Chapter 2 - Record Keeping

Chapter Outline

Overview
Definitions
List of Subtopics
Literature Review
Assessment Criteria
Recommendations (Guidelines)
Comments, Summary or Conclusions
References
Minority Opinions

Overview [Top]

For professional and legal reasons a chiropractor is required to keep and maintain adequate patient records which clearly reflect the course of patient management. Records must be accurate, legible, and comprehensive so that a reviewer of these records can establish the essential relationship between the patient and the practitioner in terms of past, present and future health care. Records are usually the only tangible evidence of examinations, findings and treatment.

The health care record has many uses. Its most important function is to assist in the immediate care and treatment of the patient. The record also permits different members of the health care team, or successive health care providers, to have access to relevant data. It is important for documenting specific services received by the patient so that the provider can be reimbursed. The health record is also helpful in peer review, in providing data for public health purposes, and may be used for the purposes of teaching and research. It is critical in a variety of legal contexts, including defensive malpractice claims.
It is understood that record keeping styles may vary from practitioner to practitioner. It is not the purpose of this chapter to recommend a particular style, but rather to give guidelines on necessary elements of record keeping as supported by the reviewed literature.

The health care record contains confidential information which, as a matter of law, must not be released except on the express consent of the patient or pursuant to a court order or otherwise as compelled by law. The taking and recording of informed consents, an increasingly important aspect of record keeping, is dealt with in Chapter 1.
Definitions [Top]

For definitions see the Glossary at the end of this publication.
Contemporaneous
External Records
Health Record
Patient Confidentiality
Peer Review
POMR
Progress Notes
Record Keeping
SOAP
List of Subtopics [Top]
1. Appointment Book
2. Patient File
3. Initial and subsequent and clinical and accounting records
4. Confidentiality of clinical records
5. Practical and technical aspects of recording clinical recordkeeping
6. Retention of clinical records
Literature Review [Top]

This chapter is based upon material found in provincial laws and ethics (Quebec 1973), published textbooks, refereed journal articles, conference material and anecdotal information from lawyers, chiropractors, educators, and professional organizations. A major resource was the current American Guidelines for Chiropractic Quality Assurance and Practice Parameters (Haldeman et al. 1992).

Twenty years ago Simmons (1973) prepared a concise guide to assist the practitioner in maintaining daily records and recording elements of case history and consultation. Schafer (1978 and 1987) published procedural manuals through the American Chiropractic Association which underscored the importance of documenting necessity of chiropractic care through adequate record-keeping and the support of chiropractic paraprofessionals. In a publication of the International Chiropractors' Association, Kranz (1987) provides guidance for the practitioner in the hospital environment.

There have been three recent publications promoting malpractice prevention, or risk management strategies, for practitioners. Campbell, Ladenheim, Sherman and Sportelli (1990 and 1992) identify many pitfalls of lax patient chart management and failure to obtain patient consents, and offer recommendations that can be implemented in office management systems. Harrison (1991) crisply identifies shortcomings of patient records and the risks in the context of malpractice claims.

The Canadian chiropractic literature has a number of recent articles in referenced journals relative to risk management, charting procedures and report writing. Authors such as Carey (1988), Cassidy (1985), Gotlib (1984), Nixdorf (1990), Vear (1992) and Vernon (1990) have contributed material that assists practitioners in management of patient records and obtaining appropriate consents. Elsewhere Reinke and Jahn (1988) provide pointed commentary correlating the importance of the patient's health record and the practitioner's "legal well-being". Other direction has been offered by Turnbull (1987) from New Zealand and Gledhill (1990). Bolton (1990) adds to the published knowledge base on informed consent. Nyiendo and Haldeman (1986) have analyzed practice activities of student interns in a chiropractic college teaching clinic, and summarize the need for standardized accountability in patient care.

Recently many monographs have been establishing guidelines for the management of chiropractic cases. These include a surge in efforts to publish standards of care in a number of American state and Canadian provincial jurisdictions. Within these are position statements or "standards" on obtaining and documenting clinical information. Chiropractors in Connecticut in 1985 were among the first to provide formal practice guidelines, noting that there must be adequate documentation of the necessity for chiropractic care. They established recommended formats for interval reporting. The workers' compensation guidelines produced by the Washington State Chiropractic Advisory Committee (Hansen 1988) adapted an outline proposed earlier by Vear, Haldeman and West citing six primary case management objectives supported by "standards." Vear (1992) has subsequently republished these objectives and standards in a major text. Efforts by Olson (1987), LaBrot (1990) and state chiropractic organizations in Ohio (1990) Michigan (1991) and Minnesota (1991) have all produced practice guidelines that emphasize the need for better standards in record keeping. Similar efforts are underway in Manitoba, Ontario, and Quebec, and many US states including Florida, Oklahoma, Oregon, South Carolina and Texas.

