Editor's Note: Part 1 of this article appeared as a digital exclusive in the December 2018 issue.
Standard of Care and Documentation (Cont.)
I save (print and scan in file) all emails and texts to and from patients regarding any recommendations of care, follow through of therapies, and especially urgent or emergency care recommendations. I saved 33 emails and texts from one patient over a three-day period (while teaching this very same topic out of town), which showed my compassion, communication, decision-making mindset and clinical documentation.
All of my clinical documentation, SOAP notes, treatment notes of three months, emails and texts were reviewed (subpoenaed) by all parties involved. I was not sued, but the MD involved from another facility was. The case was settled in less than 11 months. *Many claims can take between 4-6 years.)
After I take the simple initial lateral view in this typical sample scenario, I would do a report of findings explaining the results. This usually encompasses C5-6 mild to moderate degeneration or lower lumbars, osteophyte spurring, spondylolithesis (ligament laxity analysis, which is quantified per AMA guides), desiccated or diminished disc space.
During the ROF, I always correlate the patient's symptoms with the X-ray, give a treatment plan for the next 1-4 months, and my mindset of ordering an MRI to further diagnose the discogenic lesions involved either in a period of time (number of visits) without seeing clinical results or asap. I tell the patient that the MRI will tell us how many discs are involved and how severe the discs are. In addition, the MRI will tell us if there are any curve balls involved, such as severity of disc lesions (migrating or worse) that I would not typically expect in these types of cases.
After I get the MRI, we will correlate the symptoms with the discogenic levels involved and decide on a second-opinion referral to help us out with breaking the inflammatory cycle (and another doctor with another set of eyes to optimize your patient's success). Then the treatment begins if the patient and I are on the same page.
Paper Trail: Key Recommendations
But wait, we are not done. We need to document the initial exam and patient's file for our paper trail, especially if the patient never comes back to our office for follow-up care. From all my reviews of case files and my trial experience with court testimony, I have come up with some suggested recommendations that will help with clinical competency and patient care. My suggested recommendations (when necessary depending on the patient's file, and case scenario) are the following:
1. Explain the patient's current condition utilizing spinal models, the patient's X-rays, current symptoms, treatment options, diagnostic recommendations to further analyze the patient's condition, and follow-up with primary / ortho / surgical consult for further evaluation.
2. X-ray studies of the lumbar and cervical regions are medically necessary based upon signs, symptoms, and patient presentation to rule out instabilities, degeneration and osteophytic formations. Stress views are recommended if indicated by initial set of lateral views to quantify instability (document when necessary).
3. MRI studies of the lumbar and cervical regions are medically necessary based upon signs, symptoms and patient presentation to rule out disc herniations in 4-8 consistent visits or asap. [I recommend selecting an avenue (time frame) when you are ordering advanced imaging based on symptoms, patient presentation, history, etc.]
4. Recommend second opinion for evaluation (possible injections, further diagnostic testing) with ortho, surgical consult, or primary based upon symptomatology and patient consultation with initial X-rays and current MRI findings.
Your Best Defense: Great SOAP Notes
A defense attorney I have multiple cases with tells me constantly, "The best defense I have to walk into court with is competent, complete and legible SOAP notes from the doctor." The four SOAP note recommendations above will aid in showing medical necessity, your decision-making mindset, your clinical expertise, and your patient's well-being.
At the end of the day I want to provide competent and compassionate care to increase the credibility of our profession, decrease liability in our practices, and increase clinical excellence in our communities.
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
