AN OVERIVIEW OF CLINICAL DOCUMENTATION

FOR THE CHIROPRACTIC PROFESSION

Steven G. Yeomans, DC, FACO404 Eureka StreetRipon, WI 64971-0263

920-748-3644 (Ph)920-748-3642 (Fax)s@yeomansdc.com

Course Objective:

TO BULLET-PROOF YOUR DOCUMENTATION AGAINST AN ADVERSARIAL REVIEW PROCESS

Table of Contents

Content Page #ACA Recommendations (2001) 3-4

WCA Recommendations (1996)

Intro & Acknowledgements ………………………………………………...

Chapter 1: Documentation recommendations ………………………….…..

Chapter 2: Commonly used mechanisms of record keeping ……….………

Chapter 3: Commonly used outcome assessment measurements ………….

Chapter 4: A primer on chiropractic listings ……………………….………

Chapter 5: Glossary ………………………………………………………..

Chapter 6: Commonly used abbreviations ………………………….………

Appendix A: HCFA Guidelines for Patient History Level Selection ………

Appendix B: Bibliography …………………………………………………

5-8

9-18

19-21

22-24

25-26

27-28

29-32

33

34-35

Chart Audit 36

Yellow Flags (psychometrics) 37-38

CPT Codes 39-40

Bibliography 41-44

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Ref: ACA Today, March 2001 The Newsletter of the American Chiropractic Association

CLINICAL DOCUMENTATION KEY TO REIMBURSEMENT FOR CHIROPRACTIC CLAIMS

ARLINGTON, VA – During its recent meeting, the American Chiropractic Association (ACA) House of Delegates passed a resolution to assist doctors of chiropractic in successfully being reimbursed for necessary patient care by insurance companies. ACA is now committed to disseminating the recommendations contained in the resolution to doctors of chiropractic, chiropractic organizations and chiropractic colleges nationwide.

Last year, representatives from 13 of the largest insurers in the United States met with ACA representatives during the second meeting of the ACA-sponsored Claim Solutions Work Group. Based on the suggestions made during this meeting and on recent trends, ACA recommends certain basic requirements be considered as appropriate clinical documentation in patient record keeping. Some of the insurers present at the meeting agreed that using these practices will also reduce clinical record requests by 50 percent.

“The mutual goal of the insurers and doctors of chiropractic at this meeting was to simplify the claims process,” explained Pat Jackson, vice president of professional development for ACA. “This way, chiropractors can reduce administrative costs and get paid for more covered claims, and insurers can reduce claims expenses.” According to Ms. Jackson, many insurers are already adopting the recommended guidelines resulting from the meeting in order to educate their claim personnel on appropriate requests for chiropractic clinical documentation.

The ACA also contends that a concerted effort by the chiropractic profession to standardize clinical documentation will improve reimbursement experience exponentially for doctors of chiropractic. For this reason, a special effort will be made to share this information with chiropractic colleges so it can be incorporated into the curricula.

ACA recommends the following documentation procedures:

1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed.

2. Subjective, objective, and treatment (if rendered) components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.

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3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors.

4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined.

5. Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the history and physical and the anticipated patient treatment plan. The initial treatment plan, except in chronic cases, should not extend beyond a 30-45 day interval.

Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan needs to be reevaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.

6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.

7. Records can be attached to each billing to pre-empt requests; however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).

8. All records must be legible and understandable, released within the authority given by the patients, in a secure, confidential manner and in compliance with existing state (or federal) statutes.

9. The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record.

10. If the above recommendations have been met, then the answers as to why the necessity for continuing treatment are answered.

11. The insurance industry must improve their claim adjusting procedure by using chiropractic consultants. The ACA can use its resources to assist in this initiative.

Contact the American Chiropractic Association Office of Professional Development by phone at (800) 986-4636, ext. 222, or by e-mail at pjackson@amerchiro.org for more information.

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Wisconsin Chiropractic Association

Recommendations for

Chiropractic Documentation(1996)

Wisconsin Chiropractic Association Recommendations for Chiropractic Documentation

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General Disclaimer

This document contains recommendations for the clinical documentation of chiropractic care. These recommendations are intended for educational and instructional purposes only and do not constitute a standard of care for any specific clinical situation. These recommendations, which may need to be updated, are intended to be flexible.

In is not the purpose of this document, which is advisory in nature, to take precedence over any federal, state or local statute, rule, regulation or ordinance which may affect chiropractic practice.

This document may provide some assistance to third parties in the evaluation of chiropractic care, but it is not by itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity.

Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Further, these recommendations will require constant re-evaluation as additional scientific and clinical information becomes available.

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Wisconsin Chiropractic Association Recommendations for Chiropractic Documentation

Table of Contents:AcknowledgmentsIntroductionChapter 1: Documentation recommendations ……………………………… 8-17

Format Legibility Patient consent Initial entry: Subjective Initial entry: Objective Initial entry: Assessment Initial entry: Treatment plan Daily notes Progress notes X-ray reports

Chapter 2: Commonly used mechanisms of record keeping ……………… 18-20Chapter 3: Commonly used outcome assessment measurements …………. 21-23Chapter 4: A primer on chiropractic listings ………………………….…… 24-25Chapter 5: Glossary ……………………………………………………….. 26-27Chapter 6: Commonly used abbreviations ………………………………… 28-31Appendix A: HCFA Guidelines for Patient History Level Selection ………32Appendix B: Bibliography ………………………………………………… 33-34

Acknowledgments:The Wisconsin Chiropractic Association is indebted to chiropractic colleges and insurers who provided valuable background information for the work of the Committee, and also to the Committee members for their diligent effort on this project.

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Introduction: Over the past decade, chiropractic has occupied a constantly growing position in today’s complex health care delivery system. Chiropractors in Wisconsin now work routinely with a myriad of parties who are interested in assessing the quality of clinical work performed by the chiropractor.

The principal method through which other parties attempt to assess the quality and necessity of a chiropractor’s work is through submitted clinical documentation. The clinical records of Wisconsin chiropractors are now examined with an increased amount of scrutiny. Many different payors and agencies have the right to access a chiropractor’s clinical records, including:

insurers who wish to determine whether a claim is a covered benefit under the terms of their contract with the patient

managed care organizations who conduct reviews of clinical record keeping as part of their quality assurance and utilization review programs

attorneys who utilize clinical documentation as evidence in personal injury litigation

attorneys who represent patients in malpractice suits against chiropractors other health care providers who may request records in order to coordinate

interprofessional patient care other chiropractors who assist with treatment for a patient state regulatory agencies, who investigate consumer complaints, review

payment for government programs, etc.

Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Because chiropractic practice patterns vary from medical practice patterns, recommendations for chiropractic documentation necessitate additional modifications when compared to generally accepted medical record keeping formats.

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Chapter 1:Wisconsin Chiropractic Association Recommendations for Clinical Documentation

1. General information: The purpose of these recommendations are:

A. to serve as an informational source to doctors. These recommendations represent well-accepted, contemporary views on documentation issues as reported in the biomedical literature. Some of the source materials include:

Health Care Financing Administration documentation guidelines Record keeping standards for the National Committee on Quality

Assurance. chiropractic and medical textbooks peer-reviewed journal articles submissions from chiropractic colleges input from insurers

B. to serve as voluntary guidelines for chiropractors to use when developing documentation systems for their offices.

C. to encourage more uniform and more understandable clinical documentation, which should serve as a benefit to patients, providers, and insurers.

The Wisconsin Chiropractic Association recognizes that the management of every individual patient is unique. Different styles of practice, or areas of clinical specialization, may prompt the doctor to vary the clinical information to be gathered and recorded.

