CLINICAL DOCUMENTATION Mighty Oak, Inc. Tony Hamm, DC 2015.

CLINICAL DOCUMENTATION Mighty Oak, Inc. Tony Hamm, DC 2015

Reasons for proper record keeping Risk management Third party reimbursement Provides for a chronological story of the evaluation and management of the chiropractic patient

Risk Management Provides valuable protection for the provider in professional liability claims Patient protection If it was not written down, it was not done Proper documentation may prove clinical skill level

Third Party Reimbursement Proper documentation provides proof of clinical necessity for initial and follow-up care May prove the necessity for on-going or supportive care for chronic or recurrent conditions

Chronological Story Allows a provider or staff to review the manner in which a patient was evaluated or managed in the past. Allows a provider to review the patient response to a particular treatment plan Allows another provider to review the management of a patient

Chiropractic-specific Documentation Problems High Medicare error rate Untenable error rates Professional liability issues

Resources ACA Clinical Documentation Manual, 3 rd Edition Consensus development process involving chiropractic colleges, the insurance industry and practicing DCs

ACA Clinical Documentation Manual Recommendations, not guidelines Recommendations do not supersede state or federal regulations Medicare has its own guidelines

Population Based Care Based on age Gender Age

Types of Patient Reimbursement Medical coverage Workers comp Liability Medicare Medicaid Cash

Patient Health Record

General Considerations Records should be consistent, accurate and contemporaneous Legible and indelible Dated entries and chronological order Correct with a single line-through & initial No white-out

General Considerations May be hand-written, typed, computer-generated or dictated Ensure confidentiality and privacy (HIPAA) Retention based on state regulations Facility identified on each page Authentication

Meaningful Use Problem list Allergies Medication list Vitals Smoking history BMI CQM

General Considerations Records release/request authorization Consent to examine/treat minors and mentally impaired Written or verbal consent to treat- dictated by state regulation or advice from professional liability carrier

Abbreviations Standard vs. non-standard Encourage use

Abbreviations Examples AMA b.i.d. CMT DISH ext fx GERD HNP IVD kVp LBP mvc NSAID OTC prn q.i.d. RLE SOB TP UTI URI VBI wnl ORIF yo

Components of the Health Record Demographic Clinical Miscellaneous

Demographics Patient name DOB Address/e-mail Phone numbers Employee information

Demographics Occupation Spouse information Social Security Number Emergency contact File number if applicable Generally completed on intake forms

Clinical (SOAP NOTE) Patient history and physical examination including ROS Counseling and coordination of care Imaging Lab studies Treatment plan/procedures/modalities

Clinical Disability/work status Home instruction/education Referral/consultation Maintenance/preventative/wellness care Patient compliance Patient discharge

Evaluation/Management History Examination Clinical decision making Counseling Coordination of care Nature of presenting problem Time

E/M Example Pleasant 42yof bent over to lift her child from a car seat 1 wk earlier. Immediate onset R LBP rad. into right leg with numbness R foot. Pain is constant and aggravated by bending and sneezing. Denies BB dysfunction. Self tx with Tylenol and heat. Prior hx of recurrent LBP and dx with grade 1 spondylo L.4 at age 22.

E/M Example (cont) Healthy appearing 43 yof in painful distress. Ht. 65, wt. 132, BP 118/72, p. 68, rr 18. Abd. soft and non-tender. L. sp is hypolordotic and pt is antalgic left. + Valsalva. Midline tenderness L.4-5-S.1. Right L. ps. mm hypertonic. L. ext and B rot. diminished. SLR + right 45 degrees. LE DTRs 2+ symm. LE motor 5/5. Diminished sensory right L.5 dermatome. Peripheral pulses full. Proprioception normal. Impression: Acute right L.5 radiculopathy

Diagnostic Imaging Document all imaging studies performed and/or interpreted by the provider X-rays are a part of the permanent health record. Imaging reports should be written and signed

Imaging Reports Facility name and address Patient name and DOB (sex?) Date(s) of study Areas of study/views

Imaging Reports Body of report to include description of findings and impressions Recommendations for follow-up or additional studies

Imaging study example John Smith, DC 117 Main St. Lizard Lick, NC 00000 Patient: Ura Hogg DOB: 01/12/1955 AP/Lateral Lumbar spine Date of Study: July 5, 2006 Mild right rotation of the L sp. is present along with an inferior right pelvis. Narrowing of the disc spaces is evident at L.4-5 and L.5-S.1 with vacuum phenomenon at L.5-S.1. No evidence of fracture. Impression: Postural changes noted above. Degenerative disc disease lower lumbar spine. John Smith, DC (signature)

Lab Studies Document results of studies ordered by the provider or another provider if they are pertinent to the case Correlate findings with the patient condition and/or treatment plan Document necessity for follow-up lab work

