The importance of accurate charting rests within the chiropractic report of findings: the discussion regarding how your clinical findings relate to recommended treatment. The U.S. Office of Inspector General (OIG), a department within U.S. Human Health Services, not only investigates healthcare fraud, but also offers healthcare compliance program guides. OIG publishes special healthcare fraud alerts, influential to a state’s regulatory professional licensure boards.
For example, one OIG advisory opinion concerns copy-pasting, which allows users to select information from one source and replicate it in another. When healthcare providers copy-paste, but fail to update or ensure accuracy, inaccurate information may enter a patient’s health records. (OIG identified a potential risk whereby some EHR technologies auto-populate fields using templates built into their systems.)
EHR templates may properly record examination findings, but the DC’s professional opinion should be a separate, charted discussion, not a templated one. This can be satisfied by the use of a separate headnote labeled, Discussion to Acknowledge the DC’s Ethical Obligation, while submitting factual information to the patient's legal advisers and other nonmedical parties. The medicolegal case study below offers an example of an appropriate clinical discussion that should be included in the patient’s record.
A Medicolegal Case Example
History: A 44-year-old male delivery carrier employed 20 years, presents with a cumulative / chronic history of lower extremity pain-numbness and recent-onset low back pain attributed to work-related injury. Over time he also developed pain in the ankles / feet prior to a first diagnosis of plantar fasciitis with heel spurs. Obtained podiatry specialty exam, failed conservative therapy cortisone injections, physical therapy, and custom orthotics.
Surgical history includes 2013 right plantar fasciitis release and heel spur-shaving. Routine use of replacement custom-molded ankle-foot orthotics. Ankle / feet complaints with daily pain, stiffness, numbness (severity 3-4); reports “warm” sensation in right ankle. Aggravated by walking or running at work. Heel pain precipitated by recent increase in work-related weight-bearing activity. Interference daily when walking outdoors on flat ground. LBP localized, severity mild; denies pain to midline or paresthesias.
Functional Capacity Intake: Lower Extremity Functional Scale (LEFS) scores: 40% ADL interference during the past week, mildly swollen-stiff, moderately painful when walking on flat surfaces, and mild pain going up or down stairs. Pain drawing depicts lumbar facetal, paraspinals; none to midline spine. ADL 25-item questionnaire reveals hindrance to daily activities; inability to achieve restful sleep; pain when standing on toes (e.g., to reach overhead shelf) and ankles / feet; and sharp pain during recreational hiking.
Examination: Well-healed surgical scar (3-inch) right heel medial. Antalgic limp, shortened, asymmetric stance with external orthotic devices. Gait stride length shortened. Palpable right medial plantar arch. Right plantar medial heel pain on plantar stretch test. Left foot pain along medial longitudinal arch, retrocalcaneal medial and lateral aspect. Right post-operative foot painful light touch at rear calcaneal, and sole plantar arch. Moderate palpatory plantar fascia adhesions.
Single right-leg stance needs wall assist, a proprioceptive disorder. Full-motion pain upper limit of motion. Spinal sensory dermatomes normal at legs, ankles and feet. Tinel’s sign for tarsal tunnel negative. Motor grade 5/5. Vertebral listings L4-5, sacroiliac pelvic. Lumbar motion symmetrical, moderately reduced, sensory-motor intact. Special testing absent any radicular patterns.
Discussion (Objective Findings)
Chiropractic lumbar spinal adjusting and extra-spinal joint manipulation to break up facetal and planter adhesions. Findings support referral consultation for potential right surgical revision.
Right Baxter’s nerve entrapment lies within reasonable medical probability; MRI is required. Below the plantar fascia, between muscles of the foot, is a first branch of the lateral plantar nerve called Baxter’s nerve (aka inferior calcaneal nerve). The nerve controls an intrinsic foot muscle and sensory area of the foot.
Baxter’s neuritis can be misdiagnosed as plantar fasciitis but serves as its differential. Today’s exam finds functional loss on activity. Differentiated from the usual initial weight-bearing pain seen in plantar fasciitis. Baxter’s commonly presents with pain on increased activity, paresthesias, and sharp/ shooting pain. It is reproducible along the medial heel, as opposed to the plantar medial arch.
Conservative treatment is much the same as with plantar fasciitis; but if conservative care fails, surgical nerve decompression is considered the procedure of choice according to the medical literature.
Today’s sensory was intact, however, inconsistent with a lumbar dermatomal pattern; yet a warmth paresthesia sensation. History of post-operative right foot plantar fascia release and shaving off the retrocalcaneal spurring. Exam found reproducible sharpness to the post-operative foot at the medial heel and shortened gait pattern – doubling the potential for progressive worsening on the contralateral left limb due to compensatory efforts.
There is loss of function, inability to balance on the post-op foot without holding onto something for support (proprioception interference), and difficulty standing on toes reaching for a top shelf per ADL 25- item questionnaire.
The patient’s work history involving prolonged walking, and his current status, raises suspicion of a plantar aponeurosis issue, as it is extremely susceptible to injury from overuse activities. Heel spur formation has long been associated with the proximal plantar fascia, but the spur growth is deep to the plantar fascia and lies within the origin of the flexor digitorum brevis muscle, an intrinsic foot muscle that plays a pivotal role in the foot's biomechanics.
Centrally located within the sole of the foot, the digitorum brevis muscle acts mainly to flex the middle phalanges of the second to fifth toes. Its functionality has significant implications for a patient’s gait effort, balance and various foot-related activities.
The midtarsal / midfoot is located proximally to the forefoot and is comprised of five bones: three cuneiforms, navicular and cuboid. This contributes to the foot’s stability during various phases of gait to transfer load throughout the body.
The rearfoot consists of the talus and calcaneus. The subtalar joint is instrumental in stabilization. Today’s intake records stiffness to both ankles and necessitates obtaining AP weight-bearing ankle radiographs to measure loss in joint interval spaces (i.e., degenerative joint disease).
Practical Takeaway
Charting the clinical discussion regarding the above opinions should provide clarity relative to the patient’s situation and recommended chiropractic treatment; as well as other conditions that necessitate referral for MR, ankle X-ray imaging and surgical consult.
Resources
- Donovan A, et al. MR imaging of entrapment neuropathies of the lower extremity, part 2. The knee, leg, ankle, and foot. RadioGraphics, 2010; 30:1001-1019.
- U.S. OIG advisory opinion on copy/paste use in electronic health records. (Note: OIG advisory opinions are an important resource for other risk management and compliance guidance.)