Documentation performed within the intent of these recommendations need not be rigid and inflexible, but should be adapted to the needs of a particular case. These guidelines are intended to provide a common framework for patient records which allows for more consistent reporting and improved communication.

2. Format: A SOAP format is regarded across the country as the most widely accepted method for keeping clinical records. This format records information about subjective complaints, objective findings, the doctor’s assessment and treatment plan in an organized manner. Used less frequently are recognized derivatives of the basic SOAP schema, such as POMR, SORE or SNOCAMP.1 2 3

1 Journal of Family Practice, Oct. 1995 41:42 Jordan E. St. Anthony’s guide to E/M coding and documentation. St. Anthony’s Publishing, Reston, VA 19953 Vernon H. Clinical note: S-O-R-E, a record keeping system for chiropractic treatment visits. Can Chir Assoc J. 1990;34:93.

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An organized format [whether it is classic SOAP or a modification of the SOAP format] allows information to be recorded in a predictable, repetitive manner. Proprietary or “in-office” systems of documentation are, by definition, difficult or impossible for a reviewer to understand.

Abbreviations: The proper use of accepted abbreviations [such as those listed in these recommendations] can facilitate the documentation process by saving both record space and time. However, the use of non-standard abbreviations can lead to confusion in the interpretation of clinical records. Doctors who choose to utilize non-standard abbreviations should “translate” those abbreviations prior to the records being submitted to a third party.

Methods: The methods used to complete clinical record keeping is a matter of preference for each practitioner. The doctor may prepare documentation by using dictation and transcription, narrative-style writing, pre-prepared forms or other methods preferred by the doctor.

Documentation of evaluation/management services: During the course of a complicated case, the chiropractor may be presented with clinical situations which require varying complexities of decision making and/or the services required. The level of detail contained in the documentation will often increase as the complexity of the decision making or the complexity of the provided services increases.

For example:

at the onset of the complicated case, or at other critical time periods during the patient’s treatment, the chiropractor often functions at a specialist level. When functioning at that level, a corresponding increase in the detail of documentation is typically expected to fully detail the patient’s symptoms, findings, diagnosis and treatment plan. The chiropractor will usually choose to utilize a higher level [99204, 99205, 99214, 99215] evaluation/management code when performing these specialist-level services.

at other times during the same case, the chiropractor may serve on a level very similar to a general practitioner. The level of documentation typically expected at this level is sufficient to tell the story of the patient, but may not include the full level of detail expected of the specialist-level documentation. The chiropractor will often use a mid-level [99202, 99203, 99212, 99213] evaluation/management code when performing these general practitioner-level services.

on a daily treatment basis, the doctor is applying the treatment which has been fully described in the most recent treatment plan. Therefore, the documentation for daily visits will be much more concise.

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Chart organization: Clinical notes consist of three distinct elements:1. Initial entry. The initial entry generally includes:

pertinent baseline information about the patient the patient’s chief complaint[s] the results of initial physical examination the chiropractor’s assessment the recommended treatment plan

2. Daily note. The daily note represents a concise record of pertinent changes in the patient’s condition and treatment on that day. A series of daily notes will show changes on a visit-to-visit basis. The daily note is used most often to document:

adjustment or manipulation physical modalities

3. Progress note. At different points in a case, a progress note is used to document additional patient services. These services may include:

reevaluations reexaminations counseling coordination of care

One respected author in the field of chiropractic documentation4 has described the initial entry as “SOAP-ing” the patient. He then explains that the progress note can be thought of as a kind of “midi-SOAP”, or a somewhat abbreviated version of the original SOAP work-up. This so-called “midi-SOAP” retains the same database format, yet is not necessarily as detailed as the original evaluation. The notation for a daily or routine visit is described as a “mini-SOAP”, displaying the same general organizational scheme of the of the initial evaluation, but on a significantly smaller scale.

3. Legibility: Clinical documentation should always be legible. If patient records are hand written, it is especially important that the handwriting is legible to the reviewer. If the handwriting is not legible to the reviewer, the provider should be informed and given the opportunity to transcribe the information.

4. Documentation of patient consent: Doctors should review with their legal counsel their responsibilities5 to obtain written proof of the patient’s consent in the following critical areas:

general consent to examine and treat: Many doctors will have the patient complete this written consent as part of their initial patient questionnaire.

informed consent: if any proposed treatment procedure poses a meaningful risk to the patient, the doctor is expected to disclose that risk to the patient and to document that the patient has consented to proceed with the proposed

4 Mootz RD. Maximizing the effectiveness of clinical documentation. In: Top Clin Chiropractic 1994 1[1] p. 60-65. Aspen Publishers, Gaithersburg, MD.5 Campbell L, Ladenheim CJ, Sherman R, Sportelli L. Informed consent: a search for protection. Top Clin Chiropractic 1994; 1 (30): 55-63.

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treatment. [In some cases in which the patient has significant difficulties communicating, such as Alzheimer’s disease, stroke victims or the mentally impaired, the informed consent should be obtained from a family member.]

parent’s consent to examine and treat minor children: generally recommended before evaluating or treating any child under the age of 18.

5. The initial patient entry The initial entry generally includes pertinent baseline information about the patient, the patient’s chief complaint[s], the results of physical examination, the chiropractor’s assessment, the recommended treatment plan. An initial patient entry may be made anytime a patient presents with a new chief complaint.

5a. Subjective: Initial New Patient History This section forms the subjective area of the documentation. HCFA has recently defined elements which may be included in the subjective portion of the patient records6.

The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of the these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

These elements of the subjective portion of clinical record keeping include the following:

History of the present illness: [HPI] HCFA has defined the following factors to constitute a complete history of the present illness:

history of trauma description of the chief complaint[s] onset of symptomatology palliative factors provocative factors quality of pain (burning, numbness, tingling) radiation of pain severity of pain (scale of 1-10) frequency or timing of complaint previous episodes of chief complaint.

As an alternative, the elements of the history of the present illness can be represented by the use of the mnemonic “O, P, Q, R, S, T”7.

O = onset of symptoms6 Reported in: St. Anthony’s Physician’s Claims and Billing Manager. St. Anthony’s Publishing, Reston, VA Vol. 3, No. 6, March 1995

7 Foreman S, Croft A. Whiplash injuries; the cervical acceleration/deceleration syndrome. 2nd ed. Williams and Wilkins, Baltimore, 1995.

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P = provocative or palliative factors Q = quality of pain R = radiation S = severity of pain T = timing of pain

When using this mnemonic, many doctors add an additional element to indicate whether the patient has experienced prior episodes of the chief complaint:

U = previous episodes [have you ever had this problem before?]

Past history: prior major illnesses and injuries prior operations prior hospitalizations current medications allergies (food or drug) age appropriate immunization status age appropriate feeding/dietary status.

Social history: current employment occupational history (discretionary) use of drugs, alcohol, and/or tobacco other relevant social factors.

Family history: Significant health factors which may be congenital or familial in nature should be noted.

Review of systems: [ROS] HCFA has defined the following fourteen areas for review of systems:

constitutional symptoms [fever, weight gain or loss, fatigue, etc.] eyes ears, nose and throat cardiovascular respiratory gastrointestinal genitourinary musculoskeletal integumentary [skin/breast] neurologic psychiatric endocrine hematologic/lymphatic allergic/immunologic

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Appendix A includes the requirements from HCFA for the proper coding of evaluation and management codes by the number of included elements from the elements of the history above.

