AN OVERIVIEW OF CLINICAL DOCUMENTATION FOR THE ...



AN OVERIVIEW OF

CLINICAL DOCUMENTATION

FOR THE CHIROPRACTIC

PROFESSION

Steven G. Yeomans, DC, FACO

404 Eureka Street

Ripon, WI 64971-0263

920-748-3644 (Ph)

920-748-3642 (Fax)

s@

Course Objective:

TO BULLET-PROOF YOUR DOCUMENTATION AGAINST AN ADVERSARIAL REVIEW PROCESS

Table of Contents

|Content |Page # |

|ACA Recommendations (2001) |3-4 |

|WCA Recommendations (1996) | |

|Intro & Acknowledgements ………………………………………………... |5-8 |

|Chapter 1: Documentation recommendations ………………………….….. |9-18 |

|Chapter 2: Commonly used mechanisms of record keeping ……….……… |19-21 |

|Chapter 3: Commonly used outcome assessment measurements …………. |22-24 |

|Chapter 4: A primer on chiropractic listings ……………………….……… |25-26 |

|Chapter 5: Glossary ……………………………………………………….. |27-28 |

|Chapter 6: Commonly used abbreviations ………………………….……… |29-32 |

|Appendix A: HCFA Guidelines for Patient History Level Selection ……… |33 |

|Appendix B: Bibliography ………………………………………………… |34-35 |

|Chart Audit |36 |

|Yellow Flags (psychometrics) |37-38 |

|CPT Codes |39-40 |

|Bibliography |41-44 |

Ref: ACA Today, March 2001 The Newsletter of the American Chiropractic Association

CLINICAL DOCUMENTATION KEY TO REIMBURSEMENT FOR CHIROPRACTIC CLAIMS

ARLINGTON, VA – During its recent meeting, the American Chiropractic Association (ACA) House of Delegates passed a resolution to assist doctors of chiropractic in successfully being reimbursed for necessary patient care by insurance companies. ACA is now committed to disseminating the recommendations contained in the resolution to doctors of chiropractic, chiropractic organizations and chiropractic colleges nationwide.

Last year, representatives from 13 of the largest insurers in the United States met with ACA representatives during the second meeting of the ACA-sponsored Claim Solutions Work Group. Based on the suggestions made during this meeting and on recent trends, ACA recommends certain basic requirements be considered as appropriate clinical documentation in patient record keeping. Some of the insurers present at the meeting agreed that using these practices will also reduce clinical record requests by 50 percent.

“The mutual goal of the insurers and doctors of chiropractic at this meeting was to simplify the claims process,” explained Pat Jackson, vice president of professional development for ACA. “This way, chiropractors can reduce administrative costs and get paid for more covered claims, and insurers can reduce claims expenses.” According to Ms. Jackson, many insurers are already adopting the recommended guidelines resulting from the meeting in order to educate their claim personnel on appropriate requests for chiropractic clinical documentation.

The ACA also contends that a concerted effort by the chiropractic profession to standardize clinical documentation will improve reimbursement experience exponentially for doctors of chiropractic. For this reason, a special effort will be made to share this information with chiropractic colleges so it can be incorporated into the curricula.

ACA recommends the following documentation procedures:

1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed.

2. Subjective, objective, and treatment (if rendered) components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.

3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors.

4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined.

5. Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the history and physical and the anticipated patient treatment plan. The initial treatment plan, except in chronic cases, should not extend beyond a 30-45 day interval.

Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan needs to be reevaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.

6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.

7. Records can be attached to each billing to pre-empt requests; however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).

8. All records must be legible and understandable, released within the authority given by the patients, in a secure, confidential manner and in compliance with existing state (or federal) statutes.

9. The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record.

10. If the above recommendations have been met, then the answers as to why the necessity for continuing treatment are answered.

11. The insurance industry must improve their claim adjusting procedure by using chiropractic consultants. The ACA can use its resources to assist in this initiative.

Contact the American Chiropractic Association Office of Professional Development by phone at (800) 986-4636, ext. 222, or by e-mail at pjackson@ for more information.

