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Doctor and patient

4 Must-Knows About Documentation

After a grueling day, it can be easy to fall behind on your charting. It's tempting to get it done as quickly as possible to focus on other business or personal commitments. But in today's environment of high patient expectations and increased regulatory scrutiny, shortchanging your documentation duties is not a wise move.

Remember, your note is your patient’s story, helps with the continuity of care, aids in patient safety and can provide a legal safety net. The following strategies can help make your documentation more timely and accurate.

The Basics

The initial visit note should be the most thorough and include the following components:

  1. History of Present Illness (HPI)—If there is a gap in care, it may be advisable to follow new patient protocols as the patient’s health or medications may have changed
  2. Review of Systems (ROS)—Any notes taken a few days later probably won’t need a complete ROS as the patient’s status probably wouldn’t have changed significantly
  3. Physical Exam (PE)—A full exam generally is not needed at subsequent visits, but you should evaluate the treatment to make sure it’s still appropriate
  4. Clinical Decision Making (CDM)—Develop a plan during the first visit, and carry it out and update it as needed

These components combine to tell the story of your patient encounter and support the final diagnosis. Therefore, avoid inconsistencies between sections, consider using a legend if needed and proofread the document before signing it, especially if someone else generates some of the chart.

HPI

The HPI should contain as much detail as possible about any relevant factors that brought the patient to you. This can be an exhaustive set of details and figuring out what to include may be tricky.

Tailoring the questions you ask will take some practice, but with time, it will become automatic. Quoting the patient is helpful and helps personalize the note. For example, knowing specific details about their back or neck pain is important.

Therefore, the HPI should include the important information on why they came in to see you, including:

  • What are their symptoms and how long have they had them?
  • What alleviates the symptoms, if anything?
  • What makes the symptoms worse?
  • Have they had these symptoms before, and if so, what was the cause?
  • What have family members or other health care providers told you about the patient?
  • What is the patient’s clinical, surgical or family history?
  • Do they have allergies?
  • What medications do they take? Over-the-counter medications, vitamins and supplements are important, too.

Along with the pertinent positives, it is important to include the symptoms the patient does not have. These are the pertinent negatives, which are exceedingly important to include in your record. Pertinent negatives show the reader you thoughtfully considered other processes and procedures as the root cause of the patient’s chief complaint.

Both pertinent positives and pertinent negatives help generate a differential diagnosis—a list of possible causes of the patient’s illness or injury, without specifically spelling them out.

ROS

ROS represents symptoms the patient has and does not have in organ systems outside of the one associated with the chief complaint. A good record will include all clinically relevant systems, which may be just a few but could include ten or more. On the surface, this seems time consuming. However, simply asking the patient about their symptoms and documenting their answer, even if it is “no problems,” completes this task.

A strong chart note specifically outlines what you asked and how the patient responded in both the HPI and the ROS. As an example, the elusive spinal epidural abscess or cauda equina syndrome diagnosis is “missed” or undiagnosable 50 percent of the time during a patient’s initial clinical encounter.

If you ask about and document the lack of risk factors and specific ROS features for this disease, the reader will know that you thought about this diagnosis and did not find it. If you leave these details out, you may be in a difficult position in any subsequent litigation.

PE

The PE should be fairly straightforward. It is what you found when you met, looked at and examined the patient. Be objective, specific and concrete. When possible, quantify your findings by citing specific numbers or ranges.

More complex chief complaints require a more complete PE. The PE should include both specific positive and negative findings and not simply be listed as “negative” or “normal.”

Pertinent negative PE features are just as important as pertinent positive findings. This helps augment what you have been doing so far in the chart—developing a differential diagnosis. You are telling the reader, without specifically spelling it out in a differential diagnosis list, what you believe the patient has and what you believe the patient doesn’t have.

During litigation, some doctors have testified that by not noting anything in the records, they meant that the finding was negative. This incorrect approach to negative findings may lead to documentation being scrutinized, potentially creating a challenge for the defense.

