Documentation Guidelines February 2018– NYCC Health Centers

This document is to be used as a guide for proper documentation and in conjunction with the

File Review process by both students in the DCP and by clinicians as it relates to quality

assurance. This guide describes proper documentation and location details that are expected in

the SmartCloud EHR. Paper SOAP notes and other documentation items are expected to be

present within the patient’s case file in a similarly organized system. For evaluation and

mentoring purposes, the draft version of SOAP notes submitted by chiropractic students should

be utilized. [In SmartCould, the student’s SOAP note submissions can be viewed by using the

“View Document History” function.]

Contents 1) Privacy practice ............................................................................................................... 3

2) Problem list – The Problem Oriented Medical Record (POMR) ................................ 3

3) Patient history .................................................................................................................. 4

4) Clinical Examination ....................................................................................................... 6

5) Diagnostic testing and diagnostic imaging .................................................................... 8

6) Diagnosis .......................................................................................................................... 8

7) Informed consent ........................................................................................................... 10

8) In-office treatment plan (Patient Care Plan) .............................................................. 13

9) Self-care recommendations / Home Care recommendations .................................... 14

10) Treatment goals ........................................................................................................... 15

11) Outcome measurements .............................................................................................. 16

12) Progress notes .............................................................................................................. 17

13) Patient response to care per formal assessment of patient progress ...................... 18

14) Management plan modification ................................................................................. 20

15) Documentation supports billing ................................................................................. 20

Appendix............................................................................................................................. 21

Privacy practice – details .................................................................................................. 21

Example of an executed Report of Findings (ROF) and Informed Consent (IC) form:

............................................................................................................................................. 21

Patient history – details ....................................................................................................... 25

Clinical examination – Objective Speed Note example: ...................................................... 26

Clinical examination – Examinations page example: ........................................................... 26

Clinical examination – Physical Exam page example: .......................................................... 27

Patient Care Plan (Case Types) ............................................................................................ 27

Example patient care plan in SmartCloud: .......................................................................... 34

Progress notes – SmartCloud Plan Speed Note ................................................................... 36

Discharge documentation: .................................................................................................. 37

In-office treatment plan – details ........................................................................................ 37

Self-care recommendations - details ................................................................................... 37

Treatment goals – details .................................................................................................... 38

Outcome measurements - details ....................................................................................... 40

Revised Oswestry Back Pain Disability Questionnaire ....................................................... 41

Management plan modification – details ............................................................................ 42

Documentation supports billing – details ............................................................................ 42

1) Privacy practice The patient privacy verification is located on the back of the patient registration packet. The

HIPAA Notice of Patient Privacy Practices may be provided to the patient upon request, unless

emergency conditions make it impossible (the latter should be documented). The privacy

verification should be signed by the patient on the first day they present to the health center

and scanned into the patient record in the EHR. A form not dated the first day or signed by the

patient (or a form not present at all) is a clear deficiency.

Click here for detailed privacy practice information

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2) Problem list – The Problem Oriented Medical Record (POMR) POMR is a method of recording data about the health status of a patient in a problem-solving

system. The POMR preserves the data in an easily accessible way that encourages ongoing

assessment and revision of the health care plan by all members of the health care team. The

particular format of the system used varies from setting to setting, but the components of the

method are similar. A data base is collected before beginning the process of identifying the

patient's problems. The data base consists of all information available that contributes to this

end, such as that collected in an interview with the patient and family or others, that from a

health assessment or physical examination of the patient, and that from various laboratory and

radiological tests. It is recommended that the data base be as complete as possible, limited only

by potential hazard, pain or discomfort to the patient, or excessive assumed expense of the

diagnostic procedure. The interview, augmented by prior records, provides the patient's history,

including the reason for contact; an identifying statement that is a descriptive profile of the

person; a family illness history; a history of the current illness; a history of past illness; an

account of the patient's current health practices; and a review of systems. The physical

examination or health assessment makes up the second major part of the data base. The extent

and depth of the examination vary from setting to setting and depend on the services offered

and the condition of the patient. The next section of the POMR is the master problem list. The

formulation of the problems on the list is similar to the [assessment section of the SOAP note].

Each problem as identified represents a conclusion or a decision resulting from examination,

investigation, and analysis of the data base. A problem is defined as anything that causes

concern to the patient or to the caregiver, including physical abnormalities, psychological

disturbance, and socioeconomic problems. The master problem list usually includes active,

inactive, temporary, and potential problems. – An excerpt from Mosby's Medical Dictionary, 9th

edition. © 2009, Elsevier.

See sample Problem List

3) Patient history An appropriate, structured, complete history should be obtained and recorded at any clinical

evaluation. Every clinical evaluation history should include:

- Items relevant to the chief complaint and problems revealed during the evaluation

- A review of medical, social, and family histories, appropriate to the complexity of the

complaint and patient; each element should be noted

- A review of relevant systems

Various mnemonics are used to represent the “core” components of a patient history, some

more common to specific regions or disciplines. These include:

OPQRST (onset, provoking/palliative factors, quality, radiation, site, temporal factors

LMNOPQRST (location, mechanism or medical history, new symptoms, other symptoms,

provoking/palliative factors, quality, radiation, severity, timing)

SOCRATES (site, onset, character, radiation, alleviating factors, timing, exacerbating

factors, severity).