###

Wisconsin Chiropractic Association

(

Recommendations

for

Chiropractic Documentation

(1996)

Wisconsin Chiropractic Association

Recommendations for Chiropractic Documentation

General Disclaimer

This document contains recommendations for the clinical documentation of chiropractic care. These recommendations are intended for educational and instructional purposes only and do not constitute a standard of care for any specific clinical situation. These recommendations, which may need to be updated, are intended to be flexible.

In is not the purpose of this document, which is advisory in nature, to take precedence over any federal, state or local statute, rule, regulation or ordinance which may affect chiropractic practice.

This document may provide some assistance to third parties in the evaluation of chiropractic care, but it is not by itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity.

Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Further, these recommendations will require constant re-evaluation as additional scientific and clinical information becomes available.

Wisconsin Chiropractic Association

Recommendations for Chiropractic Documentation

Table of Contents:

Acknowledgments

Introduction

Chapter 1: Documentation recommendations ……………………………… 8-17

Format

Legibility

Patient consent

Initial entry: Subjective

Initial entry: Objective

Initial entry: Assessment

Initial entry: Treatment plan

Daily notes

Progress notes

X-ray reports

Chapter 2: Commonly used mechanisms of record keeping ……………… 18-20

Chapter 3: Commonly used outcome assessment measurements …………. 21-23

Chapter 4: A primer on chiropractic listings ………………………….…… 24-25

Chapter 5: Glossary ……………………………………………………….. 26-27

Chapter 6: Commonly used abbreviations ………………………………… 28-31

Appendix A: HCFA Guidelines for Patient History Level Selection ……… 32

Appendix B: Bibliography ………………………………………………… 33-34

Acknowledgments:

The Wisconsin Chiropractic Association is indebted to chiropractic colleges and insurers who provided valuable background information for the work of the Committee, and also to the Committee members for their diligent effort on this project.

Introduction:

Over the past decade, chiropractic has occupied a constantly growing position in today’s complex health care delivery system. Chiropractors in Wisconsin now work routinely with a myriad of parties who are interested in assessing the quality of clinical work performed by the chiropractor.

The principal method through which other parties attempt to assess the quality and necessity of a chiropractor’s work is through submitted clinical documentation. The clinical records of Wisconsin chiropractors are now examined with an increased amount of scrutiny. Many different payors and agencies have the right to access a chiropractor’s clinical records, including:

insurers who wish to determine whether a claim is a covered benefit under the terms of their contract with the patient

managed care organizations who conduct reviews of clinical record keeping as part of their quality assurance and utilization review programs

attorneys who utilize clinical documentation as evidence in personal injury litigation

attorneys who represent patients in malpractice suits against chiropractors

other health care providers who may request records in order to coordinate interprofessional patient care

other chiropractors who assist with treatment for a patient

state regulatory agencies, who investigate consumer complaints, review payment for government programs, etc.

Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Because chiropractic practice patterns vary from medical practice patterns, recommendations for chiropractic documentation necessitate additional modifications when compared to generally accepted medical record keeping formats.

Chapter 1:

Wisconsin Chiropractic Association

Recommendations for Clinical Documentation

1. General information:

The purpose of these recommendations are:

A. to serve as an informational source to doctors. These recommendations represent well-accepted, contemporary views on documentation issues as reported in the biomedical literature. Some of the source materials include:

18. Health Care Financing Administration documentation guidelines

19. Record keeping standards for the National Committee on Quality Assurance.

20. chiropractic and medical textbooks

21. peer-reviewed journal articles

22. submissions from chiropractic colleges

23. input from insurers

B. to serve as voluntary guidelines for chiropractors to use when developing documentation systems for their offices.

C. to encourage more uniform and more understandable clinical documentation, which should serve as a benefit to patients, providers, and insurers.

The Wisconsin Chiropractic Association recognizes that the management of every individual patient is unique. Different styles of practice, or areas of clinical specialization, may prompt the doctor to vary the clinical information to be gathered and recorded.

Documentation performed within the intent of these recommendations need not be rigid and inflexible, but should be adapted to the needs of a particular case. These guidelines are intended to provide a common framework for patient records which allows for more consistent reporting and improved communication.

