Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT
We all know that most patients come to us for some pain complaint: neck pain, back pain, sciatica, carpal tunnel, etc. We also all know that acupuncture is a great first-line care for these issues, as well as supporting overall health and wellness. For many providers, the problem is not in getting the patient better, but in knowing what to do when the patient does feel better.
The unfortunate reality today is that many patients define their need for care by what their insurance covers. I will never suggest that you limit your care to the narrow scope of some insurance limitation – arguably, that path only allows insurers to "control and eliminate" treatments just by decreasing the parameters of coverage. But sometimes, John Q. Public only wants a service if his insurance approves it. It is our responsibility as physicians to review an appropriate care plan with a patient, regardless of their coverage – at that point they may elect for some or all of your recommendations. What you recommend to a patient for care may reasonably be very different from what the policy coverage allows, or what the patient even expects. Your care plan should never be defined by a third party policy, but the treatment you ultimately provide might be.
As a care plan progresses, one would expect that a patient feels better. Just because someone feels better does not automatically mean that they are better. There are plenty of medications that can make someone feel good, but that doesn't mean it is the right choice – good care goes beyond just the "feel good." When reviewing the stages of healing, remember that as the acute phase resolves, often the pain will, too. Stopping care at this point is rarely advised. Often, the patient needs further care to stabilize function and rehabilitate the compromised mechanics. I usually explain to a patient that if I make them feel better today, but the pain comes right back tomorrow, then I have not really helped them at all – I need to make them feel better today, then make sure that the problem does not recur. This needs to be discussed with the patient up front, at the beginning of care while they still have pain. If the whole focus from the outset is the resolution of their pain, then they have not understood the bigger picture – when they feel better, they will assume their care is done.
It is the provder's responsibility to fully document all aspects of the case – the initial consultation, case history, examination findings, care plan, treatment rendered, and the response to the care rendered. Follow-up evaluations should review these findings, note the changes in the patient's condition, and discuss appropriate modifications to the care plan. The normal standard of care for follow up evaluations is every 12 visits. If a patient has not returned for care in more than 90 days, and then comes back in for treatment, it is also reasonable to perform at least a cursory file update – even if their complaints are exactly the same.
Often, insurers will base a decision to deny care solely on improved pain scores. In my experience, this is often because the provider has not accurately documented any other objective data to support the care rendered. The patient's record, examinations and SOAP notes, should include more than just a subjective notation of pain level (the 1 – 10 scale). Improved pain scores are a good sign, but are not a valid indicator of the patient's condition – activity, medications, therapies, and even the weather are all variables that can impact a pain level. The notes must include good objective documentation of the patient's changing status as well. Orthopedic testing, palpatory assessment, motion palpation, ADL questionnaires, and functional capacity tests are important measures that can show improvement with treatment, but can also show that there is still irritation or limitation that needs treatment. Other good objective measures could be improved motion, less medication, increased activity, or even a decrease in your treatment frequency.
It is also important to notate other information regarding the patient's case in general. Other physician evaluations or recommendations, diagnostic testing, and parallel care should also be noted. If the patient has a significant life change – a move, a divorce, a new job – these are also factors that may affect their response to care. Certainly, if there is a new exacerbating injury – an MVA, a slip and fall, an injury at home or while playing weekend sports – these are also worthy of note and will show a need for further care, or validate the need for a new course of care. Any of this information must be noted in the patient's record at that time – not retrospectively at some later date. The notes should always be contemporaneous with the patient's status – notes after the fact give the impression that the provider is not well organized and does not have a good handle on the patient's care.
I have written before, there is a standard of care in this country that is clearly defined. It is dangerous to think that because we are acupuncturists, we do not need to keep records to the same degree as medical doctors do. We must think outside our own bubble – in terms of healthcare in general. Ultimately, it is the patient that we take care of - not the insurance companies, attorneys or other doctors. Recording a subjective improvement in pain is good, but documenting objective improvement with your care is necessary. Whether or not you feel obligated to document your case- responsible patient care mandates it. Acupuncture deserves every bit of respect that any other health profession does, but that respect comes with a level of responsibility. Yes, it is a pain; yes, it takes more time – but like it or not, documentation paperwork is part of professional healthcare.
References:
Iyer, P, Levin B, Medical Legal Aspect of Medical Records, 2nd Ed., Vol II: Clinical Specialty Records. Lawyers & Judges Publishing Company: Tucson, AZ 2010, Chapter 1.
Clinical Documentation Manual – Clinical Documentation Essentials for Doctors of Chiropractic. 2nd Ed. American Chiropractic Association. Arlington, VA 22209.
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