While these can guide the taking of a structured, complete history, it is important that all

relevant information is obtained and recorded, not only regarding the chief presenting

complaint(s) (e.g. course/progression of the complaint, previous treatments and response to

SmartCloud Location: “Problem List” Page

The Problem List in the SmartCloud EHR is the starting point of the patient’s initial and subsequent SOAP

notes. Due to the functionality of the SmartCloud electronic health record, it is necessary to choose a

problem (an ICD-10 code) in order to introduce the subjective history of a patient concern. It should NOT

be considered the final diagnosis at this point since the highest level of understanding of the problem has

not been determined at this time. In order to standardize the entries in the EHR, the subjective

symptomatology should be entered by region of the body for musculoskeletal complaints. It is suggested

that the regional joint dysfunction codes should be used to enter the subjective description or history of a

problem for musculoskeletal complaints (M99.01 through M99.08). For visceral complaints, is suggested

that the general “unspecified” codes be used to start the note (i.e. the “R” ICD-10 codes). Once the

differential diagnosis or highest level of understanding of the patient’s problem is determined, it will be

entered into the problem list before the note is closed. When entering the problem in the problem list,

use one of the macros in the comment box to direct the reader’s attention to the regional area where the

subjective description is already entered and no further details are necessary. Non-musculoskeletal codes

such as hypertension (I10)and type 2 diabetes (E11) should be in the problem list, but not in the SOAP

notes as a treated condition.

CAUTION: Once an ICD-10 code has been entered in the problem list it can only be deactivated, it cannot

be deleted.

prior care), but also for other problems revealed during the evaluation (e.g. headaches indicated

on the systems review, an unreported surgical scar discovered upon examination).

For chief complaint history, review of systems, family history, medical history, and social history,

items should be relevant, obtained to sufficient degree to differentially diagnose, and recorded

in sufficient detail to inform future care and allow third parties to render judgment on standards

of care. Remember that SmartCloud has a separate system of entry for many of the past

medical history and family history items. This includes the Meaningful Use (MU) requirements,

including:

Allergies

Family history

Medications

Smoking history/tobacco use

Vital signs (although not technically history, the vital signs are entered here)

These items should be entered/updated and included in the SOAP note during an examination

visit. In addition, there may be problems that are complicated by or associated with these items

and need to be recorded in the problem list as such, i.e. hypertension, diabetes, etc.

It is also appropriate to report that “the patient reports no changes in family, past medical, or

social history” where these histories have been previously recorded. This statement should be

in subjective freeform section of the subjective speed note in the EHR (Paper notes will require

separate documentation). Remember that Meaningful Use (MU) reporting may require an

update in the patient record (Histories Section of the EHR).

SmartCloud Location: History Speed Note

SmartCloud has the commonly asked questions on the History Speed Note page as easy entry buttons. It

should be emphasized that these may not be able to portray the complete picture. There are both

complaint and subjective freeform tabs. It is necessary to enter information that completes the history of a

problem (in the complaint freeform tab) or general information that does not link to one of the problems

being evaluated (in the subjective freeform tab).

If the patient presents with more than one problem, then each problem needs a complete history unless

there is a reference to a regional or visceral code (see starting a note in “Problem List” above).

Whenever appropriate, a body diagram should be entered in the note with problem areas marked and

labelled.

This item is deficient if patient care documentation lack an appropriate, structured, and sufficiently comprehensive chief complaint, medical, social, and family history, and a review of relevant systems, all correctly documented. See sample history Return to the top.

4) Clinical Examination Clinical examination is necessary for all patients presenting to the clinic whether wellcare, health

clearance or symptomatic. The clinician in consultation with the chiropractic student will need

to decide the appropriate level of evaluation necessary to arrive at a working diagnosis. Further,

this examination should also be used as a risk management tool (similar to a pre-surgical

screening) so that any procedures we select in our treatment plan are safely delivered/modified

for the individual patient.

The examination must include minimal core components. Additional case specific components

that will relate to significant findings are warranted on a case-by-case basis. The case specific

examination will focus on the unique patient condition being examined that might not be

evaluated by the minimum core components. The clinician may direct the student to perform or

not perform specific exam procedures due to special circumstances unique to the patient both

for the core or case specific examinations.

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Minimal core components of the examination (must be performed on all new patient examinations and usually performed on established patient examinations):

Postural evaluation Spinal joint and soft tissue assessment

Spinal range of motion Spinal screening orthopedic assessment

Vital Signs – includes: o Ht., Wt., bilateral B/P, pulse, respiration and

temperature

Neurological assessment o Screening of motor, sensory and reflex

functions related to cervical/lumbar spine and upper/lower extremities

o Pathological reflex

The examination The clinician along with the chiropractic student must: a) Perform, interpret, and document appropriate clinical examination procedures. b) Order and use specific diagnostic tests when appropriate based on information obtained in the case history and other clinical examination procedures (see diagnostic imaging to review). c) Record a working diagnosis based on the highest current level of knowledge and understanding of the patient’s case.