5b. Objective: Initial New Patient Physical ExaminationThis section forms the objective area of clinical documentation. The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

The elements of the objective portion of the patient records may include the following: Vital signs

height weight blood pressure [age dependent; recommended at initial exam, follow-

up depending on condition] pulse [recommended at initial exam, then prn] respiration [if indicated by symptoms] temperature [if indicated by febrile symptoms]

observation auscultation [if indicated by symptoms] percussion [if indicated by symptoms] palpation range of motion [Note that range of motion can be measured using many

different methods, such as actively (AROM), passively (PROM) or active assisted (AAROM). In addition, range of motion can be measured visually, with a goniometer or a manual or electronic inclinometer. The doctor may wish to note the methods used to measure range of motion.]

reflexes deep tendon: use of Wexler [0-5] scale superficial [if indicated by symptoms] pathologic [if indicated by symptoms]

vascular examination [if indicated by symptoms] provocative orthopedic tests neurologic testing [if indicated by symptoms]

cranial nerves station, gait and balance sensory testing muscle strength testing: may be tested manually or with the use of

various machines. When tested manually, most doctors use a modified Lovett scale, which assigns a number grade to the muscle strength8.

The most common usage of this system uses 5 to indicate “normal”.

8 Legg AT, Physical therapy in infantile paralysis. In Mock. Principles and practice of physical therapy. Vol. II. Hagerstown, MD: WF Prior, 1932:45

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Grades 4+, 4, and 4- are used to indicate decreasing muscle function within the “good” category, which is defined as the ability to raise the part against gravity and some resistance.

Grades 3+, 3, and 3- are used to indicate decreasing muscle function within the “fair” category, which is defined as the ability to raise the part against gravity only.

Grades 2+, 2, and 2- are used to indicate decreasing muscle function within the “poor” category, which is defined as the ability to raise the part only with gravity eliminated.

Grade 1 means that the muscle contraction can be felt, but there is no joint movement. Grade 0 means no contraction is felt.

the use of various types of instrumentation, leg length tests or other objective measurements which the chiropractor judges to be relevant to the case.

5c. Assessment: Initial New Patient Assessment Diagnostic impression in a narrative or descriptive format. Assessment of risk factors, if applicable.

5d. Plan: Initial New Patient Treatment Plan The complexity of the patient’s health problem will determine which of the following elements a chiropractor will choose to include in the patient’s record. It is not necessary to include all of these elements in the records of patients with less severe health problems. The elements of the treatment plan may include the following:

Diagnostic treatment plan: describes the need for further tests, including reexamination, etc.

Therapeutic treatment plan: describes the frequency and duration of adjustments and in-office therapies and modalities.

Educational treatment plan: home exercises, modification of daily or work activities

Short and long term goals Referral for other necessary services Coordination of care with other health professionals, if applicable

6. Daily notes: The daily note represents a concise record of pertinent changes in the patient’s condition and treatment on that day. A series of daily notes will show the significant changes in the patient’s condition and treatment which occur over a period of time. The daily note is used most often to document ongoing treatment, such as adjustments/manipulation or physical modalities.

After the initial entry, each subsequent office visit will usually be documented by a daily note, until the next specified reevaluation. If the initial entry clearly states the assessment and plan, it is not usually necessary to reevaluate the patient on a daily basis

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or to reiterate the assessment or the treatment plan. Any significant modification of the treatment plan should be recorded in the daily note.9

Because of its brevity, the daily note will list only the most important changes in the daily presentation of the patient, and the management of the case. Therefore, the treating chiropractor is best qualified to decide which objective and subjective elements of the case should be recorded via the daily note.

7. Progress notes At many different points in a case, a progress note is often used to document additional patient services. These services may include:

reevaluations reexaminations counseling coordination of care

7a. Re-examination frequency: Periodic reexaminations of the patient are an important element of case management, and are used to assess the effectiveness of treatment. It may be appropriate to reexamine a patient or reevaluate a patient’s condition anytime there is a significant change in the patient’s symptoms or response to treatment.

Reexaminations are especially important when a patient exacerbates their injury or if the clinical condition of the patient changes, which may indicate the need for the doctor to reassess the treatment plan. The following chart which describes typical frequency of re-examinations for established patients:

Patient type Definition Typically, a reexamination is performed within:

Acute Symptomatology is present less than six weeks

Acute exacerbation of a chronic or recurring condition.

30 days or 12 visits or as clinically indicated

Chronic Symptomatology present more than 18 weeks

3 months or 18 visits or as clinically indicated

Supportive Symptomatology is present due to a known, permanent deficit;

Six months to one year or as clinically indicated

9 Bronston LJ. Record Maintenance and Narrative Writing. In: Ferezy JS. The Chiropractic Neurological Examination. Aspen, Gaithersburg MD, 1992, p. 153.

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a full recovery is not expected. Maintenance or preventative

No active symptomatology. As clinically indicated

A re-examination for an established patient is particularly appropriate in the following circumstances:

a patient who presents with a new chief compliant a patient who presents with a new, distinct episode of a recurring condition. a patient who presents with symptoms, and has not received treatment for 90

days or more

8. Documentation of x-ray findings: X-ray documentation is usually produced on the day the film was read and/or billed. These x-ray findings may be in the form of a separate report, or may condensed to the major findings, and included with the objective portion of the patient’s documentation.

Just as the “SOAP” format is used to methodically prepare patient records, formal x-ray reports often follow a repeatable format. When preparing formal x-ray reports, the following format has been advocated by Yochum and Rowe10:

Introductory InformationLetterhead Information

Name of physician Clinic name and address

Patient information Full name and address Date of birth File identification

Radiographic information Views submitted Dates and location of films taken Technique factors [optional]

ReportClinical information

Chief complaint Key clinical findings Reason for study Numbered summary of pertinent findings

Radiologic findings Descriptive narrative of findings

10 Yochum TR, Rowe, LJ. Essentials of Skeletal Radiology, 2nd Ed. Williams and Wilkins, Baltimore, 1996, p.1371-1396.

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Findings are usually listed in the order of alignment, bone, cartilage, soft tissue, which can be easily remembered by the mnemonic “ABCs”.

ConclusionsRecommendations

Indications or contraindications to treatment Follow-up procedures indicated

Signature and qualifications

Chapter 2:Mechanisms of documentationThere are many different mechanisms that a chiropractor may successfully use to keep excellent clinical documentation. Some of the most commonly used methods are discussed below:

Dictation and transcription:

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Dictation of clinical records remains the benchmark against which all other forms of record keeping are measured. Dictation has many obvious advantages:

impeccable legibility the ability to use as much detail as may be needed there are no restrictions imposed by the format itself transcriptionist does not need special computer training

There are also minor disadvantages of the dictation/transcription method: labor intensive, therefore tends to be relatively costly dictation tapes can break or be lost digital dictation systems can lose data

Computer-assisted record keeping [commercial programs]: These systems are available in many different formats. Various methods of inputting information to the computer have been devised, each claiming to be the most efficient. Information may be input into the computer via voice or through the use of keyboard, light pens, scanning sheets, touch screens, bar code readers or other devices.

These systems have the advantages of: automating some of the repetitive aspects of patient records

a comprehensive approach to inputting clinical data.

Disadvantages may include: relatively high purchase cost relative difficulty of editing your copy from the pre-defined format in some of

the products lost data if the system is not “backed up” frequently.

With new technology comes intriguing new ethical questions. For example, some of the programs will automatically vary the verbiage to avoid the appearance of repetitive notes. There are computer programs which will “write” a narrative report or “calculate” a disability rating. Only the individual practitioner can decide if a particular product truly represents a time-saving tool in completing the patient’s documentation, or a clinically unacceptable “short cut”.