Diagnosis/Assessment List all diagnostic impressions including differential diagnoses List in order of importance-primary, secondary, tertiary Update changes in diagnosis in progress notes

Diagnosis/Assessment Past diagnoses/conditions/symptoms can be discovered as listed in the ROS Utilize the most updated version of ICD-9-CM

Treatment Plan DC will establish a clinically indicated plan necessary for improvement of patient health (Clinical Necessity) Plan is subject to change as the patient condition changes throughout the course of care

Treatment Plan Document alterations to the plan Document the necessity for follow-up and re-exams If applicable, document the fact that no treatment is indicated Document referral to other source

Treatment Plan CMT Modalities Therapeutic procedures Home care/patient instructions Goals DME Ancillary services

CMT Documentation must support the code reported 98940-98943 Record specific segments/regions manipulated/adjusted Pre, intra and post-service work (critical) Examples: Adjusted C. 6-7, T. 4-7 and L.5-S.1.

Modalities Supervised Example: HP thoraco-lumbar spine. Example: Intermittent traction L.4-5. Constant Attendance Example: US R sub-acromial space X 12 min.

Therapeutic Procedures Direct one-on-one patient contact Most are 15 minute time-based Record the procedure, rationale, area treated and time/duration Examples: 15 min. core stabilization exercise instruction. Once daily at home.

Home Care/Patient Instruction Pain control Avoidance of aggravating activities Postural suggestions Ergonomic considerations ADL modifications Dietary/nutritional recommendations

Treatment Goals Short and long term (OATs) Pain reduction Improved muscle tone Increased strength/flexibility Improved ability to perform ADL`s Improved endurance, coordination, proprioception

Ancillary Services Acupuncture Additional testing-NCV/EMG Manual muscle/ROM testing Others?

Treatment plan example EMS right L.5-S.1 to modulate pain. FDT L4-5 and manual CMT left pelvis and SI. Home ice 15 min. q 2 hrs. Advised to avoid off act. Placed in a S-L support to be utilized when ambulating. See pt daily X 1 wk and 3X/wk X 2 wks and re-eval. Order imaging if pt is unresponsive or with progressive neuro findings. Further advised to refrain from all work X 2 wks.

Treatment plan example (cont) Short term goals: minimize pain and spasm and increase LS flexion. Long term goals: Restore ability to sit and stand for prolonged periods, return to normal sleep pattern, increase core strength and rtw.

Referral/Consultation Document relevant information when referring a patient to another source for consultation, testing or treatment Clinical rationale Details of the appointment Example: As a result of progressive L EHL weakness, pt is referred to Dr. Fine for neurosurgical evaluation. 1/29/07 3:00pm. Send x-rays and office notes.

Disability/Work Status Submit documentation/forms to appropriate source with proper patient authorization Exception with workers comp (state regulations) Note time frame out of work and expected return Document restrictions and duration Examples: Pt advised to refrain from work through 2/14/2007

Patient Compliance Record cancelled/missed appointments Refusal to follow home care instructions, including active care Example: Pt admits that she has not been diligent with exercise protocol.

Patient Discharge Record should reflect the outcome of the treatment plan at the conclusion of care Detail any subsequent steps related to the patient condition

Patient Discharge At the conclusion of a treatment plan document: The necessity for continued care Referral for further diagnostic testing or different treatment services Patient discharge Example: Cervical strain has responded favorably to tx plan. Condition has resolved. Pt is D/C with advice to rtc if necessary.

Established Patient Visit Progress notes/SOAP notes Document significant subjective and objective changes Established patient E/M when appropriate Document changes in assessment or clinical impression VAS and OATS

Established Patient Visit Document CMT Modalities/procedures Document any changes to treatment plan Record next scheduled appointment date

Established patient visit Example: S: Pt continues to c/o R LBP. Worse with sitting/coughing. Better with ice. O: lumbar ps mm hypertonic. Ext limited. VAS 6/10. A: Acute lumbar facet syndrome, unchanged. P: EMS R LS ps mm. Adjust L. 4-S.1. Continue ice. RTC 2 days. Continue work restrictions.

Maintenance/Preventive/Wellnes s Care Visit Describe any symptoms if present Document objective findings ( subluxation, tone, posture) CMT Any health-related recommendations Follow-up appointment if applicable

Maintenance/Preventive/Wellnes s Care Visit Example: Pt reports no significant complaints. No subsequent UE pain since last visit. Subluxation C. 4-5 and T. 2-3. Adjust per above. RTC 4 weeks for continued maintenance care.

Renewal Visit How would you document that visit?

THE END

CLINICAL DOCUMENTATION Mighty Oak, Inc. Tony Hamm, DC 2015.

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