Examples of inappropriate or unacceptable work that would indicate a deficiency:

1) Is not complete (missing key components necessary for diagnostic conclusion i.e.

orthopedic and/or neurological tests not present for a radiculopathy diagnosis)

2) Lacks essential core examination components for a clinical evaluation of a new or existing

patient – missing one or more of the following:

a) vital signs (includes height, weight, B/P, pulse, respirations and temperature) b) postural evaluation c) spinal ROM d) spinal joint and soft tissue assessment e) orthopedic assessment of the region (spinal screening) f) neurological assessment of the region (MRS) and other necessary assessment(s)

3) Lacks essential case-specific examination components – depending on the case, certain

exam procedures would be expected in order to determine the appropriate course for the

patient. Example: Low back complaint does not include evaluation of the abdomen including

auscultation of the abdominal aorta; or thyroid exam in a CTS case or weight issue.

4) Examination results are incompletely documented.

5) Missing/not documented

This item is deficient if essential core or case specific items are missing, or if the documentation of the examination is not clear or absent. See sample Clinical Examination Return to the top.

Case specific examination (determined by the history and area of the condition i.e. shoulder): o May require orthopedic and neurological exam of a peripheral joint/segment of the body.

o Detailed segmental peripheral neurological examination and peripheral vascular examination to

investigate complaints of tingling, numbness or weakness in an extremity.

o Cardiovascular, cardiopulmonary, lymphatic, and/or abdominal examination may be required.

o Specific physical examination procedures should be performed and evaluated when related to

the area of chief complaint.

o Record the results even when negative.

SmartCloud Location: The examination information should be documented in the EHR:

1. Objective Speed Note page 2. Examination page 3. Physical examination page

Paper notes must contain the same elements.

5) Diagnostic testing and diagnostic imaging During each course of care, it must be determined whether or not a patient needs special

testing procedures. Additionally, if a patient has already had testing completed, results should

be requested and reviewed. These reports should be signed by the clinician and scanned into

the patient record. This information may be utilized as part of the diagnosis and management

plan. A summary statement should be documented indicating that the test results were

reviewed.

There are 4 possible outcomes:

1) imaging, lab work, or other special tests WERE critically required in management of

the case and WERE ordered

2) imaging, lab work, or other special tests WERE critically required in management of

the case, but WERE NOT ordered

3) imaging, lab work, or other special tests WERE NOT critically required in management

of the case and WERE NOT ordered

4) imaging, lab work, or other special tests WERE NOT critically required in management

of the case, but WERE ordered

This item is deficient if outcomes 2 or 4 above are indicated in the chart. Outcome 2

represents gross under-management (including ordering the wrong test with information

available at the time), and outcome 4 represents gross over-management. This item is also

deficient if documentation of the review of testing is not noted, management modification if

critically needed is not documented, or the results shared with the patient was not

documented.

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6) Diagnosis The diagnosis should be listed at the highest level of understanding. It should be supported by

the patient’s history and examination findings. The diagnosis should be clearly evident in the

patient file in at least 4 places and on the Patient Encounter Form. The diagnosis/es should be:

SmartCloud Location:

A summary of the results of the diagnostic testing (including the place, date and if appropriate, the reason

for testing) should be listed in the General Assessment section of the Assessment Speed Note. The actual

report should be scanned into the EHR and the summary should be present in the student draft note.

1) Written in plain and medically accurate language (not codes or abbreviations) on the

informed consent form for the patient. See informed consent.

2) Written in the header of the Patient Care Plan both the case type and ICD-10

diagnosis code numbers. See Case Types in appendix. The diagnosis codes should be

listed in the order used in the Plan Speed Note section of the SOAP note. Codes used for

billing should be consistent with the patient encounter form (routing sheet). [Note: In

order to be aware of possible complicating factors, the footer of the patient care plan

should also include all critical review of systems, comorbidities, or other relevant past

medical history findings as well as relevant family history.]

If the diagnosis lacks important elements related to the chief complaint, review of

systems, comorbidities, or other relevant findings, or if the diagnosis is inconsistent

with significant findings, is not a sufficient level of understanding (“radiculopathy, site

unspecified” or “headache” instead of “cervicogenic headache” when these are

indisputably clear), is not current (resolved diagnoses are still listed, or diagnoses that

have been refined in the SOAP notes have not been refined in the care plan), or is

missing, documentation in the chart is deficient.

NOTE: The case type should be listed as a type of ‘care plan’ to avoid student

confusion (a problem may have been present for more than 3 months, but is

being treated on an acute care basis, i.e. 3 visits per week for a period of time

with expectations of resolution in a relative short phase of care). The care plan

should be fairly consistent with the case type selected.

NOTE: A “wellness” case type (non-“medically necessary” elective and generally

non-third party reimbursable care) may have only subluxation diagnoses and

codes without secondary diagnoses and codes. No other case types should have

subluxation codes without secondary codes. There may be secondary codes for

wellness care, but it is not required for elective, wellness-orientated care. Non-

third party reimbursable problems need to be coded, for student management,

but not used in the billing. These problems should be evident in the adjustment

page of the SOAP note with the modalities used to address them (usually

student services and not the clinician’s).