Word processing programs: All of today’s computer word processing programs have the ability to be easily programmed by the user to perform repetitive functions. These special, user-defined commands are usually called a macro. With the use of a macro, it is possible to automate many of the repetitive tasks required in patient record keeping, such as typing the clinic name, patient name, date and other commonly required data.

In addition, a macro can generate frequently used text, often called boilerplate text. This can enable the doctor to add significant depth to records without expending much time. For example, complete instructions can be prepared for a routine of lumbar extension

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exercises. When a patient’s clinical condition indicates that these particular exercises are appropriate, the entire exercise routine can be added to the patient’s records with the touch of the macro button.

The advantages of this type of system are: low cost system may be adapted completely to your needs and changed at any time

The disadvantages of this type of system are: set-up is labor intensive professional assistance is seldom available doctors and staff must thoroughly understand the system they have devised data may be lost if not “backed up” frequently

Hand written records:It is possible to keep excellent quality patient records by hand writing each record. However, many doctors will simply not be able to utilize hand written records because they possess illegible or poor quality handwriting. In addition, the sheer volume of information required in a quality patient record often lends itself to some sort of mechanization, especially in a busy practice.

If hand written entries are to be part of clinical records: make sure that the handwriting is clearly legible be sure that the areas of the record reserved for handwriting are not cluttered

with other information use only common, standardized abbreviations, such as those listed in these

Wisconsin Chiropractic Association documentation recommendations.

Proprietary or “in-office” chiropractic record keeping systems:Over the years, many chiropractors have developed proprietary [non-SOAP] formats or shorthand systems for various aspects of their patient records. These may include the use of abbreviations or symbols which are not well recognized within the chiropractic profession.

The use of these types of devices within records can often be confusing to other parties who wish to review the patient’s records. This potential problem can often be avoided by the use of standardized abbreviations and conventions, such as those described in these recommendations.

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Chapter 3:Outcome Assessment Measurement DevicesPain is the primary complaint for 80% of all office visits to physicians each year in the U.S. [National Center for Health Statistics, 1986]. It is important to use the proper measurement device in order to get meaningful data of a patient’s baseline status. The measurement must then be reapplied to get meaningful data of a patient’s improvement. The testing device must be comprehensive enough to give a reliable clinical picture, simple to understand, easy to score, and able to be administered at a low cost.

The devices listed in bold are used very commonly within the chiropractic profession, and it is recommended that you become familiar with these outcome assessment devices. Unfortunately, copyright restrictions do not allow for the reproduction of these materials within these Wisconsin

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Chiropractic Association recommendations. Generally, you may access the original articles and use any of these devices in your office for the treatment of your individual patients.

A. General health questionnaire1. Health Status Questionnaire v.2.0 [Health Outcomes Institute, 1993]11 2. SF-36 [Stewart, 1988; Interstudy, 1990]12

3. RAND 36 [RAND Corporation, 1986]13

4. Dartmouth COOP charts [Nelson, 1987]14 15 16

5. Sickness Impact Profile [Bergner, 1981]17

6. Nottingham Health Profile18

B. Pain1. Visual analog scale [VAS] [Huskisson, 1982]19 20 21 22

2. Numerical pain scale [NPS] [Jenson, 1986]23

3. McGill/Melzak pain questionnaire [Melzack, 1975]24

4. Pain drawing [Mooney and Robertson, 1976] 25 26

5. Pain Disability Index [Tait, 1987]27

6. Dallas Pain Questionnaire [Lawlis, 1989]28 29

11 Health Outcomes Institute. Health Status Questionnaire 2.0. Health Outcomes Institute, Bloomington, MN12 Interstudy: An introduction to Interstudy’s outcomes management system development plans. October, 1990. Interstudy, Excelsior, MN. 13 Rand 36-item health survey 1.0. Rand Health Sciences Program, Santa Monica, CA: RAND; 1986, 1992. 14 Johnson D. Dartmouth COOP Project. Hanover, NY: Dartmouth Medical School, 1989. 15 Nelson E, Berwick D. The measurement of heath status in clinical practice. Medical Care 1989 27 [3]:S7716 Kraus N. The Dartmouth primary care cooperative [“COOP] information project. Interstudy Qual Edge, 1991; 1:33-39. 17 Bergner M, Bobbitt R, Carter R, Carter W, Gilson B: The sickness impact profile: Development and final revision of a health status measure. Medical Care 1981, 19 [8]:787. 18 Reviewed in: Deyo RA. Measuring the functional status of patients with lower back pain. Chiropractic Technique. 1990;2[3]:127-137. 19 Huskisson S. Measurement of pain. J Rheumatol 1982, 9:76820 Merskey H. The perception and measurement of pain, J Psychosom Res. 17:251-155, 1973. 21 Ventafridda V, DeConno F, DiTrapani P, Gallico S, Guarise G, Rigamonti G, and Tamurini M. A new method of pain quantification based on a weekly self-descriptive record of the intensity and duration of pain. In Bonica JJ, Lindblom U Iggo A eds: Advanceds in pain research and therapy, Vol 5: Proceedings of the Third World Congress on Pain. 22 Jensen MP, Koroly P, O’Riordan EF, et al: The subjective experience of actual pain: an assessment of the utility of 10 indices. Clin J. Pain 5:153, 1989.23 Jensen M, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods. Pain 1986, 27: 117. 24 Melzack R: The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975, 1:277.25 Mooney V. Robertson J. The facet syndrome. Clin Orthop 115:149, 1976. 26 Rainsford AO, Cairns D, Mooney V. The pain drawing as an aid to the psychologic evaluation of patients with lower back pain. Spine 1:127-134. 1974. 27 Tait R, Pollard C Margolis R, Duckro P, Krause S. Pain disability index: psychometric and validity data. Arch Phys Med Rehabil 1987, 68:438.28 Review in: White A, Schofferman J. ed. Spine Care. Mosby, St. Louis, 1995. P. 919-922. 29 Lawlis GF, Cuencas R, Selby D, et al. The development of the Dallas Pain Questionnaire for illness behaviour. Spine 14:511, 1989.

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C. Disability: lower back pain1. Modified Oswestry Low Back Pain Questionnaire [Fairbank, 1980]30 31

2. Roland-Morris Disability Questionnaire ROL-SIP [Roland, 1983]32

3. Low Back Pain TyPE Specifications [Health Outcomes Institute, 1992]33

4. Million Disability Questionnaire [Million, 1982]34

5. Waddell Disability Index [Waddell and Main, 1984]35

D. Disability: cervical or headache1. Neck Disability Index [Vernon-Mior, 1991]36

2. Headache Disability Index: HDI [Jacobson, 1994]37

E. Pychometrics1. Psychosocial Pain Inventory [Heaton, 1980]38

2. Illness Behaviour Questionnaire [Pilowsky, 1976]39

3. Health Status Questionnaire 2.0 40 [Questions 37-39: depression screens]4. Waddell Non-Organic LBP signs [Waddell, 1980] 41

