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Documenting During COVID-19 - What You Need to Know

In today's crisis environment, things are constantly changing. One thing that should remain constant, however, is your thorough, accurate and timely documentation.

As a doctor, it’s only natural to want to help your patients attain their best health status. But this has been a challenge as a result of state restrictions on providing chiropractic care at the office and patients who are self-isolating to avoid catching the virus.

That’s why many medical professionals have been consulting with patients outside of the normal practice setting and through nontraditional means.

Documenting the Nontraditional

Many doctors, for example, are using video, phone, email or text messaging to advise patients about their past or present health concerns, proper nutrition and exercises. As well-intentioned as these efforts may be, what can happen is that proper documentation gets shortchanged, putting the doctor and the doctor’s practice at risk.

Keep in mind that you should use the same standards for documenting clinical advice, continuity of treatment and informed consent discussions that you would use in your office. Patient interactions are supposed to be part of the chart, and in some states, they could be deemed to include electronic messaging, such as text messages. If you are not uniform in which messages you keep and which ones you delete, it could also give rise to an argument that certain messages were intentionally deleted.

Additionally, HIPAA and state scope of practice requirements are at play, so make sure to maintain proper protocols and keep patient privacy paramount.

Especially with electronic communication, such as texting or email, there are some limitations you should recognize, which include:

  • You will not be able to hear the patient’s tone or voice inflections and may misinterpret their intentions.
  • You cannot see the patient’s body language or other nonverbal communication.
  • You may not be as careful about what you say and how you say it as you would be in person at your practice.

After a Gap in Care

As a result of COVID-19 restrictions, many of your regular patients may be returning after a gap in care. With a new patient, you have certain protocols you follow. However, the issue can become a bit trickier if the patient has a lapse in care due to COVID-19 restrictions.

Consider that things may have changed with the patient’s health, medications or other areas, Depending on how long it has been since you last saw the patient, it may be advisable to follow the protocols you would use with a new patient with any patients you see after a gap in care. This may include:

  • Taking a complete history and performing a thorough examination of the patient’s subjective complaints.
  • Assigning a working diagnosis to that patient’s condition.
  • Developing a treatment plan and determining if you feel the patient would still respond to the treatment in which you are trained. If not, refer the patient to an appropriate specialist.
  • Obtaining the patient’s informed consent after discussing:
    • The nature of the treatment to be rendered
    • The material risks associated with the treatment and the possibility that those risks will occur
    • Alternative treatments available and their associated risks
    • The risks of not being treated
  • Properly documenting all of the above, as well as charting the patient’s complaints in the SOAP notes. Without a contemporaneously made record, there is no proof of anything—and make no mistake, people remember things differently, which could become an issue if there is a later concern about your care.

Beyond the Patient Encounter

Recent board complaints have alleged that some doctors are not adhering to the various jurisdictional pandemic guidelines (e.g., shut down orders). Thorough documentation relating to the practice’s administration may help in the doctor’s defense. This includes documenting any:

  • Staffing/duty changes
  • Changes in policies, procedures and advertising—and the rationale behind these decisions
  • Technical problems, such as computer crashes and power outages, and the need to use other devices as a result

Benefits for You—And Your Patients

Even with existing patients, it’s important to take all the necessary steps and to not let your guard down, especially during times of crisis. Your goal should be to provide the best clinical care and documentation possible. As a bonus, your patients will see you as a thorough and caring doctor—a doctor they’ll want to reward with their loyalty.

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