a “best practice?”
The old (but sage) wisdom, which is universally applicable to all providers of healthcare is worth another recitation here: if something is not written down, the assumption is made that you did not do it, you failed to consider it or you are careless and deleterious with your responsibilities as a clinician.