5. Somatic Amplification Rating Scale [Korbon, 1987]42

6. Modified Zung Depression Index 43 44

7. Modified Somatic Perception Questionnaire MSPQ [Main, 1983]45

8. Minnesota Multiphasic Personality Inventory [MMPI]46 47

30 Fairbanks J, Davies J, Couper J, O’Brien J. The Oswestry low-back pain disability questionnaire. Physiotherapy 1980, 66:271.31 Hudson-Cook N, Tomes-Nicholson K, Breen A. The revised Oswestry low back pain questionnaire. Thesis, Anglo-European College of Chiropractic, 1988. 32 Roland M, Morris R. Study of natural history of back pain, part I: development of a reliable and sensitive measure of disability in low back pain. Spine 8:141; 1983. 33 Health Outcomes Institute. Low Back Pain TyPE Specifications. Health Outcomes Institute, Bloomington, MN34 Million R, Nilsen K, Jayson MIV, et al. Evaluation of lower back pain and assessment of lumber corsets with and without back supports. Ann Rheum Dis 40:449, 1981. 35 Waddell G, Main C: Assessment of severity in low-back disorders. Spine, 1984, 9:204. 36 Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manip Physio Ther 1991, 14 [7]:409.37 Jacobson GP, Ramadan NM et al. The Henry Ford Hospital Headache Disability Inventory [HDI]. Neurology 1994;44:837-842.38 Heaton RK, Lehman RAW, Getto CJ. Psychosocial Pain Inventory, Odessa, FL, 1980, Psychological Assessment Resources. 39 Pilowsky, I, Spence ND. Illness behaviour syndromes associated with intractable pain. Pain 2:61-71, 1976. 40 Health Outcomes Institute. Health Status Questionnaire 2.0. Health Outcomes Institute, Bloomington, MN41 Waddell G, McCulloch J, Kummel E, Venner R. Non-organic signs in low back pain. Spine 5:117, 1980. 42 Korbon GA, DeGood E, Schroeder ME, et al. The development of a somatic amplification scale for lower back pain. Spine. 1987;12[8]: 787-791.43 Zung W. A self-rating depression scale. Arch Gen Psychiatry. 1965;32:63-70/ 44 Review in: Ahles TA, Yunus MB, Mari AT. Is chronic pain a variant of depressive disease? The case of primary fibromyalgia syndrome. Pain, 1987; 29: 105-111.45 Main C. 1983 Modified somatic perception questionnaire. J. Psychosom Res. 1983;27:503-514.46 Hanvik LJ. MMPI Profiles in patients with lower back pain. J. Consul Psychol. 15:350-353, 1951.47 Hathaway SR, McKinley JC. Minnesota Multiphasic Personality Inventory: manual for administation and scoring. Psychological Corporation, New York, 1967.

23

9. Fear-Avoidance Beliefs Questionnaire FABQ [Waddell, 1993]48

F. Patient satisfaction:1. Patient Satisfaction Questionnaire [Ware, 1983]49

2. GHAA Consumer Satisfaction Survey [Ware, 1991]50

3. Low Back Pain Patient Satisfaction [Deyo, 1986]51

4. Chiropractic Satisfaction Questionnaire [Coulter, 1994]52

Chapter 4:A Primer on Chiropractic ListingsChiropractors use a variety of different systems to indicate the deviation of a motor unit from its normal position. While a comprehensive survey is far beyond the scope of this document, the following information should prove helpful to anyone attempting to understand a chiropractic listing.

Spinal segments: The following abbreviations are commonly used to refer to segments of the spinal column and pelvis:

C0, O: OcciputOC: Occipital condyleC1, A: AtlasC2, AX: AxisC3: Third cervicalC4: Fourth cervicalC5: Fifth cervicalC6: Sixth cervicalC7: Seventh lumbarT1: First thoracic [or dorsal]T2: Second thoracicT3: Third thoracic

T4: Fourth thoracicT5: Fifth thoracicT6: Sixth thoracicT7: Seventh thoracicT8: Eighth thoracicT9: Ninth thoracicT10: Tenth thoracicT11: Eleventh thoracicT12: Twelfth thoracicL1: First lumbarL2: Second lumbarL3: Third lumbar

48 Waddell G, Newton M, Henderson I, et al. A fear-avoidance beliefs [FABQ] questionnaireand the role of fear avoidance beliefs in chronic low back pain and disability. Pain 1993:52:157-168. 49 Ware J, Davies AR. Defining and measuring patient satisfaction with medical care. Eval and Program Plan. 1983;6:247-263. 50 Davies AR, Ware JE. GHAA’s consumer satisfaction survey and user’s manual. 2nd ed. Washington, DC: GHAA: 1991. 51 Deyo R, Diehl A. Patient satisfaction with medical care for low back pain. Spine 1986, 11:28. 52 Coulter I, Hays R, Danielson C. The chiropractic satisfaction questionnaire. Topic in Clin Chiropractic. 1994; 1[4]: 40-43.

24

L4: Fourth lumbarL5: Fifth lumbarS: SacrumS1: First sacral segmentS2: Second sacral segment

S3: Third sacral segmentS4: Fourth sacral segmentS5: Fifth sacral segmentCO: CoccyxIL: Ilium

Additionally, some of the prominent landmarks of spinal segments are abbreviated below. These landmarks are often used as points of reference to define the orientation of the vertebra within a three-dimensional space:

SP: spinous process TP: transverse processM: mamillary process

L: laminaP: pedicleB: body

25

Direction of Vertebral Misalignment:

A bone or spinal segment is usually “listed” in the direction it deviates from normal. The following abbreviations are commonly used. The international coordinate system53, which is often used in biomechanical research, is described in parenthesis:

Two-Dimensional Translational Motion:A: Anterior (+Z)P: Posterior (-Z)R: Right (-X)L: Left (+X)S: Superior or cephalad (+Y)I: Inferior or caudal (-Y)EX: ExternalIN: Internal

Three-Dimensional Motion:Clockwise rotation: (+)Counterclockwise rotation: (-)F: Flexion (+X)E: Extension (-X)LLF: Left lateral flexion (-Z)RLF: Right lateral flexion (+Z)RR: Right spinous rotation (+Y)LF: Left spinous rotation (-Y)

Examples of Combination Listings: These two components of location and direction are often combined to describe a bone or motor segment which has deviated from its normal position. For example,

L5 PL: 5th lumbar vertebra has deviated with spinous moved to the left. C6 PLI-BR: 6th cervical vertebra has deviated with its body moved to the right.T6 RP: 6th thoracic vertebra has deviated with the body posterior on the right.

Chapter 5: Glossary53 White A, Panjabi M. Clinical biomechanics of the spine. Lippincott, Philadelphia, 1978

document.doc

The following glossary is essentially limited to terms which involve the process of documentation. In addition, definitions are suggested for some terms which are used in so many different contexts, [such as acute and chronic] that they have become difficult to define accurately.

AAROM: Active assisted range of motion. The patient is asked to perform voluntary movement of the joint throughout its arc of movement, and the examiner applies a mild force in the same direction as the patient’s movement. The purpose is to ensure that full range of motion has been measured, and to assess the quality of the joint movement upon reaching the endpoint of movement. Acute: having symptomatology for a relatively short length of time. A common definition is symptoms which are noticed for less than 6 weeks upon presentation.54

AROM: Active range of motion, performed with the patient voluntarily moving the joint. The examiner is looking for differences in range of motion and the patient’s willingness to perform the movement.55

Assessment: The portion of the patient clinical record which details the doctor’s impression, diagnosis or opinions of the case.Chief complaint: The patient’s primary health concern which results in seeking treatment from the doctor. Chronic: having symptomatology for an extended length of time. A commonly accepted criteria for a chronic complaint is symptomatology which are apparent for more than 16 weeks upon initial presentation.56 Disability: The alteration of an individual’s capacity to meet personal, social or occupational demands, or statutory or regulatory requirements because of an impairment. Disability refers to an activity or task the individual cannot accomplish.57 Disability is the inability to perform specific work-related activities. Disability is a functional deficit. Impairment: The loss, loss of use or derangement of any body part, system, or function. Impairments are defined as conditions that interfere with an individual’s “activities of daily living”, or the inability to perform certain physical tasks, which may or may not be associated with work activities58. An impairment is an anatomic deficit. Maintenance care: 1. Treatment given in the absence of significant symptomatology; 2. well-person care; 3. preventative or prophylactic careObjective: Items in the patient record which can be accurately and repeatedly measured.

