In my previous article, I wrote about how important a great Assessment is in our SOAP notes and how most chiropractors don’t even come close to documenting a good assessment.
Some chiropractors complain that some patients respond more slowly than others and that should be taken into consideration. I couldn’t agree more. In fact, a great idea is to document complicating factors for EACH condition you’re treating for each patient, if they exist. A great resource for this is a set of chiropractic guidelines, called Clinical Compass (formerly known as CCGPP). They did all the hard work and found the research to support these. They split up the complicating factors into three categories:
Patient Characteristics
Injury Characteristics
History
Patient characteristics include older age, psychosocial factors, delay of treatment > 7 days, non-compliance, lifestyle habits, obesity and type of work activities.
Injury characteristics include severe initial injury, > 3 previous episodes, severe signs and symptoms, number/severity of previous exacerbations and treatment withdrawal fails to sustain maximum therapeutic improvement.
History includes pre-existing pathology/surgery, history of lost time, history of prior treatment, congenital anomalies and symptoms persist despite previous treatment.
I recommend documenting these complicating factors on every visit, just in case your records are ever audited. Medicare, in particular, is notorious for requesting records between “this date” and “that date.” If you don’t have the complicating factors noted on each visit, they may not be present for the dates that are being looked at. And there goes more power out the window.
In my EMR, I document any of these complicating factors that exist for each condition on the initial visit. My EMR then has these complicating factors appear on every visit after that – automatically.
When documenting the complicating factors in addition to the changing metrics of pain intensity, pain frequency and the outcome assessment scores, your assessment can effectively show how each patient is different and how effective your treatment is, as well as comparing today’s visit to the previous visit. Once we understand and embrace the “rules of engagement,” we can really make our documentation rock.
Gregg Friedman, DC, CCSP, FIACA
Creator of The Bulletproof Chiro EMR