2. Format:

A SOAP format is regarded across the country as the most widely accepted method for keeping clinical records. This format records information about subjective complaints, objective findings, the doctor’s assessment and treatment plan in an organized manner. Used less frequently are recognized derivatives of the basic SOAP schema, such as POMR, SORE or SNOCAMP.[1] [2] [3]

An organized format [whether it is classic SOAP or a modification of the SOAP format] allows information to be recorded in a predictable, repetitive manner. Proprietary or “in-office” systems of documentation are, by definition, difficult or impossible for a reviewer to understand.

Abbreviations: The proper use of accepted abbreviations [such as those listed in these recommendations] can facilitate the documentation process by saving both record space and time. However, the use of non-standard abbreviations can lead to confusion in the interpretation of clinical records. Doctors who choose to utilize non-standard abbreviations should “translate” those abbreviations prior to the records being submitted to a third party.

Methods: The methods used to complete clinical record keeping is a matter of preference for each practitioner. The doctor may prepare documentation by using dictation and transcription, narrative-style writing, pre-prepared forms or other methods preferred by the doctor.

Documentation of evaluation/management services: During the course of a complicated case, the chiropractor may be presented with clinical situations which require varying complexities of decision making and/or the services required. The level of detail contained in the documentation will often increase as the complexity of the decision making or the complexity of the provided services increases.

For example:

at the onset of the complicated case, or at other critical time periods during the patient’s treatment, the chiropractor often functions at a specialist level. When functioning at that level, a corresponding increase in the detail of documentation is typically expected to fully detail the patient’s symptoms, findings, diagnosis and treatment plan. The chiropractor will usually choose to utilize a higher level [99204, 99205, 99214, 99215] evaluation/management code when performing these specialist-level services.

at other times during the same case, the chiropractor may serve on a level very similar to a general practitioner. The level of documentation typically expected at this level is sufficient to tell the story of the patient, but may not include the full level of detail expected of the specialist-level documentation. The chiropractor will often use a mid-level [99202, 99203, 99212, 99213] evaluation/management code when performing these general practitioner-level services.

on a daily treatment basis, the doctor is applying the treatment which has been fully described in the most recent treatment plan. Therefore, the documentation for daily visits will be much more concise.

Chart organization: Clinical notes consist of three distinct elements:

1. Initial entry. The initial entry generally includes:

27. pertinent baseline information about the patient

28. the patient’s chief complaint[s]

29. the results of initial physical examination

30. the chiropractor’s assessment

31. the recommended treatment plan

1. Daily note. The daily note represents a concise record of pertinent changes in the patient’s condition and treatment on that day. A series of daily notes will show changes on a visit-to-visit basis. The daily note is used most often to document:

32. adjustment or manipulation

33. physical modalities

2. Progress note. At different points in a case, a progress note is used to document additional patient services. These services may include:

34. reevaluations

35. reexaminations

36. counseling

37. coordination of care

One respected author in the field of chiropractic documentation[4] has described the initial entry as “SOAP-ing” the patient. He then explains that the progress note can be thought of as a kind of “midi-SOAP”, or a somewhat abbreviated version of the original SOAP work-up. This so-called “midi-SOAP” retains the same database format, yet is not necessarily as detailed as the original evaluation. The notation for a daily or routine visit is described as a “mini-SOAP”, displaying the same general organizational scheme of the of the initial evaluation, but on a significantly smaller scale.

3. Legibility:

Clinical documentation should always be legible. If patient records are hand written, it is especially important that the handwriting is legible to the reviewer. If the handwriting is not legible to the reviewer, the provider should be informed and given the opportunity to transcribe the information.

4. Documentation of patient consent:

Doctors should review with their legal counsel their responsibilities[5] to obtain written proof of the patient’s consent in the following critical areas:

general consent to examine and treat: Many doctors will have the patient complete this written consent as part of their initial patient questionnaire.

informed consent: if any proposed treatment procedure poses a meaningful risk to the patient, the doctor is expected to disclose that risk to the patient and to document that the patient has consented to proceed with the proposed treatment. [In some cases in which the patient has significant difficulties communicating, such as Alzheimer’s disease, stroke victims or the mentally impaired, the informed consent should be obtained from a family member.]

parent’s consent to examine and treat minor children: generally recommended before evaluating or treating any child under the age of 18.

5. The initial patient entry The initial entry generally includes pertinent baseline information about the patient, the patient’s chief complaint[s], the results of physical examination, the chiropractor’s assessment, the recommended treatment plan. An initial patient entry may be made anytime a patient presents with a new chief complaint.