3) Coded in the Plan Speed Note. The Plan Speed Note should have all of the diagnosis

codes entered that are in the header (these codes need to be within chiropractic scope

of practice). They should remain consistent from visit to visit until the problem is

resolved or there is a change, such as a diagnostic imaging revealing a finding or a new

problem arises.

4) Coded in the Problem List. The problem list will also contain any other non-

musculoskeletal conditions of note such as hypertension, diabetes, etc.

5) The Patient Encounter Form. The form also known as the “Routing Sheet” should

have the ICD-10 codes listed in the order for billing and consistent with the order in the

header of the Patient Care Plan and the Plan Speed Note.

Please refer to the case types document and case types decision tree for more detailed

information related to diagnosis.

Click here for example diagnosis in the Plan Speed Note Return to the top.

7) Informed consent Informed consent must be obtained for all diagnoses and procedures, but must particularly address “significant” risk procedures. The informed consent is obtain during the report of findings procedure. It requires documentation of any health risks and management options considering the patient’s health care needs and goals*. The diagnosis should be written out in plain language and highest level of understanding for the patient’s benefit. Including only diagnosis codes and/or abbreviations on the informed consent form does not meet NYCC guidelines. The SOAP note should indicate that informed consent was obtained on the same day it was received. The patient care plan should indicate that informed consent was obtained. The treatment and diagnosis should be consistent across the SOAP, the patient care plan, and the informed consent. The patient and clinician should sign the informed consent form. Any new diagnosis, added treatment modality, or significant risk would require obtaining a new informed consent. An informed consent must be obtained by a licensed provider. In order to train the student, the following procedure and SOAP note documentation is suggested: “the student discussed the report of findings and tenets of the informed consent with the patient while the clinician was present and the clinician confirmed that the patient understood.” The patient and clinician signature are still required on the informed consent form that is scanned into the EHR. *CCE 2013 Accreditation Standards – Meta competency Outcome 4.2 http://www.cce-usa.org/uploads/1/0/6/5/106500339/2018_cce_accreditation_standards.pdf

The Informed Consent process and definition as per the Association of Chiropractic Colleges:

a. Recognizing that all care including diagnostic studies and chiropractic care have some

potential for causing injury to a patient, it is the recommendation of the Association of

Chiropractic Colleges that, prior to performing diagnostic testing and prior to

implementing chiropractic procedures, the patient should be informed about the

SmartCloud location of diagnosis: 1. Problem list 2. Header of Patient Care Plan and in the ‘Problems’ line in the Care Plan 3. Plan Speed note 4. Informed Consent form 5. Patient encounter form (Routing sheet – not found in the EHR but same as Plan Speed Note)

material and inherent risks and common options to the recommended care and the

associated risks, including the risk of refusing care. If the patient wishes to continue

he/she should give his/her consent. The Doctor should have a record in his/her clinical

file documentation which confirms that consent was given by the patient to the

diagnostic testing and/or the chiropractic procedure.

b. “Informed consent" is more of a process than a documented procedure. The

Association of Chiropractic Colleges recommends that the Doctor engage in a thorough,

verbal discussion with the patient, thus enabling the Doctor to be in a position to verify

that he/she took the time to explain the material risks inherent in the recommended

procedures and that the patient consented. Beyond this, the Association of Chiropractic

Colleges recommends that the patient execute some document acknowledging that: (a)

he/she has been part of an informed consent process; (b) that the material risks have

been disclosed to the patient, including a description of those material risks; and (c) that

the patient, after assessment, has agreed ("consented") to the procedures

understanding any material risks which are inherent to that procedure.

c. Whereas it is beneficial for the Doctor to have notations in the clinical records

reflecting that the patient was advised of the material risks and consented to the

treatment, there is no substitute for the patient's written confirmation of those facts. It

is the Association of Chiropractic Colleges belief that the profession and the public

interest are better served by an occasional patient refusing to execute an informed

consent acknowledgment form as opposed to having licensed Doctors exposed to claims

of informed consent violations when, in fact, informed consent was secured but not

irrefutably documented and verified. It is the recommendation of the Association of

Chiropractic College's to document the patient's consent to both the diagnostic

procedures which the practitioner proposes to use, as well as to document the patient's

consent to the "patient care plan" which lists the patient's diagnosis and identifies the

particular procedures and/or modalities to be used.

Resource: ACC Policy - Informed Consent Guidelines

http://www.chirocolleges.org/resources/informed-consent-guideline/

Report of Findings (ROF) and Informed Consent (IC) process and documentation:

Indicators that initiate the need for an IC: Anytime there is a significant change in risk the IC should be obtained, signed, dated and noted on the date of the onset of care for a particular condition. As new complaints/diagnosis(es) arise requiring additional evaluation procedures or different care procedures additional informed consent(s) should be obtained from the patient and documented in the SOAP note(s).

Diagnoses or significant risk procedures in the SOAP or patient care plan that are not consented to in writing by the patient are a clear deficiency. -Return to the top.