54 Fromeyer J. Back Pain and Sciatica. N Engl J Med., 318:291-300, 198855 Magee D. Orthopedic Physical Assessment. WB Saunders, Philadelphia, 1992. 56 Mayer T, Gatchel R. Functional restoration for spinal disorders: a sports medicine approach. Leee & Febiger, Philadelphia, 1988. 57 American Medical Association. Guides to the evaluation of permanent impairment, 4th ed. AMA, Chicago, 1993.58 American Medical Association. Guides to the evaluation of permanent impairment, 4th ed. AMA, Chicago, 1993.

27

OPQRST: A mnemonic device for the essential elements of the history of the present illness. The initials represent: onset, palliative and provocative factors, quality of pain, radiation, severity, and timing (frequency).Plan: Treatment plan; a written outline of the proposed care for the patientPROM: Passive range of motion. The patient is asked to relax as much as possible, and the examiner supplies all the force necessary to move the joint throughout its arc of movement. Passive testing is usually performed if deficits in active range of motion are noted. SOAP: A mnemonic for subjective, objective, assessment, plan. Sub-acute: symptoms which are present for a period greater than an acute presentation, and less than a chronic presentation. A commonly accepted definition of sub acute would be the presence of symptomatology for 6-16 weeks upon initial presentation.Subjective: Items in the patient record which are derived from the patient’s verbal or written communications with the doctor. Supportive care: 1. Treatment provided after the patient has reached maximum medical/chiropractic improvement and has not reached a full recovery; 2. treatment given to diminish permanent or chronic symptomatology when a full recovery is not possible; 3. treatment provided to alleviate the symptomatology of a known anatomic deficit.

28

Chapter 6: Commonly used abbreviationsThe abbreviations listed below do not represent a comprehensive listing, or an attempt to replace a medical dictionary. These abbreviations are often used by chiropractors , and originate in the following areas:

1. Commonly encountered diagnoses2. Commonly used abbreviations describing patient symptomatology in daily or

progress notes.3. Commonly used anatomic abbreviations.

Note that some of the abbreviations can take on different meanings, depending upon the context. For example, the abbreviation “P” can mean either “pulse” or “treatment plan”, depending upon its usage.

>: greater than<: less than: arc: frequency: change: decreased: increased: none, no: right L : left B : bilateral ~: approximately1: primary2: secondary3: tertiarya.: beforeA: assessmenta.c.: before mealsAAROM: active assisted range of motionab: abdominalAC: acromioclavicularad feb.: fever presentad int.: in the interimad lib.: as wanted

adj.: adjustmentadl: activities of daily livingagg: aggravate ant.: anteriorAP: anteroposterior AROM: active range of motionAS: ankylosing spondylitisb.i.d.: twice per dayB: bilateralB/B: Bowel/bladder BCP: birth control pillsBM: bowel movementBP: blood pressureBX: biopsyc: withc/o: complains of C: cervicalCA: carcinomaCB: contrast bathCBC: complete blood countCBR: complete bed restcerv: cervical cmt: chiropractic manipulative therapyCOPD: chronic obstructive pulmonary disease

29

CP: cold packsCP: cerebral palsycp: cervical painc-s: cervical spinec-t: cervicothroaciccsa: chiropractic spinal adjustmentCT: computed tomographyctd: cumulative trauma disordercts: carpal tunnel syndrome CVA: cerebrovascular accidentCVP: central venous pressureD: dorsal [syn. thoracic]D/C: discontinueDD: differential diagnosisDDD: degenerative disc disease DIP: distal interphalangeal jointdimin: diminished DJD: degenerative joint diseaseDRG: dorsal root ganglion DSLR: double straight leg raise DTR: deep tendon reflex Dx: diagnosisECG or EKG: electrocardiogramEEG: electroencephalogramEMG: electromyographyems: electrical muscle stimulationEPP: end point painES: erector spinae muscles ESI: epidural steroid injection ESR: erythrocyte sedimentation rateexacer: exacerbationext: extensionFBG/FBS: fasting blood glucose/sugarFH: family historyfix: fixationflex: flexionFUO: fever of unknown originFx: fractureG-H: Gleno-humeralGI: gastrointestinalGU: genitourinaryHA: headacheHb or Hgb: hemoglobin

Hct: hematocritHEENT or EENT: head/eyes,ears,nose,throathmp: hot moist packsHNP: herniated nucleus pulposishpi: history of present illnessHR: heart rateHTN: hypertensionhv: high voltHVG: high volt galvanismHx: historyice mass: ice massageIF, IFC: interferential currentim: intermittentimp: improvedinf.: inferioriso: isometricIT, IST: intersegmental tractionITB: iliotibial bandIUD: intrauterine deviceivd: intervertebral disc ivf: intervertebral foramenJVP: jugular venous pressureKJ: knee jerkL or lum: lumbarL or Lt: leftlat: lateralLATX: long axis tractionLBP: lower back pain lbp: lower back painLC: lower cervicalLD: lower dorsalLE: lower extremityllf: left lateral flexion LLI: leg length inequalityLLQ: left lower quadrantlm: lateral meniscusLMN: lower motor neuronlr: left rotationlum or L: lumbarL/S: lumbosacral l-s: lumbar spineLT: light touch [sensation]

30

LUQ: left upper quadrantlv: low voltm: muscle mass: massagembp: midback painMCP: metacarpophalangeal jointMCRC: maximum cervical rotatory compression MCV: mean cell volumemed: medialMI: myocardial infarctionMLR: maximum lifting restriction mm.: musclesmm: medial meniscusmp: motion palpationMTP: midthoracic pain or metatarsalphalangeal jointMVA: motor vehicle accidentmyo: musclen: nervenad: no abnormalities detected NBM or NPO: nothing by mouthNCV: nerve conduction velocityNKC: no know causeNKI: no known injuryn/l: normal limitsnn.: nervesnr: nerve rootNSR: normal sinus rhythmO: objectiveOA: osteoarthritisOB/GYN: obstetrics and gynecologyOC: oral contraceptiveoc: office callocc.: occipitalocc.: occasionalOTC: over the counterp: afterP: PlanP: pulsep.c.: after mealsp.r.n.: as neededpap.: papanicolaou smear

PE: physical examinationPERRLA: pupils equal, round, reactive to light and accommodationPFA: patellofemoral arthralgiaPH: past historyphono: phonophoresisPIP: proximal interphalangeal jointPMI: point of maximum intensitypn, px.: painPND: postnasal drainagePNF: proprioceptive neuromuscular facilitationPPD: permanent partial disability prn: whenever necessary; as needed PROM: passive range of motionPT: physical therapyPt. ed.: patient educationPt., pt.: patientPT: physical therapistPVC: premature ventricular contractionpx, pn: painq.a.m.: every morningq.d.: every dayq.h.: every hourq.i.d.: four times per dayq.o.d.: every other dayq.p.m.: every afternoon/eveningQL: quadratus lumborumR: respirationRA: rheumatoid arthritisrad: radiate, radiationrlf: right lateral flexionRLQ: right lower quadrantRTW: return to work RO, R/O: rule outROM: range of motionrr: right rotation RUQ: right upper quadrantRx: therapy or prescriptionRx: medications: withoutS: subjectiveS: sacral