5a. Subjective: Initial New Patient History

This section forms the subjective area of the documentation. HCFA has recently defined elements which may be included in the subjective portion of the patient records[6].

The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of the these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

These elements of the subjective portion of clinical record keeping include the following:

History of the present illness: [HPI] HCFA has defined the following factors to constitute a complete history of the present illness:

41. history of trauma

42. description of the chief complaint[s]

43. onset of symptomatology

44. palliative factors

45. provocative factors

46. quality of pain (burning, numbness, tingling)

47. radiation of pain

48. severity of pain (scale of 1-10)

49. frequency or timing of complaint

50. previous episodes of chief complaint.

As an alternative, the elements of the history of the present illness can be represented by the use of the mnemonic “O, P, Q, R, S, T”[7].

51. O = onset of symptoms

52. P = provocative or palliative factors

53. Q = quality of pain

54. R = radiation

55. S = severity of pain

56. T = timing of pain

When using this mnemonic, many doctors add an additional element to indicate whether the patient has experienced prior episodes of the chief complaint:

57. U = previous episodes [have you ever had this problem before?]

Past history:

58. prior major illnesses and injuries

59. prior operations

60. prior hospitalizations

61. current medications

62. allergies (food or drug)

63. age appropriate immunization status

64. age appropriate feeding/dietary status.

Social history:

65. current employment

66. occupational history (discretionary)

67. use of drugs, alcohol, and/or tobacco

68. other relevant social factors.

Family history:

Significant health factors which may be congenital or familial in nature should be noted.

Review of systems: [ROS] HCFA has defined the following fourteen areas for review of systems:

69. constitutional symptoms [fever, weight gain or loss, fatigue, etc.]

70. eyes

71. ears, nose and throat

72. cardiovascular

73. respiratory

74. gastrointestinal

75. genitourinary

76. musculoskeletal

77. integumentary [skin/breast]

78. neurologic

79. psychiatric

80. endocrine

81. hematologic/lymphatic

82. allergic/immunologic

Appendix A includes the requirements from HCFA for the proper coding of evaluation and management codes by the number of included elements from the elements of the history above.

5b. Objective: Initial New Patient Physical Examination

This section forms the objective area of clinical documentation. The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

The elements of the objective portion of the patient records may include the following:

Vital signs

height

weight

blood pressure [age dependent; recommended at initial exam, follow-up depending on condition]

pulse [recommended at initial exam, then prn]

respiration [if indicated by symptoms]

temperature [if indicated by febrile symptoms]

observation

auscultation [if indicated by symptoms]

percussion [if indicated by symptoms]

palpation

range of motion [Note that range of motion can be measured using many different methods, such as actively (AROM), passively (PROM) or active assisted (AAROM). In addition, range of motion can be measured visually, with a goniometer or a manual or electronic inclinometer. The doctor may wish to note the methods used to measure range of motion.]

reflexes

deep tendon: use of Wexler [0-5] scale

superficial [if indicated by symptoms]

pathologic [if indicated by symptoms]

vascular examination [if indicated by symptoms]

provocative orthopedic tests

neurologic testing [if indicated by symptoms]

cranial nerves

station, gait and balance

sensory testing

muscle strength testing: may be tested manually or with the use of various machines. When tested manually, most doctors use a modified Lovett scale, which assigns a number grade to the muscle strength[8].

The most common usage of this system uses 5 to indicate “normal”.

Grades 4+, 4, and 4- are used to indicate decreasing muscle function within the “good” category, which is defined as the ability to raise the part against gravity and some resistance.

Grades 3+, 3, and 3- are used to indicate decreasing muscle function within the “fair” category, which is defined as the ability to raise the part against gravity only.

Grades 2+, 2, and 2- are used to indicate decreasing muscle function within the “poor” category, which is defined as the ability to raise the part only with gravity eliminated.

Grade 1 means that the muscle contraction can be felt, but there is no joint movement. Grade 0 means no contraction is felt.

the use of various types of instrumentation, leg length tests or other objective measurements which the chiropractor judges to be relevant to the case.

5c. Assessment: Initial New Patient Assessment

Diagnostic impression in a narrative or descriptive format.

Assessment of risk factors, if applicable.

