Progress note documentation

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Progress note documentation
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Patient documentation is essential for1.
patient management keep track of progress,
matching tx with best results. 2. provider
reimbursement provides evidence of medical
necessity and treatment performed. 3. risk
management provides evidence of adherence to
standards of care.
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The SOAP Mnemonic is used to guide chiropractors
for proper documentation during patient visits.
S Subjective findings of patientO
Objective findings of patient A Assessment
of patient progressP Plan/ procedures
performed
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Clevelands SOAP note (aka Progress Note)
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• S The subjective section.
• We want to document how the patient is doing
  presently and compared to previous visit.
• VRS used. If the condition that you are treating
  presents as significantly worse, no change,
  follow up questions are needed. OPPQRST needed.
• Ex. Doctor, my neck and upper back pain is
  significantly worse today. Should ask questions
  based on OPPQRST.
• If a patient presents with significant pain in
  a new area, then a focus case history and or a
  focus examination may be indicated.

Note the location, quality, and severity of the
pain.
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• S Various scales or instruments can be used
  dependent on the clinical circumstances. They
  provide a reliable means of measuring pain levels
  and its affect on the patient. Examples include
• Visual Analog-Type Scale The patient is asked to
  grade the pain on a visual analog-type scale from
  0-10.
• Verbal Rating Scale (VRS) Like the visual analog
  scale, the patient is asked to verbally grade his
  or her pain from 0-10.
• Pain Questionnaires Various patient
  questionnaires, such as the Neck Disability Index
  or the Oswestry Low Back Pain Questionnaire can
  be used for the patients pain description.

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O The objective section is where the results
of the neuromusculoskeletal examination is
recorded. This section is broken down into six
catagories which is collectively called the
PARTS system.PARTS is a CCC Clinic
Mnemonic. PART is a Medicare Mnemonic which
is used to document the presence of joint
dysfunction or a subluxation.
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A The Assessment section is where we record
patient progress or lack of it. It is this
section where we list the results of any
Subjective and or Objective findings since the
last visit. Ex. Verbal rating scale of pain,
Range of motion findings, any changes in muscle
spasm or muscle tightness or the amount of
joint dysfunction. This is an abbreviated
version of an evaluation (Blue progress
evaluation) that is performed at the end of a
treatment plan.
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A The Assessment section
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P The Plan/ procedure section is where we record
the treatment procedures used during the patient
visit. We also document any new recommendations
made to the patient, and how the patient felt
after care.
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Documentation of joint dysfunction/subluxation
The PARTS System


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• P Pain and Tenderness Identify, using one or
  more of the following
• Observation You can document by personal
  observation the pain that the patient exhibits
  during the course of the examination or how the
  patient walks to your treatment room and how they
  get onto or off the treatment table.

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P Pain and Tenderness Percussion, Palpation,
or Provocation When examining the patient, ask
if pain is reproduced, such as, Let me know if
any of this causes discomfort.
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• A Asymmetry/Misalignment
• Identify on a sectional or segmental level by
  using one or more of the following
• Observation You can observe patient posture or
  analyze gait.
• Ex. Scoliosis,
• Forward head
• carriage

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A Static Palpation Describe the spinal
misaligned vertebrae, and symmetry.Ex. T5 TVP on
L
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A Diagnostic Imaging You can use x-ray, CAT
scan, and MRI to identify misalignments.
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• R Range-of-Motion Abnormality
• Identify an increase or decrease in
  global/regional and or segmental mobility by
  using the following
• Global/regional ROM by observation You can
  observe an increase or decrease in the patients
  range of motion.
• Segmental motion by motion palpation You can
  record your palpation findings, including
  listing(s). Be sure to record the various areas
  that are involved and relate them to the regions
  manipulated

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• R Range-of-Motion Abnormality

Regional ROM
Segmental mobility
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R Range-of-Motion Abnormality

• Stress Diagnostic Imaging You can x-ray the
  patient using bending views. ex.
  Flexion/extension views of lumbar or cervical
  spine
• Range-of-Motion Measuring Devices Devices, such
  as goniometers or inclinometers, can be used to
  record specific measurements.

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• T Tissue, Tone Changes
• Identify, using one or more of the following
• Observation Visible changes, such as signs of
  spasm, inflammation, swelling, rigidity, etc.
• Palpation Palpated changes in the tissue, such
  as hypertonicity, hypotonicity, spasm,
  inflammation, tautness, rigidity, flaccidity,
  etc., can be found on palpation.

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T Tissue, Tone Changes

• Use of Instrumentation Document the instrument
  used and findings. Ex. SEMG
• Tests for Length and Strength Document muscle
  length, contracture, and strength of muscles that
  relate.

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S Special tests (if applicable)

• Examples
• Activator
• Sacral Occipital Technique (SOT) protocol
• Thompson leg check eval.
• Muscle Endurance tests (Static back endurance
  test(Sorensens)
• Abnormal motor control tests (Hip extension test,
  craniocervical flexion test)
• X-rays, MRI
• labs

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Plus () (if applicable)

• For monitoring risk factors such as blood
  pressure, weight, etc.

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General documentation protocols for chiropractic
office visits

• More than ever, adequate documentation of patient
  encounters is an essential part of patient care.
  Here are some general guidelines for
  documentation in practice.

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General protocols

• 1. Records must be legible. Other Interns,
  clinicians or other health care providers depend
  on your records. They must be able to read them.
• 2. Entries must be dated. Include the year. 5
  years later you wont know which October it was.
• 3. Entries may be changed, but not obliterated.
  If you notice an error, draw a single Iine
  through the script, date and initial it, then
  make your correction.

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General protocols

• 4. Note the date for follow-up. Tell your patient
  when to follow up with you, but to let you know
  sooner if any problems arise.
• 5. For a report of findings, or informed consent,
  Note the consent discussion has occurred. State
  the procedures, alternatives, risks, and benefits
  (PAR-B) been discussed. Patient questions should
  be noted.
• 6. Document patient non-cooperation. If a patient
  misses appointments, fails to comply with
  instructions about activities, or continues
  detrimental actions, enter it in the record.

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General protocols

• 7. Document phone calls. Note doctor
  recommendations, patient questions or comments.
  Follow up should also be noted.
• 8. Document patient education offered or
  provided. Note instructions given about lifting,
  sleeping, or exercise.

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General protocols

• 9. Outside test results should be noted. Initial
  a report received from an outside MRI or other
  exams. Note when you discuss results with the
  patient.
• 10. Dont leave blank spaces on the page. Adding
  entries at a later time is unacceptable unless
  accurately dated. Dont leave yourself open to
  accusations of doctoring the records.

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General protocols

• 11. Entries must be signed. Dont sign for
  someone else.
• 12. Records must be written in ink. Go ahead and
  invest in a pen, its a business expense. Pencils
  are fine in 3rd grade, but not for documentation.

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General protocols

• 14. Record patient comments about concurrent care
  with other doctors. Also document your attempts
  to receive information from other providers.
• 15. Use standard abbreviations, or construct a
  glossary of your own symbols.