Documentation & Record-keeping FCLB Annual Conference May 4, 2007 Kirk J. Shilts, D.C.

2 Standards of care 1° - state and federal Statutes & Regulations - state Board guidelines 2° - Info. taught in accredited institutions 3°- What is actually practiced in the field licensing Boards have the responsibility to establish record-keeping standards and educate their licensees on them!

3 Research Data  50 States, 4 no websites available  46 States, 22 have Statute or Regulation that specifically pertains to record-keeping: 48%  46 States, 2 have (non-enforceable) record- keeping guidelines: 4%

4 Statistics OIG report:  94% of claims had missing information  26% had no evaluation  29% had no diagnosis  67% did not show medical necessity

5 Patient record should: “accurately reflect the nature of the problem and the care provided” contain information that justifies the examination, diagnosis, and treatment contain information that supports the clinical necessity of care

6 Patient record should: contain the nature of the presenting problem to differentiate between condition-based care vs. wellness based care

7 seat belts steering wheel engine A patient record is like a car, it has essential component parts transmission tires fuel tank

8 registration age of operator change oil A patient record is like a car, it has essential rules & maintenance speed limits tire pressure gasoline

9 Records content 4 Doctor’s name 4 Patient’s name 4 Patient’s DOB 4 Patient’s gender 4 Date of entry

10 Records content, initial work-up 4 Patient complaint: 4 History: medical, social (occupational), family, & ROS 4 Physical Findings: exam, test results, imaging, ortho/neuro, spinal ROM-function, etc. 4 Diagnosis: 4 Treatment Plan: procedures anticipated, any supportive procedures, short/long-term goals

11 Records content, initial work-up 4 Prognosis: expected outcome within specified temporal parameters 4 Home instructions: any referral 4 Informed Consent: benefits, options, & material risks (documentation of this discussion)

12 Records content, daily follow-up 4 SOAP format (“P” includes plan & procedures) 4 Progress to care: 4 Descriptions of aggravating occurrences: 4 Procedures performed: 4 Periodic reassessments: work status 4 Modification to the plan: 4 Actions by ancillary staff : who & what done?

13 Records rules & maintenance 4 Legible 4 Contemporaneous 4 Reliable and accurate info. 4 Free of irrelevant/ unnecessary info.

14 Records rules & maintenance 4 Security policy: held in safe and secure manner, a back-up system of electronic records 4 Privacy policy : confidentiality of info. 4 Retention policy: 5?, 6?, or 7-years?

15 Records rules & maintenance 4 Access policy: who has access?, how quickly are the records released 4 Ownership policy: treating doctor?, clinic? 4 Amending of records policy: how corrections/ addendums are recorded

Kirk Shilts, D.C. Massachusetts Board of registration of Chiropractors