5d. Plan: Initial New Patient Treatment Plan

The complexity of the patient’s health problem will determine which of the following elements a chiropractor will choose to include in the patient’s record. It is not necessary to include all of these elements in the records of patients with less severe health problems. The elements of the treatment plan may include the following:

Diagnostic treatment plan: describes the need for further tests, including reexamination, etc.

Therapeutic treatment plan: describes the frequency and duration of adjustments and in-office therapies and modalities.

Educational treatment plan: home exercises, modification of daily or work activities

Short and long term goals

Referral for other necessary services

Coordination of care with other health professionals, if applicable

6. Daily notes:

The daily note represents a concise record of pertinent changes in the patient’s condition and treatment on that day. A series of daily notes will show the significant changes in the patient’s condition and treatment which occur over a period of time. The daily note is used most often to document ongoing treatment, such as adjustments/manipulation or physical modalities.

After the initial entry, each subsequent office visit will usually be documented by a daily note, until the next specified reevaluation. If the initial entry clearly states the assessment and plan, it is not usually necessary to reevaluate the patient on a daily basis or to reiterate the assessment or the treatment plan. Any significant modification of the treatment plan should be recorded in the daily note.[9]

Because of its brevity, the daily note will list only the most important changes in the daily presentation of the patient, and the management of the case. Therefore, the treating chiropractor is best qualified to decide which objective and subjective elements of the case should be recorded via the daily note.

7. Progress notes

At many different points in a case, a progress note is often used to document additional patient services. These services may include:

102. reevaluations

103. reexaminations

104. counseling

105. coordination of care

7a. Re-examination frequency:

Periodic reexaminations of the patient are an important element of case management, and are used to assess the effectiveness of treatment. It may be appropriate to reexamine a patient or reevaluate a patient’s condition anytime there is a significant change in the patient’s symptoms or response to treatment.

Reexaminations are especially important when a patient exacerbates their injury or if the clinical condition of the patient changes, which may indicate the need for the doctor to reassess the treatment plan. The following chart which describes typical frequency of re-examinations for established patients:

|Patient type |Definition |Typically, a reexamination is performed within: |

|Acute |Symptomatology is present less than six weeks |30 days or 12 visits or as clinically indicated |

| |Acute exacerbation of a chronic or recurring condition. | |

|Chronic |Symptomatology present more than 18 weeks |3 months or 18 visits or as clinically indicated |

|Supportive |Symptomatology is present due to a known, permanent |Six months to one year or as clinically indicated|

| |deficit; a full recovery is not expected. | |

|Maintenance or |No active symptomatology. |As clinically indicated |

|preventative | | |

A re-examination for an established patient is particularly appropriate in the following circumstances:

a patient who presents with a new chief compliant

a patient who presents with a new, distinct episode of a recurring condition.

a patient who presents with symptoms, and has not received treatment for 90 days or more

8. Documentation of x-ray findings:

X-ray documentation is usually produced on the day the film was read and/or billed. These x-ray findings may be in the form of a separate report, or may condensed to the major findings, and included with the objective portion of the patient’s documentation.

Just as the “SOAP” format is used to methodically prepare patient records, formal x-ray reports often follow a repeatable format. When preparing formal x-ray reports, the following format has been advocated by Yochum and Rowe[10]:

Introductory Information

Letterhead Information

109. Name of physician

110. Clinic name and address

Patient information

111. Full name and address

112. Date of birth

113. File identification

Radiographic information

114. Views submitted

115. Dates and location of films taken

116. Technique factors [optional]

Report

Clinical information

117. Chief complaint

118. Key clinical findings

119. Reason for study

120. Numbered summary of pertinent findings

Radiologic findings

121. Descriptive narrative of findings

122. Findings are usually listed in the order of alignment, bone, cartilage, soft tissue, which can be easily remembered by the mnemonic “ABCs”.

