Documentation is a funny thing. For years, chiropractors have been told that our documentation has to “tell the story.” Unfortunately, many chiropractors take that to think they have to write a novel for each patient encounter. The good news is…
You may be talking too much.
I agree with the premise that we need to tell the story about what is going on with our patients and with each patient encounter. As one who reviews a lot of chiropractic records for insurance companies and attorneys, I can tell you that saying too much does not help. We need to know what parts of the story need to be told.
Let’s take our SOAP notes. For the Subjective part, it’s important to document a thorough history on the first visit. The standard for many years has been the OPQRST (onset, provocative/palliative, quality, radiating, site/severity and timing) format, which is required by Medicare. We need to document all of these letters for EACH condition we’ll be treating. On this initial visit, we also need to establish measurable and functional baselines. The key which will make this easier and faster is the use of metrics. Instead of saying “neck pain,” or “moderate neck pain,” we could have the patient rate the intensity of each symptom with the Verbal Numeric Rating Scale (0-10). For more accuracy, we can also have the patient tell us the percentage of their awake time they experience each symptom. Using 5 or 10% increments of time is all we need and is much better than documenting very broad ranges like Occasional, Intermittent, Frequent and Constant. We want to be able to show that the intensity of pain changed from one number to another, and the frequency improved from 95% to 90%, for example. The metrics of intensity and frequency should be documented on every visit. Outcome questionnaires are the part of the story that tells us about the patient’s function.
After the first visit, though, we don’t need to be that thorough. All we need to document for the subjective complaints on subsequent visits are the Site, Intensity and Frequency of each symptom, and if the symptom radiates. This should only take SECONDS to document. The outcome questionnaires should be done every 30 days or sooner, according to Medicare, but it’s even better if we re-assess our patients with these questionnaires every two weeks.
For our daily “objective” findings, we only need to follow the P.A.R.T. format that Medicare requires. It’s actually really easy to document, so let’s do it for ALL of our patients. We’ve already hit the requirement for the P of P.A.R.T., which is Pain/Tenderness, in the subjective part of our SOAP note. The A of P.A.R.T. stands for Asymmetry/Misalignment, which includes documentation of spinal and/or extremity restrictions (subluxations), posture and gait. If we document the restrictions on every visit, documenting posture and/or gait are optional. All we need to document for the restrictions are the specific segments, like C4, T5 and so on, and left shoulder, right wrist, etc. This should take all of a few seconds to document. No big deal.
The “R” of P.A.R.T. stands for Range of Motion Abnormality. If you want to actually measure range of motion (dual inclinometers for spine, goniometer for extremities), this only needs to be done every 30 days. If you want to assess range of motion on each visit, we only need to document if there is an increase in pain or not with each plane of motion. We can also document if there appears to be diminished or restricted motion in each plane, without measuring it or making up a number.
The “T” of P.A.R.T. stands for Tissue/Tone. For this, we only need to document muscle spasms and/or trigger points. Instead of documenting the infamous “paraspinal muscles,” though, it’s much better to document the specific muscles, like “left supraspinatus muscle.”
That covers the Subjective and Objective part of our S.O.A.P. note. While the metrics for pain intensity and frequency may change on each visit (but not necessarily), the A, R and T of P.A.R.T. may stay the same for a little while. Change them as they change.
So, when we think of “telling the story” for each patient encounter, let’s think in terms of a “short story.”
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