Chiropractic professional liability carriers have contributed to the information pool with monographs that are a part of their risk management programs. The Canadian Chiropractic Protective Association (CCPA), the OUM Group and the National Chiropractic Mutual Insurance Company (NCMIC) have produced many articles through newsletters and booklets.

Chiropractic popular publications produced by the national and state associations periodically give guidance on efficient record keeping, risk management and report writing. Other popular publications that contribute articles include The American Chiropractor (Oxford 1988), Today's Chiropractic (Mootz 1989), Digest of Chiropractic Economics (Baird 1981 and 1986), and Dynamic Chiropractic. Chiropractic specialty councils have contributed white papers (Gunderson 1989) on essential elements of the patient's case file, report composition and clinical workup. Popular publications outside the chiropractic field also contribute valuable knowledge that can be used in the development of guidelines.

Probably the richest technical source of information relative to documentation and patient consents is found in legal publications (e.g. MacDonald et al. 1986). The legal advice found in these publications is supported with citation of case law. Publications such as these are not easily accessed by the average practitioner in the field, nor are they available in all chiropractic college libraries. The profession must rely on its legal consultants to assist in review of such literature. Fortunately, publications such as Legal Update (formerly Chiropractic Amicus) edited by Ladenheim at al., and the Chiropractic Report edited by Chapman-Smith have emerged to fulfil this role and assist practitioners in their understanding of the legal ramifications of health care practice.
Assessment Criteria [Top]

Rating System 2 assessment criteria are used in this chapter. For an explanation of this system see the Introduction and Guide to Use (p. xxiii).

Initial Documentation and Record keeping
Appointment book
2.1 The name of each patient and the date when seen shall be recorded in an appointment book.
Rating: Necessary
Evidence: Class II, III
Consensus level: 1

Patient file
2.2 The first step in the processing of a new patient shall be the establishing of a patient file to serve as a permanent record. Information may include:

name, age, gender, address, and other demographic data
health insurance and other billing information
occupation and employer
referring practitioner
case history
examination
special study findings
imaging and laboratory findings
diagnosis
treatment plan

Pre-printed history questionnaires that contain much of the above and other information may be used at the time of initial documentation.
Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

2.3 The patient file shall be identified by name or number and shall be stored in hard copy form. This may be in a folder which will become part of the record if the practitioner writes patient data upon it. Outdated portions of progress notes and other documentation may be removed and stored in an archive file. However, a note should be kept in the active file identifying these additional records.

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

Patient history

2.4 A case history shall be kept and may include the following:
demographic data including date, name, address, telephone number, gender, date of birth and guardian, if applicable

patient chief complaint data
relevant past and present health history
family and social history, when indicated
systems review (as appropriate)
prior history of therapeutic and diagnostic procedures

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

Financial record

2.5 A financial record for each patient shall be kept. It shall include:

a.	date and type of professional service provided (initial visit, subsequent visit, x-ray, examination and any other services provided to the patient);
b.	fee for service(s);
c.	payment received and from which source; and
d.	balance of account to date.

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

Record of examination and diagnosis

2.6 All examination procedures performed, ordered or requisitioned must be recorded.
Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1
2.7 A diagnosis of the patient's presenting complaint(s) must be recorded.
Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

2.8 A plan of management shall be recorded, and may include:

a.	therapeutic approach;
b.	additional testing or referral to another health care provider when indicated;
c.	proposed frequency and duration of treatments;
d.	any complicating factors should also be included.

Rating: Necessary
Evidence: Class I, II, III
Consensus level: 1

2.9 A prognosis may be recorded.
Rating: Recommended
Evidence: Class I, II, III
Consensus level: 1

2.10 Relevant clinical findings, both positive and negative, should be recorded.
Rating: Recommended
Evidence: Class II
Consensus level: 1

Consent

2.11 Patient consent to treatment may be oral, written, or implied, depending upon the circumstances, and it is not necessary in most cases to record the giving of consent in the patient file. It may be wise to make a record in some circumstances, such as:

oral consent following explanation of a material risk of treatment - consent for treatment of a minor when circumstances suggest that consent may later be challenged
consent for treatment of a legally incompetent patient

The best record of any consent is one that is objectively documented and signed by the patient.
Rating: Recommended
Evidence: Class I,II,III
Consensus level: 1

Special studies

2.12 Documented results of special studies when received become a component part of the file. If an outside facility is used, there should be a record of the date of the study, and the names of the interpreting practitioner and facility.

