The Advocate Update Report --  2003
by Dr. Matthew McCoy, Chair – WCA Chiropractic Advocacy Council

Commentary - Added

Since the determination of the necessity for past, present and future care can only be made when all relevant information is contained in the patient records, the issue of record keeping is an important one. 

Many chiropractors provide care solely directed at addressing vertebral subluxation and its related components.  The record-keeping practices of these chiropractors will normally contain descriptions of the care that is unique to his/her particular method or technique system.  These methods for recording subluxation and their correction can be highly idiosyncratic. These recordings should be considered acceptable as long as they adequately describe the care being provided to reduce, correct or stabilize the subluxation.

Attending chiropractors should not need to provide anything more than a simple legend that describes any non-standard abbreviations or descriptions regarding their note taking. Notes indicating the level(s), type, positions, listing, coordinates of subluxation(s) should be considered adequate. Notes may also contain information regarding the methods used to correct the subluxation(s). If a particular method is to be used on each visit it should not be considered necessary that the attending chiropractor describe this each and every visit as this would be redundant. Brief notations as to any deviation from the plan should be considered adequate.

The S.O.A.P. format is one of several acceptable approaches to recording notes and it may be used with patients who have a symptomatic presentation. However, if a patient is undergoing "wellness" type care, does not present with symptoms, and is purely undergoing subluxation analysis and resultant reduction it may not always be necessary to provide subjective reports (S) from the patient and/or a detailed assessment (A). The notes in such a case may only indicate the information pertaining to the objective, subluxation oriented chiropractic findings and the resultant plan to correct them during that visit. The assessment (A) might be considered redundant in such a case since this information (listings, coordinates, segments adjusted etc) may exist in the objective (O) section. Further, if the practice objective of the chiropractor is narrowly focused on subluxation then the practitioner may not have a listing of diagnoses other than subluxation and these might be listed in the objective section already. More detailed assessments as to long term response to care may be handled during re-examinations. Chiropractic spinal evaluation, evaluation for subluxation and other similar terms should be considered an appropriate subjective (O) notation when applicable.

Beyond the plans (P) for that particular visit additional notations regarding future plans may or may not be necessary depending on the type of care or method being rendered. Simply noting that the patient should return as needed (PRN) should be considered acceptable depending on the nature of the case.

Other note taking formats should be considered acceptable such as DAP notes.

D = DATA

A= ASSESSMENT

P= PLAN

In this system, the subjective and objective portions of the note are combined and might be more amenable to chiropractic note taking where the practitioner’s goals revolve more around wellness care. Other similar methods of note taking should be considered acceptable as long as pertinent information is provided. The use of abbreviated notations, examination checklists, and computerized notation systems should be encouraged and considered acceptable as long as patient care is not compromised.

The construction of detailed narrative reports or progress reports may be advantageous in a situation involving litigation or reporting to a third party for various reasons. If this is necessary for the third party to make a decision regarding payment or some other need, then the requesting party should expect to compensate the attending chiropractor for his or her time, effort and energy expended to compile such a detailed report. Administrative costs and time associated with the recording, storage, copying and retrieval of patient records, if overly burdensome, can interfere with what is best for the patient, may distract the doctor from the task at hand, and use up valuable resources.

The performance and/or recording of extraneous examination procedures that are not germane to the evaluation of a particular patient should be discouraged as this wastes time, money and energy and adds nothing to the patient's health benefit.  This would include any mandate that an attending chiropractor perform some predetermined procedure(s) such as provocative orthopedic maneuvers or extensive neurological examination procedures, especially if these procedures have been shown to be unreliable or invalid.

The determination of the need for such procedures should be made on a case-by-case basis and considered necessary only if indicated by the patient's presenting complaints or if a need becomes apparent through the patient history or initial examination findings and so long as they are consistent with the chiropractor’s practice objective.

If the performance of a particular examination procedure will add nothing to the determination of what the attending chiropractor is going to do with the patient then it should be apparent that this procedure is not necessary in the care of that particular patient.

For more information, to purchase a hard bound copy of the guidelines, to make a donation to CCP and for the references cited in this section please visit

http://www.ccp-guidelines.org/

Dr. Matthew McCoy – Chair - WCA Chiropractic Advocacy Council

advocate@worldchiropracticalliance.org

Dr. Matthew McCoy, Chair – WCA Council on Chiropractic Advocacy