123. Conclusions

Recommendations

124. Indications or contraindications to treatment

125. Follow-up procedures indicated

Signature and qualifications

Chapter 2:

Mechanisms of documentation

There are many different mechanisms that a chiropractor may successfully use to keep excellent clinical documentation. Some of the most commonly used methods are discussed below:

Dictation and transcription:

Dictation of clinical records remains the benchmark against which all other forms of record keeping are measured. Dictation has many obvious advantages:

impeccable legibility

the ability to use as much detail as may be needed

there are no restrictions imposed by the format itself

transcriptionist does not need special computer training

There are also minor disadvantages of the dictation/transcription method:

labor intensive, therefore tends to be relatively costly

dictation tapes can break or be lost

digital dictation systems can lose data

Computer-assisted record keeping [commercial programs]:

These systems are available in many different formats. Various methods of inputting information to the computer have been devised, each claiming to be the most efficient. Information may be input into the computer via voice or through the use of keyboard, light pens, scanning sheets, touch screens, bar code readers or other devices.

These systems have the advantages of:

automating some of the repetitive aspects of patient records

a comprehensive approach to inputting clinical data.

Disadvantages may include:

relatively high purchase cost

relative difficulty of editing your copy from the pre-defined format in some of the products

lost data if the system is not “backed up” frequently.

With new technology comes intriguing new ethical questions. For example, some of the programs will automatically vary the verbiage to avoid the appearance of repetitive notes. There are computer programs which will “write” a narrative report or “calculate” a disability rating. Only the individual practitioner can decide if a particular product truly represents a time-saving tool in completing the patient’s documentation, or a clinically unacceptable “short cut”.

Word processing programs:

All of today’s computer word processing programs have the ability to be easily programmed by the user to perform repetitive functions. These special, user-defined commands are usually called a macro. With the use of a macro, it is possible to automate many of the repetitive tasks required in patient record keeping, such as typing the clinic name, patient name, date and other commonly required data.

In addition, a macro can generate frequently used text, often called boilerplate text. This can enable the doctor to add significant depth to records without expending much time. For example, complete instructions can be prepared for a routine of lumbar extension exercises. When a patient’s clinical condition indicates that these particular exercises are appropriate, the entire exercise routine can be added to the patient’s records with the touch of the macro button.

The advantages of this type of system are:

low cost

system may be adapted completely to your needs and changed at any time

The disadvantages of this type of system are:

set-up is labor intensive

professional assistance is seldom available

doctors and staff must thoroughly understand the system they have devised

data may be lost if not “backed up” frequently

Hand written records:

It is possible to keep excellent quality patient records by hand writing each record. However, many doctors will simply not be able to utilize hand written records because they possess illegible or poor quality handwriting. In addition, the sheer volume of information required in a quality patient record often lends itself to some sort of mechanization, especially in a busy practice.

If hand written entries are to be part of clinical records:

make sure that the handwriting is clearly legible

be sure that the areas of the record reserved for handwriting are not cluttered with other information

use only common, standardized abbreviations, such as those listed in these Wisconsin Chiropractic Association documentation recommendations.

Proprietary or “in-office” chiropractic record keeping systems:

Over the years, many chiropractors have developed proprietary [non-SOAP] formats or shorthand systems for various aspects of their patient records. These may include the use of abbreviations or symbols which are not well recognized within the chiropractic profession.

The use of these types of devices within records can often be confusing to other parties who wish to review the patient’s records. This potential problem can often be avoided by the use of standardized abbreviations and conventions, such as those described in these recommendations.

Chapter 3:

Outcome Assessment Measurement Devices

Pain is the primary complaint for 80% of all office visits to physicians each year in the U.S. [National Center for Health Statistics, 1986]. It is important to use the proper measurement device in order to get meaningful data of a patient’s baseline status. The measurement must then be reapplied to get meaningful data of a patient’s improvement. The testing device must be comprehensive enough to give a reliable clinical picture, simple to understand, easy to score, and able to be administered at a low cost.

The devices listed in bold are used very commonly within the chiropractic profession, and it is recommended that you become familiar with these outcome assessment devices. Unfortunately, copyright restrictions do not allow for the reproduction of these materials within these Wisconsin Chiropractic Association recommendations. Generally, you may access the original articles and use any of these devices in your office for the treatment of your individual patients.

