Quality Medical Record Documentation
The documentation of member care has a direct impact on the quality of care that will be delivered to that individual. The patient file exists for use by the current treating practitioner, the primary care physician or other health care specialist treating the member now or in the future. It serves as a permanent record that is available to any other health care professionals that may treat the member, as well as any attorneys or insurance companies that may require review of the records. Records serve four primary purposes: 1. To help determine quality clinical care by recording an accurate case history, examination, results, and the member's response to treatment 2. To assist the practitioner in reporting and testifying on a member seeking damages 3. To protect the practitioner from professional liability claims by recording what was said and done during examination and treatment 4. To provide information to third party payors so they will pay your claims Legibility All records must be legible, comprehensible and written in English. The use of standard medical abbreviations is accepted. Abbreviations, acronyms, symbols, etc., unique to an individual office or practitioner are discouraged, but, if present, a legend or key must be provided such that the unique abbreviations, acronyms, symbols, etc., can be understood by other health care professionals. For your convenience, a list of standard medical abbreviations is included in the Glossary, Abbreviations & Index section of this manual. Records should be in chronological order and written in permanent ink. When amending records, cross out the inaccuracy but leave the original entry legible. The corrected entry should be dated and signed. Patient Identification The member’s name or ID number must be clearly present on each and every page contained within the member file. Essential Facts The member’s age or date of birth, sex, height and weight must all be recorded within the record at least once. Periodic update of the member’s height and/or weight is recommended where clinically applicable (i.e., report of loss of height due to compression fracture or degenerative changes, unexplained weight loss, weight
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gain impacting health, etc.). It is also recommended that the patient’s marital status, occupation, employer and applicable phone numbers be recorded and updated as applicable in the patient’s file. Medical History The member’s complete medical history is a required element within the file. It should include the following: Personal History § A history of any prior similar symptoms and the treatment/outcome; history of accidents (including motor vehicle accidents and industrial injuries, falls or other injuries) History of significant/serious illness; history of hospitalization § History of surgeries § Medications taken currently and in the recent past § Relative or absolute contraindications or adverse reactions to treatment(s) must be documented § Other conditions recently or concurrently diagnosed and/or treated by another health care professional; and a review of symptoms. § If an element of the history is positive, an appropriate description should be provided. If a history element is negative, it must be reflected in the history (e.g., negative for surgical history). If, in this instance, it were not recorded that the surgical history was negative, it would appear that the member was never questioned about this subject. From a third party’s standpoint, what is not documented in the record was never asked nor performed. Family History § History of immediate family members (parents, grandparents and children) Social History § Habits and hobbies Interim History The member’s interim medical history must be recorded when there has been a break or hiatus in management of the case within your office. If the interim history is negative, it should be so noted. Subjective Complaints It is suggested that the mode of onset, location, quality, intensity, and frequency of the complaints be described, in addition to any radiation or referral patterns, provocative and palliative factors, setting and severity, and timing of the complaints. This order of documentation is often referred to as the acronym “OPQRST.” The acronym represents for Onset, Palliative and Provocative factors, Quality, Radiation or Referral, Setting/Severity, and Timing of the complaint(s).
If the patient’s complaint is related to an incident that aggravated an existing condition, or resulted in a new condition, the file should contain a written description of the incident. Objective Findings Objective findings, including the following, must be documented: § Basic examination and/or reexamination elements of inspection, static and motion palpation, auscultation and percussion, range of motion, orthopedic, and where applicable, neurologic, gait analysis, biomechanical analysis and/or vascular findings must be documented. § Significant negatives must be recorded, as well as the significant positives. When an examination element is not recorded, there is a legal presumption that the test/procedure was never performed. § Please note that quantifying information is important to record with palpation, range of motion, neurologic and vascular testing; while locations of pain are important to document with palpation, range of motion, and orthopedic testing. § Quantifying information for muscle spasms, tenderness, range of motion restrictions, extent of motor deficit, extent of deep tendon reflex (DTR), or force and rate of pulses, provides proper documentation of the member’s initial condition, aids in differential diagnosis, and documents subsequent progress or deterioration in the member’s condition. Documenting the locations of pain or other symptomology is also necessary for these same reasons. § When taken, the resultant findings of xrays. If utilizing consultant reports, the report should be initialed by the treating chiropractor to signify review. Diagnosis/Assessment The initial member workup must include the working diagnosis or initial clinical impression obtained following the history, examination, and any diagnostic testing that may have been performed. The working diagnosis must be consistent with the reported findings. Any subsequent revisions or updates to the diagnosis must be reflected in contemporaneous file entries. Treatment Plan The treatment plan schedule should be consistent with the diagnosis. The practitioner must document the type, frequency, duration, specific body region involved, and anticipated goals of treatment in the member's file following the initial workup. The type of care must be specific to the particular procedures and/or modalities proposed. "Chiropractic care” or similar phrases are not sufficiently specific for the purposes of member file documentation. Diagnostic Testing The clinical reason for any diagnostic testing ordered must be documented in the records. In this way, the practitioner documents the medical necessity of the testing.