SmartCloud Location: 1. The signed Informed Consent form is scanned into the EHR. (see sample IC form)

2. A statement is listed in the Assessment Speed Note, ‘General Assessment’ section indicating that

the patient understood and consented to the treatment plan, health risks, management options

considering the patient’s health care needs and goals (a macro is available for this statement).

3. In the Patient Care Plan, in the Informed Consent Obtained line, indicate “Yes” and list the date. Do

not delete prior dates if they exist.

The clinician or the student with clinician supervision is must discuss the following with the patient prior to rendering care. The report of findings will include: a) The clinical impression/working diagnosis(es) b) The management/treatment plan c) The risks and/or complications that may be apparent regarding the condition itself, or the treatment that may be given d) Any alternatives for the management of the diagnosed conditions e) The likely outcome of chiropractic care and management for the diagnosed conditions. After the patient is informed regarding the above items and related questions answered to his/her satisfaction, the clinician must obtain the patient’s consent to initiate treatment as evidenced by the patient’s and the clinician’s signatures on the IC form. The diagnosis needs to be written out completely. There should be no abbreviations or codes used. The record needs to include a properly executed document indicating that the informed consent has been obtained from the patient. The signed document is not sufficient. A statement in the SOAP note acknowledging that the patient has understood and agreed to the care plan is necessary. Remember that the diagnosis on the IC form must be consistent with the diagnosis listed in the SOAP note(s). The treatment being provided in the SOAP note(s) must be consistent with the treatment indicated on the IC form. These must both be consistent with the “Patient Care Plan.”

8) In-office treatment plan (Patient Care Plan) In the SmartCloud EHR, the In-office treatment plan is located in the Patient Care Plan page. The

Patient Care Plan should contain all the relevant information for the comprehensive

management of this patient including all treatment modalities and specifics of who delivers

these modalities. In addition, all recommendations and factors that are needed to properly

manage the case should be found in the Care Plan. This includes recommendations for lifestyle

changes, exercise, nutrition, wellness and tracking of co-morbidities such as diabetes, and

hypertension. Collaborative care and/or referrals should also be noted here. There should be

dated ongoing notations tracking these recommendation or referrals. Nutrition handouts, rehab

exercise handouts, patient education handouts and/or any correspondence or notes need to be

documented and tracked as part of the plan.

The plan: - Must not have treatment in areas of contraindications (such as manipulation of an

anticoagulated patient whose INR is outside of therapeutic range or joint manipulation

for patients with cancer),

- Must be related to the diagnosis (there should not be a plan for lumbar manipulation

for a patient with acute cervical torticollis),

- should provide expected benefit to the patient

- Must specify parameters (this must include specific location, parameters, settings,

duration, treatment frequency and who applies the modality – clinician or student).

- Must have a planned assessment of patient progress (distinct from the plan end date

– these might be the same date, but there should be a planned assessment of patient

progress noted.

- Would promote patient dependence rather than work towards patient self-efficacy,

(grossly excessive treatment frequency might be an example).

- Needs to include all of the procedures used during treatment in the SOAP note,

- Must include treatment that is appropriate for all chiropractic scope diagnoses and

consistent with the overall patient presentation as well as any treatment/modalities

used by the student for non-billable conditions/problems.

- Includes all management for non-billable or non-musculoskeletal conditions. These

plans may be for conditions that require tracking of collaborative care, referral or

specific outcome measures.

Note: NYCC uses the language “assessment of patient progress” while Smart Cloud indicates “Re-

examination” in the Patient Care Plan. The SmartCloud line labelled “Re-examination” should be the

location of the date of assessment of patient progress and what outcome measures are to be utilized.

Each patient’s case will be unique, but all problems should be addressed. Student draft versions of SOAP

notes should have evidence of complete Patient Care Plans with the above mentioned components

addressed. There must also be evidence of problem tracking and appropriate changes to the Care Plan as

the case progresses.

Click here for a sample patient care plan

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9) Self-care recommendations / Home Care recommendations Self-care recommendations are located in the “Patient Care Plan” listed as “Home Care

Recommendations.” The recommendations should be consistent with best practices to reach a

reasonable objective. There should be appropriate detail and/or parameters listed. There should

be a typed in description or a scanned-in chart copy of all recommended self-care.

SOAP notes should indicate that there was follow up with the patient relative to home care

performance. If this is missing, the deficiency should be noted in the progress notes file review

item.

Work, school or sports restrictions must be noted in the “Patient Care Plan.” A scanned-in copy

of any notes or correspondence in regard to these restrictions should be present in the patient’s

EHR. SOAP notes should indicate that there was follow up with the patient regarding any of

these restrictions possibly with an additional scanned-in note. Example: a ‘return to work note’

should be documented and scanned into the EHR.

This item is deficient if the recommendations are: contraindicated, likely to produce no

benefit (rather than maximally effective), lack needed detail and/or parameters, do not

encourage patient self-efficacy and autonomy, or are absent.

Click here for detailed self-care recommendation information

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SmartCloud Location:

Self-care/ home care recommendations should be located in the ‘Home Care recommendations’ line in the

Patient Care Plan page. These recommendation/orders should also be listed in the Plan Speed Note

freeform section on the day the recommendations/orders were given indicating the patient understood

and agreed with the plan.