A. General health questionnaire

1. Health Status Questionnaire v.2.0 [Health Outcomes Institute, 1993][11]

1. SF-36 [Stewart, 1988; Interstudy, 1990][12]

2. RAND 36 [RAND Corporation, 1986][13]

3. Dartmouth COOP charts [Nelson, 1987][14] [15] [16]

4. Sickness Impact Profile [Bergner, 1981][17]

5. Nottingham Health Profile[18]

B. Pain

1. Visual analog scale [VAS] [Huskisson, 1982][19] [20] [21] [22]

1. Numerical pain scale [NPS] [Jenson, 1986][23]

2. McGill/Melzak pain questionnaire [Melzack, 1975][24]

3. Pain drawing [Mooney and Robertson, 1976] [25] [26]

4. Pain Disability Index [Tait, 1987][27]

5. Dallas Pain Questionnaire [Lawlis, 1989][28] [29]

C. Disability: lower back pain

1. Modified Oswestry Low Back Pain Questionnaire [Fairbank, 1980][30] [31]

1. Roland-Morris Disability Questionnaire ROL-SIP [Roland, 1983][32]

2. Low Back Pain TyPE Specifications [Health Outcomes Institute, 1992][33]

3. Million Disability Questionnaire [Million, 1982][34]

4. Waddell Disability Index [Waddell and Main, 1984][35]

D. Disability: cervical or headache

1. Neck Disability Index [Vernon-Mior, 1991][36]

1. Headache Disability Index: HDI [Jacobson, 1994][37]

E. Pychometrics

1. Psychosocial Pain Inventory [Heaton, 1980][38]

1. Illness Behaviour Questionnaire [Pilowsky, 1976][39]

2. Health Status Questionnaire 2.0 [40] [Questions 37-39: depression screens]

3. Waddell Non-Organic LBP signs [Waddell, 1980] [41]

4. Somatic Amplification Rating Scale [Korbon, 1987][42]

5. Modified Zung Depression Index [43] [44]

6. Modified Somatic Perception Questionnaire MSPQ [Main, 1983][45]

7. Minnesota Multiphasic Personality Inventory [MMPI][46] [47]

8. Fear-Avoidance Beliefs Questionnaire FABQ [Waddell, 1993][48]

F. Patient satisfaction:

1. Patient Satisfaction Questionnaire [Ware, 1983][49]

1. GHAA Consumer Satisfaction Survey [Ware, 1991][50]

2. Low Back Pain Patient Satisfaction [Deyo, 1986][51]

3. Chiropractic Satisfaction Questionnaire [Coulter, 1994][52]

Chapter 4:

A Primer on Chiropractic Listings

Chiropractors use a variety of different systems to indicate the deviation of a motor unit from its normal position. While a comprehensive survey is far beyond the scope of this document, the following information should prove helpful to anyone attempting to understand a chiropractic listing.

Spinal segments:

The following abbreviations are commonly used to refer to segments of the spinal column and pelvis:

C0, O: Occiput

OC: Occipital condyle

C1, A: Atlas

C2, AX: Axis

C3: Third cervical

C4: Fourth cervical

C5: Fifth cervical

C6: Sixth cervical

C7: Seventh lumbar

T1: First thoracic [or dorsal]

T2: Second thoracic

T3: Third thoracic

T4: Fourth thoracic

T5: Fifth thoracic

T6: Sixth thoracic

T7: Seventh thoracic

T8: Eighth thoracic

T9: Ninth thoracic

T10: Tenth thoracic

T11: Eleventh thoracic

T12: Twelfth thoracic

L1: First lumbar

L2: Second lumbar

L3: Third lumbar

L4: Fourth lumbar

L5: Fifth lumbar

S: Sacrum

S1: First sacral segment

S2: Second sacral segment

S3: Third sacral segment

S4: Fourth sacral segment

S5: Fifth sacral segment

CO: Coccyx

IL: Ilium

Additionally, some of the prominent landmarks of spinal segments are abbreviated below. These landmarks are often used as points of reference to define the orientation of the vertebra within a three-dimensional space:

SP: spinous process

TP: transverse process

M: mamillary process

L: lamina

P: pedicle

B: body

Direction of Vertebral Misalignment:

A bone or spinal segment is usually “listed” in the direction it deviates from normal. The following abbreviations are commonly used. The international coordinate system[53], which is often used in biomechanical research, is described in parenthesis:

Two-Dimensional Translational Motion:

A: Anterior (+Z)

P: Posterior (-Z)

R: Right (-X)

L: Left (+X)

S: Superior or cephalad (+Y)

I: Inferior or caudal (-Y)

EX: External

IN: Internal

Three-Dimensional Motion:

Clockwise rotation: (+()

Counterclockwise rotation: (-()

F: Flexion (+(X)

E: Extension (-(X)

LLF: Left lateral flexion (-(Z)

RLF: Right lateral flexion (+(Z)

RR: Right spinous rotation (+(Y)

LF: Left spinous rotation (-(Y)

Examples of Combination Listings:

These two components of location and direction are often combined to describe a bone or motor segment which has deviated from its normal position. For example,

L5 PL: 5th lumbar vertebra has deviated with spinous moved to the left.