CDM

The CDM is a summary of the patient encounter: What was done while you interacted with the patient and what you believed was the cause of the chief complaint. It is fairly common to not know what the patient has despite your best efforts. You may have obtained multiple tests on the patient and still don’t know.

Regardless, your CDM should fully explain your rationale for your conclusion or lack thereof. It must include your planned treatments and your interpretation of any obtained tests, especially abnormal ones. This is where you outline specific considerations and the differential diagnoses and conclude the story told by the HPI, ROS, PE and testing. 

Make sure to note the patient's response to the treatment. For example, did they feel better, worse or the same as a result of treatment? This important detail can be helpful to your defense in any litigation. 

The CDM should also include a specific follow-up plan and the reasons for the patient’s return. Prior to leaving your care, your patient should have clear idea of what will happen next. Address any questions from the patient and/or family member and note them in the chart. Clearly indicate their understanding of your instructions. The education you provide promotes recovery, helps prevent recurrence and aims to manage the condition for optimal health.

Consider additional documentation for other patient encounters such as adverse events, informed consent, informed refusal, nonadherence, telephone calls, disruptive or abusive patients and telemedicine visits.

For adverse events, document the relevant facts and the care rendered. Be factual and objective; avoid self-serving remarks.

To avoid allegations that you misguided or misinformed your patient during the informed consent or informed refusal process, consider documenting:

  • The mental status of the patient
  • The patient’s reasons for providing or refusing consent
  • Patient questions and your answers (use quotation marks when possible to record the patient’s actual statements and questions)
  • Your evaluation of the patient’s level of understanding, based on their questions
  • Your responses and confirmation of the patient’s understanding

With informed refusal, include the specific treatment refused, names and relationship of people witnessing the refusal, your encouragement to pursue recommended treatment and the consequences of not following healthcare advice.

When documenting nonadherence, include details of your discussion, the patient’s stated reason(s) for nonadherence, the teaching you provided about the treatment plan, possible consequences of nonadherence, treatment plan changes made to improve adherence and your communication with other healthcare team members regarding the patient’s non-adherence. Objectively document any nonadherent behavior.

Is Call Documentation Any Different?

Clinical telephone calls are part of a chiropractic practice. Providing sufficient details in the documentation helps the reader have a clear understanding of the reason for the call and how it was handled. Call documentation should include:

  • Date and time of the call
  • Name of person calling
  • Reason for the call
  • Advice provided (and by whom)
  • Patient’s understanding of the call

In cases of abusive callers or abusive or disruptive patients, objectively document the circumstances surrounding the incident. Use direct quotes when you can. Document what you advised the patient about the exhibited behavior and its consequences.

Documentation: Your Best Defense

A complete and accurate chart for every patient is the only way to tell your full story of the interaction and what you believed was the cause of the patient’s symptoms. Remember documenting negative finding is just as important as documenting positive findings.

All told, if you are ever faced with a legal matter regarding your care, a strong clinical record will be your best defense.


Authors

This article was based on an article written by Veronica Brattstrom and Dr. Cory Vaudt with chiropractic edits provided by Evan Gwilliam, DC.

Veronica Brattstrom

Veronica Brattstrom is a senior risk management consultant for Professional Solutions Insurance Company and has provided consulting services to healthcare professionals for more than 20 years. She received her bachelor’s degree from the University of Illinois at Chicago and her master’s degree from the University of Illinois at Champaign.

Dr. Cory Vaudt

Dr. Vaudt is a board-certified emergency medicine physician, who has been practicing in this specialty for 15 years. He is the medical director for a three-helicopter service and an EMS intra-hospital transfer service in Iowa. He is also has served as a medical malpractice expert witness for several law firms in the Midwest.

Dr. Evan Gwilliam

Dr. Gwilliam has a passion for documentation and coding. He is clinical director for PayDC Chiropractic Software, graduated from Palmer College of Chiropractic as valedictorian and is a Certified Professional Coding and ICD-10 Instructor, Medical Compliance Specialist and Certified Professional Medical Auditor. 

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