10) Treatment goals Treatment goals are located in the “Patient Care Plan.” Goals should be listed and have

corresponding outcome measures. Generally, most conditions can be evaluated with a

subjective measure and a separate objective measure. If not possible to use the accepted and

valid outcome assessment tools (OATs), then SMART goals should be used, or a combination of

SMART goals and OATs. SMART is a mnemonic for Specific, Measurable, Achievable, Relevant

and Timed (https://www.tac.vic.gov.au/__data/assets/pdf_file/0010/27595/clinical-framework-

single.pdf ). In either case, it is necessary to be specific with goals and have an expected date of

achievement as well as what is expected in the short term as appropriate for the case if not

resolution of the problem. The long term goals (if appropriate for the case) should be the best

estimate prediction of the objective being reached in fairly specific time frame. The time frame

is determined by the case type being used (acute or chronic – see “Case Types” in the appendix).

This item is deficient if any element of the goals are not in SMART format, if the goals do not

include a functional component (if appropriate to the case), or are absent.

Two example goals are provided here in poor and in SMART format – other examples are in

detailed treatment goal information.

Poor goals: Reduce hypertonicity SMART goals: No trigger point in upper trapezius will

produce pain greater than 2/10 on palpation within 3

weeks. (Even better than this, goals will focus on

function –see the following)

Poor goals: Be more active SMART goals: Patient will perform 30-50 minutes of

moderate aerobic activity 3 days per week within 4

weeks

General tip: The following terms should not be considered sufficiently specific or measureable:

Amount of hypertonicity (unless a non-subjective measure of detection is included), number of

joint restrictions, ROM in degrees unless double inclinometers are used in the SOAP/clinical

SmartCloud Location:

Goals are located in the Patient Care Plan of SmartCloud. There are both short term and long term sections in the Care Plan. Reasonable goals as outline above need to be entered into these sections unless it is expected that there is only one goal, short term. It is necessary to link the outcome measures with each goal. The outcome measures are listed directly after the goals in the Care Plan. Goals should be adjusted as they are or not met. Student draft notes should show evidence of evaluation of patient goals as the case progresses. Note: Goals listed at the end of the Patient Care Plan are the patient’s goals noted on the intake form. These are not necessarily the short or long term goals listed above. They may be physical, health or activity related. They are listed and should be tracked as the case progresses over time.

exam, or items such as “reduce pain” unless quantified (such as “reduce pain per VAS from 3/10

to 1/10”), etc. A goal is more likely to be specific and measureable by reliable and valid means if

someone unfamiliar with the patient (and even someone clinically untrained) could verify the

status on the goal with the patient without any previous interaction with the patient.

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11) Outcome measurements Outcome measures are described in the Patient Care Plan – and evaluation of this item requires

assessing the plan, as well as care notes to determine if they were used. When outcome

measure scores are obtained, they should be noted in the SOAP note in the “General

Assessment” section of the Assessment Speed Note. There should be a comparison to previous

outcome assessment scores if previously done. In addition, the scores should be noted in the

Outcome Assessment line in the “Patient Care Plan” with the date acquired for easy reference in

future SOAP notes. When used longitudinally, the scores should be related to the achievement

of goals.

This item is deficient if outcome measures are: incorrectly scored or interpreted, not valid or

reliable, not correspondent to the goals (every goal should have a way to measure it), not

used as planned to assess progress, not appropriate to the diagnosis (a headache

questionnaire used for low back pain), not signed, and missing.

NOTE: A measure should only be marked “missing” if it was done and mentioned in the note,

but the score or outcome was not recorded. If the outcome measure simply wasn’t done at all

and should have been, mark that it was “not used longitudinally” for purposes of this review.

NOTE: You may be aware of a better outcome measure than the one that was used, or you may

have an outcome measure you prefer. If an outcome measure was used that does work for the

diagnosis and is reasonable, even if not ideal, do not mark it as deficient. See OAT details

Click here for detailed outcome measurement information

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SmartCloud Location: Outcome Measure Scores and/or SMART goal objectives must be documented:

1. On the date obtained, in the “General Assessment” section of the Assessment Speed note (with comparison to past scores if a longitudinal assessment).

2. In the Outcome Measures line of the Patient Care Plan with the date the scores were obtained for easy reference in future SOAP notes.

12) Progress notes Daily progress notes or SOAP notes track the patient’s progress during the course of care. They

tend to be brief compared with examination visits or formal assessment of patient progress

visits. There are some minimal requirements that will change depending on the patient’s

condition:

- Essential subjective information: How the patient is doing today, how the patient responded

to the prior treatment, if the patient is doing homecare, if there is anything new. Key case

specific information should be present if needed. For example: Are neurologic symptoms

progressing? Did a needed follow-up with an outside provider occur as recommended? Etc.

- Essential objective information: Any treated area should be appropriately examined prior to

treatment (this may simply be observation, palpation, and/or range of motion in simple cases),

and findings during and after care should be reported as appropriate. For Medicare and other

documentation as needed, two elements of PART must be recorded, one of which is A or R (see

below).

