CLINICAL DOCUMENTATION Mighty Oak, Inc. Tony Hamm, DC 2015
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Reasons for proper record keeping Risk management Third party
reimbursement Provides for a chronological story of the evaluation
and management of the chiropractic patient
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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
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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
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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
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Chiropractic-specific Documentation Problems High Medicare
error rate Untenable error rates Professional liability issues
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Resources ACA Clinical Documentation Manual, 3 rd Edition
Consensus development process involving chiropractic colleges, the
insurance industry and practicing DCs
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ACA Clinical Documentation Manual Recommendations, not
guidelines Recommendations do not supersede state or federal
regulations Medicare has its own guidelines
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Population Based Care Based on age Gender Age
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Types of Patient Reimbursement Medical coverage Workers comp
Liability Medicare Medicaid Cash
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Patient Health Record
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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
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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
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Meaningful Use Problem list Allergies Medication list Vitals
Smoking history BMI CQM
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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
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Abbreviations Standard vs. non-standard Encourage use
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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
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Components of the Health Record Demographic Clinical
Miscellaneous
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Demographics Patient name DOB Address/e-mail Phone numbers
Employee information
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Demographics Occupation Spouse information Social Security
Number Emergency contact File number if applicable Generally
completed on intake forms
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Clinical (SOAP NOTE) Patient history and physical examination
including ROS Counseling and coordination of care Imaging Lab
studies Treatment plan/procedures/modalities
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Clinical Disability/work status Home instruction/education
Referral/consultation Maintenance/preventative/wellness care
Patient compliance Patient discharge
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Evaluation/Management History Examination Clinical decision
making Counseling Coordination of care Nature of presenting problem
Time
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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.
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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
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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
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Imaging Reports Facility name and address Patient name and DOB
(sex?) Date(s) of study Areas of study/views
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Imaging Reports Body of report to include description of
findings and impressions Recommendations for follow-up or
additional studies
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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)
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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
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Diagnosis/Assessment List all diagnostic impressions including
differential diagnoses List in order of importance-primary,
secondary, tertiary Update changes in diagnosis in progress
notes
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Diagnosis/Assessment Past diagnoses/conditions/symptoms can be
discovered as listed in the ROS Utilize the most updated version of
ICD-9-CM
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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
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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
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Treatment Plan CMT Modalities Therapeutic procedures Home
care/patient instructions Goals DME Ancillary services
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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.
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Modalities Supervised Example: HP thoraco-lumbar spine.
Example: Intermittent traction L.4-5. Constant Attendance Example:
US R sub-acromial space X 12 min.
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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.
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Home Care/Patient Instruction Pain control Avoidance of
aggravating activities Postural suggestions Ergonomic
considerations ADL modifications Dietary/nutritional
recommendations
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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
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.
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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.
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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.
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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
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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.
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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
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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.
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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
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Established Patient Visit Document CMT Modalities/procedures
Document any changes to treatment plan Record next scheduled
appointment date
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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.
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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
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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.