31

SA: sacral apexsa: spinal adjustmentSB: sacral baseSC: sternoclavicular jointSCM: sternocleidomastoidious musclesho: shoulderSI: sacroiliac joint SLR: straight leg raise test sm: spinal manipulationsmt: spinal manipulative therapy SOB: shortness of breathSP: spinous processspondy: spondylolisthesisSSLR: sitting straight leg raise test ST: sharp touch [sensation]Stat.: immediately, at onceSTM: soft tissue massagesup.: superiorSWD: short-wave diathermySx: symptomsT: temperatureT: thoracicTelecon: telephone conversationt.i.d.: three times per daythor: thoracic TIA: transient ischemic attackT/L: thoracolumbarTMJ: temporomandibular jointtos: thoracic outlet syndrome

TP: trigger pointTPD: temporary partial disabilityTPR: temperature, pulse and respirationTPT: trigger point therapytrap: trapeziust-s: thoracic spinett: taut and tenderTTD: total temporary disability ttt: tender to touch tx, txrn: tractionTx: treatmentTx: telephone callUA, U/A: urine analysisUE: upper extremity UMN: upper motor neuronURI: upper respiratory infectionUS: ultrasoundUTI: urinary tract infectionUV: ultravioletVSC: vertebral subluxation complexWLR: well leg raise test WNL: within normal limits w/o: withoutWP: whirlpoolx: number of times performed [x2 = twice; x3 =three times, etc.]XR: x-rayyo: years oldz-joint: zygapophyseal joint

32

Appendix AThe Health Care Financing Administration has recently produced guidelines which address the level of history recommended for each particular evaluation/management code. The HCFA guidelines specify which factors must be included to qualify for a particular history, as well as the documenting factors which must be included. The history is one factor which determines proper evaluation/management code selection. The factors and their use are summarized in the chart below:

Possible choices for E/M code

Type of History [used to determine proper E/M code]

History of Present Illness [HPI]

the location of the problem

the quality the severity of the

problem the duration of the

problem the timing of the

problem the context modifying factors associated signs

and symptoms

Review of Systems [ROS] eyes ears, nose,

throat and mouth cardiovascul

ar respiratory gastrointestin

al genitourinary musculoskel

etal integumentar

y neurologic psychiatric endocrine hematologic

or lymphatic allergic or

immunologic

Past Family and/or Social History [PFSH]

Past history

Family history

Social history

99201 99212

Problem-focused

Brief (1-3 of the above factors)

N/A N/A

9920299213

Expanded problem-focused

Brief (1-3 of the above factors)

Problem-pertinent (1 of the above systems reviewed )

N/A

9920399214

Detailed Extended (4 or more of the above factors)

Extended (2-9 of the above systems reviewed)

Pertinent (1)

992049920599215

Comprehensive

Extended (4 or more of the above factors)

Complete(10 or more of the above systems reviewed)

Complete (2 or 3)

Appendix B:Selected bibliography and reading list1. Arnoff GM, ed. Evaluation and treatment of chronic pain. Williams and Wilkins,

Baltimore, 1992.2. Baird, R. Health record documentation: charting guidelines. Digest Chiropractic

Econ 1981; 52: 32-3. 3. Bates, B. A guide to physical examination and history taking, 5th ed. Lippincott,

Philadelphia. 1991. 4. Boone W, et al. Practice Guidelines for Straight Chiropractic. World Chiropractic

Alliance, Chandler, AZ. 1993. 5. Braddom RL, ed. Physical Medicine and Rehabilitation. WB Saunders, London,

1996. 6. Camins M, O’Leary P. Disorders of the cervical spine. Williams and Wilkins,

Baltimore, 1992.7. Curl, DD. Chiropractic approach to head pain. Williams and Wilkins, Baltimore,

1994.8. Croft AC. Chief complaints in narrative reports. In: Dynamic Chiropractic, May 6,

1994. Motion Palpation Institute, Huntington Beach, CA.9. Evans RC. Illustrated essentials in orthopedic physical assessment. Mosby, St.

Louis, 1994.10. Ferezy, JS. The chiropractic neurological examination. Aspen, Gaithersburg, MD

1992.11. Foreman S, Stahl M. Medical-legal issues in chiropractic. Williams and Wilkins,

Baltimore, 1990.12. Foundation for Chiropractic Education and Research. Proceedings of the 1991

International Conference on Spinal Manipulation. FCER, 1701 Clarendon Blvd, Arlington, VA, 1991.

13. Gatterman, MI. Chiropractic management of spine related disorders. Williams and Wilkins, Baltimore, 1990.

14. Haldeman S, Chapman-Smith D, Peterson, D. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference, Aspen, Gaithersburg, MD. 1993.

15. Haldeman S. Principles and Practice of Chiropractic. Appleton and Lange, Norwalk, CT, 1992.

16. Hanson D. Determining how much care to give and reporting patient progress. In Topics of Clinical Chiropractic, 1[4]; 1-8. Aspen, Gaithersburg, MD 1994.

17. Hislop HJ, Montgomery J. Daniels and Worthington’s Muscle Testing, 6th edition, Techniques of Manual Examination. Williams and Wilkins, Baltimore, MD 1995.

18. Hochschuler S, Cotler B, Guyer R. Rehabilitation of the spine: science and practice. Masby, St. Louis, 1993.

19. Hoppenfeld S. Physical examination of the spine and extremities. Appleton and Lange, Norwalk, CT, 1976

20. Jordan, E. St. Anthony’s guide to E/M coding and documentation. St. Anthony’s, Reston, VA, 1995.

21. Kendall FP, McCreary EK, Provance PG. Muscles: testing and funciton, 4th edition, with posture and pain. Williams and Wilkins, Baltimore, MD 1993.

22. Kettenbach G. Writing SOAP notes. FA Davis, Philadelphia, 1990.23. Lawrence, KE, et al. Chiropractic patient resource manual. Aspen, Gaithersburg, MD

1993.24. Liebenson C. Rehabilitation of the spine: a practitioner’s manual. Williams and

Wilkins, Baltimore, 1996. 25. Magee D. Orthopedic Physical Assessment. Saunders, Philadelpia, 1992. 26. Maigne R. Diagnosis and treatment of pain of vertebral origin: a manual medicine

approach. Williams and Wilkins, Baltimore, 1996. 27. Mootz RD. Maximizing the effectiveness of clinical documentation. Topics Clin

Chiropractic. Aspen, Gaithersburg, MD 1994; 1[1] 60-65. 28. National Committee for Quality Assurance. NCQA Accreditation Manual. NCQA,

1350 New York Ave, NW., Suite 700, Washington, DC 20005, 1995. 29. Ombregt L, Bisschop P, ter Veer H, Van de Velde T. A system of orthopaedic

medicine. WB Saunders, London, 1995. 30. Plaugher G, Lopes M. Textbook of clinical chiropractic: a specific biomechanical

approach. Williams and Wilkins, Baltimore, MD 1993. 31. Sweere, J, ed. Chiropractic family practice. Aspen, Gaithersburg, MD 1992.32. Travell JG, Simons DG. Myofascial pain and dysfunction: the trigger point manual.

Williams and Wilkins, Baltimore, MD, 1983.33. Vear H. Chiropractic Standards of Practice and Quality of Care. Aspen,

Gaithersburg, MD, 1992. 34. Vear, HJ. Chiropractic standards of practice and quality of care. Aspen,

Gaithersburg, MD 1992.35. White A, Anderson R. Conservative care of lower back pain. Williams and Wilkins,

Baltimore, 1991.36. White AH, Schofferman JA. Spine Care: Volume 1: Diagnosis and Conservative

Management. Mosby, St. Louis, 1995.37. Yochum TR, Rowe, LJ. Essentials of Skeletal Radiology, 2nd Edition, Williams and

Wilkins, Baltimore, 1996.

