Document, document, document!

Documenting the information you provide your patients as well as the information you gather during your encounters with them is essential. Take extra care to document those conversations in which you make clear to your patients exactly what it is you CAN do and what you CANNOT in treating them. For those patients who you treat primarily or exclusively (effectively using your services as would someone using the services of a PCP), you may need to consider the following:

• Use a standardized format to capture relevant patient medical (and familial) history, including chronic illness, surgeries, medications and family predisposition to illness, such as cardiac-related, cancer, etc.
• Periodically inquire about changes in medications, recent medical conditions, etc.; an update form can be utilized for this purpose.
• As applicable, track vital signs, referrals for tests, specialist referrals (e.g., pain management), etc. Implement or develop a tracking mechanism so referrals for these are not lost in the daily administrative shuffle.
• Beware of preventive and maintenance issues, such as vaccines for influenza, pneumonia, etc. Documentation of any discussion should be reflected in the record, particularly if the patient elects to forego such preventive measures.

The New Jersey Board of Chiropractic Examiners Regulations (13:44E-2.2) mandate that a “contemporaneous, permanent record shall be prepared and maintained” which includes, at a minimum:

• name, address, date of birth (guardian name if the patient is a minor)
• patient complaint
• pertinent case history
• findings from examination
• diagnosis
• care (treatment) plan
• orders for tests/consults and results of same
• dates of patient visits
• description of care/services rendered at each visit
• note(s) regarding significant changes in patient condition
• periodic note regarding patient status
• radiographs and other diagnostic findings (these should be maintained for seven years from the date of last entry; for minors, seven years from date of last entry or until the age of majority -18 yrs - plus two years, whichever is later)
• radiographs must be labeled
  • patient name
  • date of film
  • age of patient or date of birth
  • facility name
  • right or left identity

We would add to this list the importance of documenting informed consent discussions. Take care to be certain your patient understands the benefits of the proposed treatment, the risks and alternatives to the proposed treatment, and note any questions the patient raised and how these were addressed to the patient’s satisfaction. Additionally, note a patient’s refusal of proposed treatment or withdrawal of consent before the commencement of treatment.

Nutritional Supplements: Beware drug-herb interactions

NJ law permits chiropractors to recommend and provide nutritional supplements to their patients. It is important to understand the potential complications that can arise when combining some medications with certain herbs and other supplements.[i]  As examples:

• Anticoagulants and ginkgo, garlic, dong quai or danshen
• Medications associated with mental health
  • SRIs (serotonin reuptake inhibitors) and St. John’s wort
  • Antidepressants with forms of ginseng
  • Trycyclic antidepressants with yohimbe
• Decreased bioavailability when using St. John’s wort with digoxin, theophylline, cyclosporine and phenprocoumon

As noted previously, an accounting of all medications and OTC supplements the patient is taking can help prevent a potential problem when suggesting nutritional supplementation.

Final thoughts

Understand and stay abreast of the new continuing education requirements, as well as the requisite training through an approved course of study for the services you provide or anticipate providing in the future. For bi-annual registration, a minimum of 30 hours of continuing education is required, two credits of which must relate to “the study of state laws and regulations governing chiropractic professional ethics or record keeping and documentation as it pertains to the practice of chiropractic in New Jersey.”