A chiropractic example might be as follows: “Patient has had acute LBP of 3 days duration which is worsening. Past history of patient complaint of fever. Temp. today of 102°F and Hx of significant I.V. drug abuse (heroin), will take AP and lateral xrays of area of chief complaint (lumbar) to aid in ruling out possible infection.” Likewise, if diagnostic testing (particularly xray) is not ordered, the reason must be documented in the member’s file. For example: "Patient woke up with stiff neck today after sleeping wrong on couch. Denies any prior problems and no red flags in history. All orthopedic and neurological tests negative. Spasm noted in left trapezius muscle with T2P only. “D/t Hx and PE of this 22 y/o which is absent of ‘red flags,’ a trial of conservative management will be attempted for 30 days. If no improvement, plan to take APOM and lateral cervical xrays after 30 days to R/O other possible causes of acute NK PN.” Chiropractic Medical Referrals The clinical reason for all medical referrals must be documented in the records. With the previous example of a 102° F fever and a history of intravenous drug abuse in the presence of lowback pain, the scenario subsequent to xray might occur as follows: “Low back xrays demonstrate apparent cortical destruction of both sacrum and ilium at the SI joints; reactive sclerosis noted in right inferior SI joint. Immediately refer pt. to PCP to evaluate for possible osteomyelitis. Referral form given to pt. following review of xrays and explanation of urgency of medical F/U. I will call PCP personally to discuss findings and ensure that pt. is seen this PM or tomorrow AM.” DC to f/up w/written letter to PCP. The entry clearly indicates an appropriate reason for medical referral and how the referral was conveyed to the member and the member’s medical physician. Consultations and Second Opinions Participating practitioners shall maintain and use the “Referral for Medical Services" (Form 4) found in the Forms & Instructions section of this manual, and follow established policies and procedures for any consultations and/or second opinions. Progress Notes in the Member File It is necessary to document within the records each and every member visit that occurs. Each entry must be written in English and dated with the month, day and year. The practitioner providing treatment on that particular date must sign each progress note entry. Any staff member able to make entries in the member's file must sign their initials after each entry. The use of standard medical abbreviations is acceptable in formulating progress notes (refer to the list of standard accepted abbreviations). However, progress notes
must not be encoded. All interactions with the member must be documented in the progress/chart notes, including phone communications with the member or other health care professionals regarding the member’s condition. A “S.O.A.P. note” format is the preferred method of documentation of member visits. By using the “S.O.A.P.” method, the Subjective complaints, Objective findings, Assessment, and Plan of treatment are recorded on each visit such that the necessity of care may be easily assessed. This type of documentation also aids in management of the member’s condition and may serve to diminish a practitioner’s malpractice exposure. The elements of the “S.O.A.P. note” are described in detail: S = Subjective Complaints A description of the location, intensity and frequency of complaints present on each visit should be noted. Any changes in the subjective condition should be recorded contemporaneously in the progress notes. O = Objective Complaints The objective findings present on each visit that support the need for treatment must be documented next. This is not to suggest that a comprehensive examination must be performed on each visit. Rather, different elements of the examination that were found to be positive in the initial workup should be checked as required to properly monitor and manage the member’s condition. For instance, if range of motion has been restricted, the ranges of motion may well be checked prior to treatment and recorded as observed and measured. If a neurological deficit is present, this should be checked at the beginning of each visit and recorded as such. The objective findings that are recorded on each visit will vary from member to member, but whatever the findings may be, they must support the necessity of treatment on each date. A = Assessment From visit to visit, the assessment will typically consist of a description of the member’s progress. If there is a change in the working diagnosis or initial clinical impression, the new diagnosis or clinical impression should be recorded under “assessment.” This is the practitioner's impression of the member's progress using subjective and objective complaints. P = Plan of Treatment On a visit by visit basis, the plan of treatment will describe the treatment rendered on that particular visit, as well as the plan to follow up with the member. The description of the treatment rendered includes the segmental levels that have been adjusted or manipulated as well as the technique used. Any physiotherapy modalities or procedures utilized should be described, inclusive of the treatment time, machine settings (where applicable), and the body parts to which the treatment was administered. Any revisions of the overall treatment plan as outlined in the initial workup should be noted contemporaneously in this section of the “S.O.A.P. notes.” In addition, the plan for followup with the member must be documented on each visit. For example, “Return Fri. for further tx.” or “Will see PCP on Thurs. to evaluate for possible inflammatory arthritide. Pt. will call here Fri. with results of visit and I will F/U with the PCP as necessary.” When discharged from care, the patient file should include a discharge record that includes the reason for discharge and patient health status. Financial Record Each patient file should include a financial record that includes the following: § Date and type of service provided
§ Fee for service(s) § Payment received and source of payment § Current balance of the account Access to Records Participating practitioners agree to store member files in a manner that keeps the patient’s information secure, but will provide access to authorized representatives and agencies when necessary to facilitate the continuity of care and compliance with regulatory requirements. This may include copying and/or releasing medical records, including radiology film and reports, in a timely manner for review, audit and/or transfer of a member. Costs incurred in facilitating prompt and thorough availability are assumed by the participating practitioner as overhead costs per your provider agreement. Record Retention Participating practitioners are required to retain all patient records for a minimum of ten years (some states may have other record retention requirements). Such obligations shall continue after termination of this Agreement, whether by rescission or otherwise. Participating practitioners shall provide access to the books, records and papers of the participating practitioner relating to the covered services provided to the member, to the cost thereof, and to payments received by the participating practitioner from the member at reasonable times upon demand.
Note: The guidelines presented in this document are supported by ChiroCare Policy CRM007, Guidelines for Record Keeping.