- Essential assessment information: Diagnoses for the visit must be recorded in plan speed

note. Response to care must be recorded here or in the Plan Speed Note Freeform section. Case

specific assessment information should be present if critical. It is helpful, but not required for

this file review, that each note indicates the patient’s response to that day’s treatment while still

in the office.

- Essential treatment information: All treatment and clinical reasoning for the visit should be

recorded. For example, if a certain treatment was not rendered per plan, the rationale should be

noted. If care is changed, rationale should be noted. If the treatment indicates “hot pack” and

does not state “per plan” (with the patient care plan elsewhere detailed enough to follow easily)

or does not state location, duration, and setting information in that section of the SOAP, it is

deficient. The same is true for “CMT-D” – it should indicate per noted restrictions, or list

restrictions – and soft tissue manipulation should include indication of muscles, regions,

techniques, or other details that will render the day’s treatment reproducible and

understandable. Referrals, new homecare provided, recommendations, suggestions, and all

clinical reasoning should be captured.

Additional information is available from the NCQA website - GUIDELINES FOR MEDICAL RECORD DOCUMENTATION: http://www.ncqa.org/Portals/0/PolicyUpdates/Supplemental/Guidelines_Medical_Record_Revi

ew.pdf

Progress notes are located in the patient’s record in the EHR and usually labelled SOAP notes. Each note during the review period needs to be assessed by reviewers. Minimal documentation requirements is governed by the PART mnemonic:

P – Pain or problem

A – Alignment

R – Range of motion

T – Tissue texture/tension At least two of the above components must be present in the SOAP and one of them must be the “A” or the “R.” The progress or “follow-up” SOAP notes should track the patient’s progress during a care plan. It is expected that brief description of the patient’s current problem(s) be documented along with significant examination findings (as noted in PART).

This item is deficient if the progress notes do not capture essential subjective, objective,

assessment, or treatment information, or if the notes are not signed or are absent.

See sample Plan Speed Note

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13) Patient response to care per formal assessment of patient

progress This is determined and documented in an “Assessment of Patient Progress” visit, which should

occur consistent with the Patient Care Plan and case type.

The following guidelines constitute the Assessment of Patient Progress (APP) credit for all clinic

courses and evaluated in the APP CRW in ExamSoft. The APP is not a complete examination, but

a review of the patient’s progress at a predetermined date. The date of this assessment may be

changed if the patient presentation warrants. Components of the APP should include any

outcome measures previously used in the case both subjective and functional, i.e. pain diagram

with VAS, Oswestry or Back Bournemouth forms. ROM, orthopedic and neurological tests may

be included if relevant from the onset of the case. The student and clinician should decide what

measures are necessary to update the Patient Care Plan. The APP procedure requires enough

information to determine if the patient requires additional care, home recommendations,

referral or discharge. There needs to be evidence of decision making with regard to the care

plan and future treatment planning.

SmartCloud Location: Progress notes should include the PART notation in the Subjective and Objective Speed Notes of the EHR. The Assessment Speed note should contain pertinent or new information such as imaging or lab reports, or reports from outside healthcare providers. These may affect the prognosis and should be noted. There are additional “buttons” that are generally used during an “Assessment of Patient Progress” visit, example: “Benefits are lasting longer.” The Plan Speed Note must have the diagnosis listed exactly as in the Care Plan Header. The procedure codes should be consistent with the Patient Encounter Form (Routing sheet). Any procedure(s) performed by the student and not billable should be described in either the Adjustment page comments section or in the Plan Speed Note freeform (both contain macros for ease of documentation). The student should insert the Patient Care Plan in the progress note to ensure care is guided properly.

The following process may be helpful: 1. Indicate in the history how the patient is doing now compared to intake and document the

comparison.

2. Re-administer or re-obtain OATs that were listed in the Care Plan, compare to previous

scores and report conclusions. Document the comparison in the General Assessment section

of the SmartCloud as well as the Care Plan.

3. Indicate if goals were met, whether they should remain the same or be revised. This should

be documented in the Care Plan.

4. If a re-examination of the patient is necessary, did it reveal pertinent positives and/or

negatives (of prior ROM, ortho or neuro tests)? Compare the current to the findings at

intake and document the comparison.

5. A revision of the diagnosis may or may not be in order. The student in consultation with the

clinician will make the appropriate changes (if any) in the Care Plan, Plan Speed note for that

day and the Problem List (some APP visits, but not all will rise to the level of E & M coding:

Established Patient Evaluation depending on the case specific needs).

6. If there is to be a continuation of care, then the dates of future assessment and possible

change to the end of care date need to be included in the modified Care Plan. Indicate the

date of last assessment to the right of the start date. Do not change the original start date

unless there is a new condition.

This item is deficient if formal assessment of patient progress occurred, but needed

information cannot be ascertained from the documentation or was not gathered. This item is

also deficient if a formal assessment of progress should have occurred during one of the

recorded visits, but the lack of formal assessment of progress is not satisfactorily explained.

Click here for detailed patient response to care information

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SmartCloud Location: An Assessment of Patient Progress SOAP note should contain all of the elements of a Progress SOAP note with the addition of:

Review of any pertinent testing (ROM, orthopedic or neurological findings) if positive at onset

Documented evidence of longitudinal outcome measure scores (OATs) / SMART goal assessments and comparison with earlier scores / assessments.