CHART AUDIT CHECKLIST

1. Billed services are documented (X-ray, PT, rehab)2. Special studies performed include explanation of why the test is necessary and a

description of the impact the test(s) had on treatment &/or diagnostic decisions3. Diagnosis made is supported by the findings of the case4. Legibility5. List risk factors of a prolonged recovery (See appendix A)

Conditions – diabetes, cardiovascular disease, CNS disorders, medication interactions, etc.

Yellow flags (depression, anxiety, poor coping strategies, fear avoidant behavior, job dissatisfaction, etc.)

6. Treatment Plan - included? Followed?7. Periodic recheck and updated treatment plan. Followed?8. Exacerbations affect recovery? Home vs. work? 9. Were work restrictions/modifications issued? Followed?10. Outcomes oriented documentation11. Goal oriented management12. Use of the Appeal process13. Reasons for care denial

a. Insurance letter/opinionb. Based on consultant file review (MD vs. DC vs. "anonymous"; qualifications

included?)c. Based on IMEd. Guidelines citede. Records reviewed listed?

14. MMI reached? If so, when? If not, any predictions or special tests needed before MMI is reached?

15. Treatment effectiveness16. Pertinent past history findings (list & describe impact to the current case)17. Rehabilitation (progression from passive to active care)

a. Anything more than "exercises given" listed? How frequently? Any follow-up? Any objective physical testing pre-/post-rehab to document outcomes?

b. If multiple units (each 15 minutes) - is this clearly documented (what was performed, SOAP approach for rehab service, "scorecard" of performance, etc.)

18. Was each page signed & dated?

APPENDIX ARisk factors of chronicity & Yellow Flags

A. Risk factors (Documentation):1. Abnormal illness behavior (Waddell's, SF-6)2. Job dissatisfaction 3. Past Hx of >4 episodes4. Symptoms > 1 wk w/o health provision 5. Severe pain intensity (Triple VAS) (>69%)6. New condition / injury related to pre-existing structural pathology or skeletal anomaly 7. Weak back extensor musculature (Static back endurance test)8. Smokes 1 pack or greater / day9. Poor self-rated health (SF/HSQ-36 or -12)10. Heavy Job Classification

B. Yellow Flags

Yellow Flags

SymptomsYellow Flag Reference

Number of pain sites Linton, 1998; Linton, 1997Duration of symptoms Cherkin, 1996; Von Korff, 1993; Linton 1998;

Linton 1997Duration of symptoms before the 1st visit Van den Hoogen, 1997Past history of numerous episodes Frank, 1996; Cherkin, 1996; Hazard, 1996;

Burton, 1995Past hospitalization or surgery for similar complaint

Van den Hoogen, 1997; Hazard, 1996; Lancourt, 1992

Severe pain intensity Frank, 1996; Cherkin, 1996; Von Korff, 1993; Linton, 1998; Hazard, 1996

Frequency of painful episodes over the last 3 months

Linton, 1998; Linton, 1997

Sciatica Frank, 1996; Cherkin, 1996; Burton, 1995; Salim, 1998; Lancourt, 1992

Psycho-social

Anxiety Cherkin, 1996Locus of control Burton, 1995Depression Cherkin, 1996; Linton, 1998; Linton, 1997;

Klennerman, 1995Catastrophizing Burton, 1995Self-rated health as poor Cherkin, 1996; Waddell, 1996Heavy smoker Waddell, 1996; Cats-Baril, 1991; Hazard, 1996Belief that you shouldn’t work with your current pain

Linton, 1998; Linton, 1997

Job dissatisfaction Cherkin, 1996; Cats-Baril, 1991Anticipation of trouble sitting or standing at work 6 weeks into the future

Hazard, 1996

Anticipation of disability 6 months into the future

Hazard, 1996

FunctionDoes physical activity make your pain worse?

Linton, 1998; Linton, 1997

Tolerance for light work Linton, 1998; Linton, 1997Is sleep affected by your pain? Linton, 1998; Linton, 1997DisabilityHeavy job demand Waddell, 1996Past disability for the same/similar complaint in prior 12 months

Hazard, 1996

Disabled at present Hazard, 1996

APPENDIX B: Physical Medicine and Rehabilitation Services

Supervised ModalitiesCode Description RVU*97010 Hot or cold packs .2997012 Traction, mechanical .4697014 Electrical stimulation (unattended) .4097016 Vasopneumatic devices .4597018 Paraffin bath .3397020 Microwave .2897022 Whirlpool .3897024 Diathermy .2997026 Infrared .2797028 Ultraviolet .28

Constant AttendanceCode Description RVU*97032 Electrical stimulation (manual), each 15 minutes .4097033 Iontophoresis, each 15 minutes .4297034 Contrast baths, each 15 minutes .3297035 Ultrasound, each 15 minutes .3397036 Hubbard tank, each 15 minutes .5197039 Unlisted attended modality (specify type and time) .47

Table 1. The use of modalities in a musculoskeletal practice is common. Various attended and non-attended or supervised modalities are described. The Relative Value Units are located in the right hand column.

Table 2. Treatment Services97110 Therapeutic procedure, one or more areas, each 15 minutes; OR,

Therapeutic exercises to develop strength and endurance, range of motion and flexibility

.60

97112 Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception, ea. 15 min.

.59

97113 Aquatic therapy with therapeutic exercises, ea. 15 min. .6697116 Gait Training (includes stair climbing), ea. 15 min. .5297124 Massage, including effleurage, petrissage and/or tapotement

(stroking, compression, percussion).47

97139 Unlisted therapeutic procedure (specify) ea. 15 min.97140 Mobilization, manipulation, manual traction, lymphatic drainage, ea.

15 minutes

97150 Therapeutic procedure(s), group (2 or more individuals) .4997504 Orthotics fitting and training upper and/or lower extremities; each

15 minutes.61

97520 Prosthetic fitting and training upper and/or lower extremities; each 15 minutes

.62

97530 Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

.63

97535 Self care/home management training (e.g., activities of daily living and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment) direct one on one contact by provider, each 15 minutes.

.64

97537 Community /work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis), work task analysis, direct one on one contact by provider, each 15 minutes. [for wheelchair management/propulsion training, use 97542, each 15 minutes]

.64

97542 Wheelchair management/propulsion training, each 15 minutes .4497545 Work hardening/conditioning; initial 2 hours NE97546 each additional hour NE

Table 2. A listing of treatment services is found in this table with the associated CPT code number. NE stands for Not Established.

Table 3 Tests and Measurements(For muscle testing, manual or electrical, joint range of motion, electromyography or nerve velocity determination, see 95831-95904)

97703 Checkout for orthotic/prosthetic use, established patient, each 15 minutes

.46

97750 Physical performance test or measurement (e.g., musculoskeletal, functional; capacity), with written report, each 15 minutes

.72

Other Procedures97770 Development of cognitive skills to improve attention,

memory, problem solving., includes compensatory training and/or sensory integrative activities, direct (one-on-one) patient contact by the provider, each 15 minutes

.75

97780 Acupuncture, on or more needles; without electrical stimulation

NE

97781 With electrical stimulation NE97799 Unlisted physical medicine service or procedure NE

* Taken from: 6th Annual edition 1998 ChiroCode DeskBook, Leavitt Crandall Institute, Inc. Mesa, AR, 1997

Table 3. When tests or measures are performed, specific CPT codes can be assigned to the service. When other services such as acupuncture is performed, CPT codes specific to those services are also available.

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