ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 3 of 10 Instructor: Paul Sherman, DC

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1 Online Continuing Education Courses ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 3 of 10 Instructor: Paul Sherman, DC Important Notice: This download is for your personal use only and is protected by applicable copyright laws. Its use is governed by our Terms of Service on our website (click on Policies on our website s side navigation bar). OBJECTIVE PORTION OF THE PROGRESS NOTES SHOULD BE DOCUMENTED USING THE P.A.R.T SYSTEM: P.A.R.T. system consists of the following: P-Pain/tenderness: Evaluated in terms of location, quality and intensity. This can be identified through observation, percussion, palpation, provocation, etc. In addition, pain intensity may be assessed using one or more of the following i.e.: visual analog scale, algometers, pain questionnaires, etc. A-Asymmetry/misalignment: Evaluated on a sectional or segmental level through static palpation, diagnostic imaging and observation i.e.: (posture and gait analysis). R-Range of motion abnormality: Evaluated in changes of active, passive and accessory joint movements which may result in an increase or a decrease in sectional or segmental mobility. In addition, ROM abnormalities may be identified by one or more of the following i.e.: motion palpation, observation, stress diagnostic imaging, range of motion measurements, etc. T-Tissue, tone, texture or temperature abnormality: Evaluated by changes in the characteristics of contiguous or associated soft tissues which include skin fascia, muscle and ligaments. This may be identified by one or more of the following i.e.: observation, palpation, use of instrumentation, etc. Note: To document a subluxation based on physical examination the doctor must meet two of the four criteria of the P.A.R.T. system, one of which must be asymmetry/misalignment or range of motion abnormality. MEDICARE DOCUMENTATION REQUIREMENTS FOR INITIAL VISIT AND SUBSEQUENT VISITS: MEDICARE DOCUMENTATION REQUIREMENTS FOR INITIAL VISIT: 1

2 1. Patient history, which should include the following: Symptoms causing the patient to seek treatment (Chief Complaint) Onset, duration, intensity, frequency, location and radiation of symptoms Quality and character of symptoms/problems Aggravating and/or relieving factors Mechanism of trauma Family history if relevant Past health history (general health, prior illnesses, injuries, surgery, hospitalizations and medications) Prior interventions, treatments, medications, secondary complaints 2. Description of present illness, which should include the following: Patient s symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine, muscle, bone, rib and joint and be reported as swelling, spasm, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine. The subluxation must be causal (the symptoms must be related to the level of the subluxation that has been idenitifed). The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined. 3. Evaluation of the NMS system through physical examination. 4. Diagnosis, which should include the following: The primary diagnosis must be subluxation, including the level. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. 5. Treatment Plan, which should include the following: Recommended level of care (duration and frequency of visits) Note: Important to reference visit number based upon duration of the care plan for the episode of care being provided i.e.: visit 1 of 12, visit 2 of 12, visit 3 of 12, etc. Specific treatment goals Note: Should have a starting point and time frame for trying to meet the goals. Quantifying and measuring goals is also important. Objective measures to evaluate treatment effectiveness i.e.: standardized pain and functional assessment tools should be used. 6. Date of the initial treatment. 2

3 MEDICARE DOCUMENTATION REQUIRED FOR SUBSEQUENT VISITS REGARDLESS IF THE SUBLUXATION IS DEMONSTRATED BY AN X-RAY OR BY PHYSICAL EXAMINATION: 1. History, which should include the following: Review of chief complaint Changes since last visit System review, if relevant 2. Physical Exam, which should include the following: Exam of area involved in diagnosis Assessment of how the patient s condition changed since last visit Evaluation of treatment effectiveness 3. Documentation of treatment given on day of visit. MEDICAL DOCUMENTATION (PROGRESS NOTES) AFTER INITIAL VISIT (SUBSEQUENT VISITS) SHOULD ALWAYS BE PERFORMED IN THE S.O.A.P. FORMAT: 1. S-Subjective complaint, which should include the following: Document how the patient is feeling. This should include location of pain, quantity and quality of pain, level of function (ADL) and severity of pain (qualify by using pain analog scale 0-10, (0-no pain, 10-severe pain). In addition, outcome assessment questionnaires should be utilized to further document care. Differentiate Quantity vs. Quality of Pain: Quantity: (Amount of time patient feels pain per day) Descriptors of Pain Quantity: Occasional Feels pain up to 25 % per day Intermittent Feels pain up to 50% per day Frequent Feels pain up to 75% per day Constant Feels pain all day 100% Infrequent Not daily Quality: (How pain affects patient s function/adl) Descriptors of Pain Quality: Minimal Pain During ADL patient forgets pain Minor (Slight) Pain Pain doesn t prevent patient from doing ADL if they briefly pause or change 3