Rating: Necessary
Evidence: Class I,II,III
Consensus level: 1

Progress notes

2.13 Progress notes shall be recorded and dated at each patient visit or communication.
Rating: Necessary
Evidence: Class I,II,III
Consensus level: 1

2.14 Progress notes should reflect the patient's subjective and objective findings, changes in the clinical presentation, specifics of the treatment(s) or recommendation(s).
Rating: Necessary
Evidence: Class I,II,III
Consensus level: 1

External documentation
2.15 Relevant documentation to and from external sources becomes part of the patient file. Examples may include:

correspondence to or from a referring practitioner - general correspondence from lawyers, third party payors, and others

Rating: Necessary
Evidence: Class II,III
Consensus level: 1

Record of discharge

2.16 When the patient is discharged there should be a record made of the reason and the patient's current health status.
Rating: Discretionary
Evidence: Class II,III
Consensus level: 1

Confidentiality of patient records

2.17 Patient records are confidential and no part of them shall be examined by or released either verbally or in writing to anyone without the written consent of the patient or where legally required.
Rating: Necessary
Evidence: Class I
Consensus level: 1

Retention of records

2.18 A chiropractor shall retain a patient's records.
Rating: Necessary (for such periods as prescribed by law)
Evidence: Class I,II,III
Consensus level: 1

Rating: Recommended to be stored indefinitely
Evidence: Class III
Consensus level: 1

Attributes of records:

2.19 Records should be:

a.	legible
b.	clear and unambiguous
c.	concise with an emphasis on essential clinical information
d.	chronological
e.	recorded contemporaneously

Rating: Recommended
Evidence: Class II,III
Consensus level: 1

Method of recording

2.20 Notes must be recorded in ink or other permanently retrievable method.
Rating: Recommended
Evidence: Class II,III
Consensus level: 1

Use of abbreviations and terminology

2.21 Recorded abbreviations and terminology should be internally consistent and a key for these abbreviations must be available.
Rating: Recommended
Evidence: Class II,III
Consensus level: 1

Amendment of records

2.22 Errors in the record should be corrected observing the following:
a. when an entry is to be deleted or amended it should be crossed out in such a manner that it can be read if necessary.
Rating: Necessary
Evidence: Class II,III
Consensus level: 1

b. record date and sign corrected entry;
Rating: Recommended
Evidence: Class II,III
Consensus level: 1

Transfer of records

2.23 Health care records, excluding data and reports from external sources, that are requested by another health professional currently treating a present or former patient should be forwarded promptly, following receipt of an appropriate request and patient consent.
Rating: Necessary
Evidence: Class I,II,III
Consensus level: 1

Office staff:

2.24 The practitioner has the responsibility to ensure that staff members involved in record keeping are properly instructed on all relevant guidelines including the confidentiality of patient records.
Rating: Necessary
Evidence: Class II,III
Consensus level: 1

Comments, Summary or Conclusions [Top]

This chapter has provided guidelines to be used by chiropractors through documentation of patient records. It is suggested in the literature that optimum patient care is enhanced by maintaining such records. The principles outlined in this chapter should be taught in chiropractic undergraduate programs and then re-enforced at the postgraduate level and at risk management seminars.
References [Top]

Baird R. Health record documentation: charting guidelines. Dig Chir Econ 1981; 24(1):32-33.

Baird R. Confidentiality statements. Dig Chir Econ 1986; 29(1)60.

Baird R. Obtaining health record information. Dig Chir Econ 1981; 24(3):137-8.

Bolton SP. Informed consent revisited. J Aust Chiro Assoc 1990; 20(4):135-38.

Campbell LK, Ladenheim CJ, Sherman RP, Sportelli L. Risk management in chiropractic. Fincastle, Virginia: Health Services Publications Ltd, 1990

Carey P. Informed consent - the new reality. J Can Chiropr Assoc 1989; 32(2):91-94.

Cassidy JD et al. Medical-chiropractic correspondence: when and how to write effectively. J Can Chiropr Assoc 1985; 29(1):29-31

Coulehan JL, Block MR. The medical interview: a primer for students of the art. F.A. Davis Co., Philadelphia, 1987.

Gatterman MI. Chiropractic management of spine related disorders. Baltimore: Williams & Wilkins, 1990.

Gatterman MI. Standards of practice relative to complications of and contraindications to spinal manipulative therapy. J Can Chiropr Assoc 1991; 35(4):232-236.
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Gotlib AC. The nature of the informed consent doctrine and the chiropractor. J Can Chiropr Assoc 1984; 28(2):272-274.

Gotlib AC. The chiropractor and third party access to confidential patient health records. J Can Chiropr Assoc 1984; 28(3):327.

Gunderson BV. The Case History. Orthopaedic Brief. Council on Chiropractic Orthopaedics of the American Chiropractic Association, 1989.

Haldeman S, Chapman-Smith D, Peterson (Jr.) DM: Guidelines for chiropractic quality assurance and practice parameters. Proceedings of Mercy Centre Consensus Conference Jan.25-30, 1992. Gaithersburg: Aspen Publications, 1993.

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Hansen DT. Chiropractic standards and utilization guidelines in the care and treatment of injured workers. Chiropractic Advisory Committee, Department of Labor & Industries. State of Washington, 1988.

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Minority Opinions [Top]

None