C6 PLI-BR: 6th cervical vertebra has deviated with its body moved to the right.

T6 RP: 6th thoracic vertebra has deviated with the body posterior on the right.

Chapter 5: Glossary

The following glossary is essentially limited to terms which involve the process of documentation. In addition, definitions are suggested for some terms which are used in so many different contexts, [such as acute and chronic] that they have become difficult to define accurately.

AAROM: Active assisted range of motion. The patient is asked to perform voluntary movement of the joint throughout its arc of movement, and the examiner applies a mild force in the same direction as the patient’s movement. The purpose is to ensure that full range of motion has been measured, and to assess the quality of the joint movement upon reaching the endpoint of movement.

Acute: having symptomatology for a relatively short length of time. A common definition is symptoms which are noticed for less than 6 weeks upon presentation.[54]

AROM: Active range of motion, performed with the patient voluntarily moving the joint. The examiner is looking for differences in range of motion and the patient’s willingness to perform the movement.[55]

Assessment: The portion of the patient clinical record which details the doctor’s impression, diagnosis or opinions of the case.

Chief complaint: The patient’s primary health concern which results in seeking treatment from the doctor.

Chronic: having symptomatology for an extended length of time. A commonly accepted criteria for a chronic complaint is symptomatology which are apparent for more than 16 weeks upon initial presentation.[56]

Disability: The alteration of an individual’s capacity to meet personal, social or occupational demands, or statutory or regulatory requirements because of an impairment. Disability refers to an activity or task the individual cannot accomplish.[57] Disability is the inability to perform specific work-related activities. Disability is a functional deficit.

Impairment: The loss, loss of use or derangement of any body part, system, or function. Impairments are defined as conditions that interfere with an individual’s “activities of daily living”, or the inability to perform certain physical tasks, which may or may not be associated with work activities[58]. An impairment is an anatomic deficit.

Maintenance care: 1. Treatment given in the absence of significant symptomatology; 2. well-person care; 3. preventative or prophylactic care

Objective: Items in the patient record which can be accurately and repeatedly measured.

OPQRST: A mnemonic device for the essential elements of the history of the present illness. The initials represent: onset, palliative and provocative factors, quality of pain, radiation, severity, and timing (frequency).

Plan: Treatment plan; a written outline of the proposed care for the patient

PROM: Passive range of motion. The patient is asked to relax as much as possible, and the examiner supplies all the force necessary to move the joint throughout its arc of movement. Passive testing is usually performed if deficits in active range of motion are noted.

SOAP: A mnemonic for subjective, objective, assessment, plan.

Sub-acute: symptoms which are present for a period greater than an acute presentation, and less than a chronic presentation. A commonly accepted definition of sub acute would be the presence of symptomatology for 6-16 weeks upon initial presentation.

Subjective: Items in the patient record which are derived from the patient’s verbal or written communications with the doctor.

Supportive care: 1. Treatment provided after the patient has reached maximum medical/chiropractic improvement and has not reached a full recovery; 2. treatment given to diminish permanent or chronic symptomatology when a full recovery is not possible; 3. treatment provided to alleviate the symptomatology of a known anatomic deficit.

Chapter 6:

Commonly used abbreviations

The abbreviations listed below do not represent a comprehensive listing, or an attempt to replace a medical dictionary. These abbreviations are often used by chiropractors , and originate in the following areas:

1. Commonly encountered diagnoses

1. Commonly used abbreviations describing patient symptomatology in daily or progress notes.

2. Commonly used anatomic abbreviations.

Note that some of the abbreviations can take on different meanings, depending upon the context. For example, the abbreviation “P” can mean either “pulse” or “treatment plan”, depending upon its usage.

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