4 positions i.e.: sitting, lifting, carrying, pushing, pulling, dancing, housework, yard work, playing golf, working on computer, etc Moderate (Significant) Pain Patient is able to perform ADL, but pain forces them to rest Severe Pain Pain precludes patient from doing anything Determining Severity of Pain: Use OAT s (outcome assessment tools) Begin at start of care to determine an initial baseline Use during follow-up/re-examinations Use during exacerbations Use at end of care/discharge of patient Always calculate outcome scores and compare results of outcomes Important Tools Utilized for Outcome-Based Care: Pain (QVAS)-Quadruple visual analog scale and pain drawings to assess pain level Disability/Function (Bournemouth questionnaires, Neck Pain Disability Index, Oswestry Low Back Pain Scale & (PSFS)-Patient specific functional pain scale all to assess impact on ADL (quantity & quality of pain) Patient s Global Impression of Change-PGIC (assesses patient satisfaction and provides an ongoing evaluation of perceived progress with treatment) Benefits to Becoming Outcome-Based: Enhances quality care for patients Helps protect against liability Improves reimbursement Provides better evidence for care 2. O-Objective findings, which should include the following: Document visual observation (inspection), physical examination findings i.e.: static and motion palpation which includes muscle spasm/tightness, tenderness, trigger points and ROM. Document orthopedic and neurological testing, laboratory studies and diagnostic imaging i.e.: X-ray findings, MRI, CT-scan, Bone scan etc. Document objective portion of SOAP notes as per the P.A.R.T. system previously discussed). In addition, physical performance tests fall under this category (see below for some examples of physical performance tests). Examples of Physical Performance Tests: Repetitive squat Repetitive sit-up Static back or neck endurance One leg stand Horizontal side bridge endurance 4

5 Grip test Purpose of Physical Performance Tests: Measures function not pain Helps motivate patients to perform exercises and adhere to better compliance Goal is to transition patient from pain relief to functional restoration Note: Performed post acute pain phase 3. A-Assessment, which should include the following: Diagnostic impressions, short and long term goals and expected functional outcomes. In addition, the doctor should evaluate the overall progress the patient is making to their treatment plan i.e.; patient better, worse or the same. Short Term Goals: Decrease muscle spasm Reduce inflammation Alleviate pain Maintain ADL Return patient to work Long Term Goals: Increase normal physiological movements of the joints (ROM) Restore strength and/or endurance Increase flexibility Increase physical work capacity Return patient to full work capacity Modify social and recreational activity (life style changes) 4. P-Plan, which should include the following: Document treatment received and frequency patient will be seen i.e.; 2 x wk for 4 wks with re-evaluation. Document what procedure was performed on the patient that day, exactly where on the body was the treatment rendered, what settings were used if P.T. was involved, how long was it done, what dosages and frequency were used. Anyone in the room or assisting in the treatment or exam should be listed. Indicate plans for future assessment i.e.: re-examination/re-evaluation, prognosis, and anticipated discharge, referral for consultations, examinations, treatment or follow-up diagnostic testing. Document any patient instructions i.e.: home care (ice/heat, belts/collars, exercises, work/home restrictions etc), medications or nutritional supplements recommended. You can indicate patient tolerated procedures well (PTPW) if in fact they did. If any complications do not ignore them, describe the problem and indicate what instructions were given to the patient to remedy the situation. In addition, a brief post assessment of that days treatment should be performed, which is intended to evaluate the patient s response to their treatment for that day. This post assessment is not considered a re-examination/re-evaluation of the patient. Note: Always date progress notes and be as specific as possible when documenting medical information as this is critical for good patient management and will be 5

6 beneficial if litigation is brought against you by the patient. Sign or initial SOAP notes when completed. Benefits of Appropriately Documenting SOAP Notes: Reduces doctor s risk of malpractice Helps document communication between doctor/patient relationship Assists in meeting NCQA guidelines Assists with associates and covering doctor s Helps to document care and improve patient management Protects doctor with regards to HIPAA Privacy Standards Enhances communication with insurance companies (third party payers) and other professionals Improves outcomes with PIP arbitration Reduces cut-offs from I.C.E/I.M.E doctor s Increases number of visits available for the patient Increases doctor s income 6