Documenting treatment goals has been an issue for many chiropractors for years. For the few chiropractors who have made the effort, typical goals tend to be things like “reduce pain, reduce muscle spasm, improve range of motion,” regardless of the conditions being treated.
When focusing on the Problem Oriented Medical Record format of documentation, which has been the standard since 1968, if we’re treating a patient for headaches, neck pain and low back pain, we should have goals for the headaches, goals for the neck pain and goals for the low back pain. In addition, our goals have to be measurable. In other words, saying “reduce pain” isn’t good enough. We need to say something like, “reduce pain from a 7 to a 5,” or “reduce pain by x%.”
Most of you reading this just got nauseous.
The next question is, what goals are most relevant to what we do as chiropractors and can be easily calculated and documented? Medicare has been telling us for years that they want to see TWO things from chiropractors: Pain Assessment and Functional Outcome Assessment. It’s not just Medicare who wants this from us now – the entire health-care universe is asking for it, too. And to be perfectly honest, we should be embracing this instead of fearing it. Why? Because we all know how GREAT chiropractic treatment is at improving BOTH pain and function. Why not SHOW it?
Let’s talk about pain assessment first. There are quite a few published studies that recommend the Numeric Rating Scale (NRS) and the Visual Analogue Scale (VAS). I’ve used both over the years, and I find the NRS is easier for most patients and doctors. This can be done verbally, as opposed to written (Verbal Numeric Rating Scale [VNRS]). The FREQUENCY of the pain is very often overlooked, though, and is a great metric to track and is easily converted to a goal. This works well when we document the frequency in 5-10% increments of time, such as 25%, 50%, 85%, etc. It does not work well when documenting ranges like Occasional, Intermittent, Frequent and Constant. These two metrics of Pain Intensity and Pain Frequency should be documented for each condition being treated and on every visit. It should only take a few seconds to ask the patient and document their answers.
The next metric for the patient’s subjective complaints is the functional outcome assessment. According to CMS (Centers for Medicare and Medicaid Services), this needs to be performed every 30 days or sooner. These work even better if we have the patients complete these every two weeks since it helps us determine quickly if we’re on the right track with the patient or if we need to change the treatment in some way.
The fourth metric, which falls under the Objective part of our SOAP note and is optional, are range of motion measurements. Range of motion only serves as an outcome assessment if it’s actually measured, though, not visually estimated by the doctor. This outcome assessment (again, it’s optional), should be performed every 30 days. Just know that the quantity of motion isn’t always clinically relevant.
Now that we know which metrics to track (pain intensity, pain frequency, functional outcome questionnaires and range of motion measurements), what should the measurable goals be? According to several published studies, to be considered “clinically significant,” we want to show at least 30% improvement in any of the outcome assessments over a four-week trial of care. You don’t need to show 30% improvement in ALL of the metrics, just one or more. If we’re tracking 3 metrics (pain intensity, pain frequency and functional outcome questionnaires), we have a much better chance of reaching this goal in at least one of these.
Some of you are MAD now. “Thirty percent? That’s a LOT!” you may be thinking.
It’s not as bad as you think. For example, if the pain intensity is a 7/10, a 30% improvement is a 5/10. Do you think you have a pretty good chance of achieving this within 30 days? If the pain frequency is 80% of awake time, a 30% improvement would be 56% of awake time. If the functional outcome questionnaire score is a 52, a 30% improvement is a 35. As the metrics improve, the 30% mark gets even easier to achieve. For example, if the pain intensity is a 4/10, a 30% improvement is a 3/10 (rounded up from 2.8). See how this works?
If you want to figure out a way to calculate these goals manually, it’s certainly doable, but will take a bit of time. This is where technology can help us immensely. In my EMR, I have the program automatically calculate the 30% goal for each metric and it documents it for me. As each metric changes, the goal changes.
Chiropractic is awesome. We all know it deep in our souls.
Now it’s time to show it.
Here are some references you can check out:
Younger J, McCue R, Mackey S. Pain outcomes: a brief review of instruments and techniques. Curr Pain Headache Rep. 2009;13(1):39–43. doi:10.1007/s11916-009-0009-x
Clinical versus statistical significance in the assessment of pain relief.
Todd KH
Ann Emerg Med. 1996 Apr; 27(4):439-41.
Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM
Pain. 2001 Nov; 94(2):149-58.
Clinically important changes in acute pain outcome measures: a validation study.
Farrar JT, Berlin JA, Strom BL
J Pain Symptom Manage. 2003 May; 25(5):406-11.
How many repeated measures in repeated measures designs? Statistical issues for comparative trials.
Vickers AJ
BMC Med Res Methodol. 2003 Oct 27; 3():22.
Documentation can be easy and exceptional and fast.
We just need to know how to justify.
Gregg Friedman, DC, CCSP, FIACA
Creator of The Bulletproof Chiro EMR