Evidence of medical decision making in an updated Patient Care Plan including diagnosis and any changes, continued care with or without changes noted, discharge at MTB or referral.

14) Management plan modification This is documented in the patient’s SOAP notes and would be most likely seen on the

assessment of patient progress (APP) visit or thereafter. However, this could occur at any visit as

clinically warranted. The “Patient Care Plan” must be modified to be consistent with any change

that is expected to continue on in future visits. A dated notation of such change should be

entered in the Care Plan’s ‘Treatment Plan Modifications’ line, i.e. change of a modality such as

cold laser, electric stimulation or rehabilitation exercises.

This item is deficient if the plan is not modified when critically needed (patient harm or

violation of patient autonomy* would result). Examples would be a patient who recovers and

becomes symptom free who is not released from care or transitioned deliberately and with their

consent to wellness care; or a patient who is not responding and whose management is left

unchanged after a reasonable trial (up to 4 treatments for most uncomplicated scenarios, with

perhaps as few as 2 treatments in very clear cut scenarios, such as uncomplicated low back

pain).

* Patient autonomy is the right of a patient to make decisions about their medical care without

their health care provider trying to influence the decision. Patient autonomy does allow for

health care providers to educate the patient but does not allow the health care provider to

make the decision for the patient.

Click here for more management plan modification information

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15) Documentation supports billing This is assessed by comparing plan speed note codes with the documentation supplied from the

ledger.

This item is deficient if CPT codes in the billing and note do not match, the SOAP does not

support the level of CPT code billed, the ICD codes in the billing statements and the billing ICD

codes in the note do not match, or the number of billing records do not match the number of

notes (with the sole exception of non-visit chart entries).

Click here for detailed documentation/billing information

Click here for a sample Patient Encounter Form (Routing Sheet) Return to the top.

The necessary documentation items are noted above in the Assessment of Patient Progress box above.

The Treatment Plan Modifications line in the Care Plan must be dated with the specific changes (changes in procedures such as added treatment modalities or stopped modalities).

Appendix

Privacy practice – details The patient should have a properly executed acknowledgement section of the Patient Intake form from the first visit. This form should be scanned into the patient’s EHR in Smart Cloud or be present in a paper chart. Example of executed HIPAA Privacy

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Example of an executed Report of Findings (ROF) and Informed

Consent (IC) form: Example IC form follows:

NYCC Health Center INFORMED CONSENT FOR TREATMENT

Patient’s Name ____Maya B. Herts__________ Date_____7/31/16___________

Diagnosis Sciatica left side associated with lumbar degenerative disc and joint

dysfunction.

Cervicalgia with cervicothoracic joint dysfunction.

Treatment Modalities (circle all that apply)

Instrument Assisted Adjusting/Activator Chiropractic Adjustment/Manipulation

Cold Laser Therapy Cryotherapy/Ice Pack Electric Muscle Stimulation

Exercise/Stretching Hot Moist Pack (HMP) Ultrasound

Instrument Assisted Soft Tissue Massage (IASTM) Manual Soft Tissue Massage

Other: ______________________________________________________________

I have received information from my doctor about my condition and proposed chiropractic treatment program, including the anticipated benefits, the reasonably foreseeable risks and side effects of the treatment, and alternatives to the proposed treatment, including no treatment. I understand that, as in all health care, there are some risks to chiropractic treatment. The risks include but are not limited to bruising, soreness, worsening of symptoms, muscle strains, sprains, fractures, dislocations, disc injuries, and strokes. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I have had the opportunity to ask questions about my condition and the recommended care, and my doctor has answered all questions to my satisfaction. I understand that I may ask further questions at any time. Comments (optional):

Maya B. Herts 7/31/16

Patient/Guardian Signature Date

Doc Ed Ucator ____7/31/16

Doctor’s Signature Date

Example of SmartCloud Problem List:

Notice that I10 Hypertension is listed in the “Active Problem Records,” but is not listed in the “Problem Records in Current Note” section. The subjective description of the patient’s symptoms is listed in the in the M99.03 Segmental and somatic dysfunction of the lumbar region. The M54.42 Lumbago with sciatica, left side was added once the history and examination determined this to be the ‘highest level of understanding’ diagnosis. The “Onset Comments” to the right of the diagnosis codes directs the reader of the note to the segmental dysfunction where the subjective description was originally recorded. Return to the top

SmartCloud Assessment Speed Note example including IC statement:

The informed consent statement is present in a macro for ease of entry.

For additional help, the following is a list of common errors with informed consent (it is not

necessarily all of the possible errors):

× Form is missing from case

× Abbreviated, missing or incomplete diagnosis

× Diagnosis codes listed with no words (missing diagnosis)

× Diagnosis is inconsistent with diagnosis being treated in SOAP note(s)

× Treatment is not listed or incompletely listed

× Treatment modalities are inconsistent with the plan and/or SOAP note(s)

× Patient’s name and/or signature is missing

× Doctor’s signature is missing

× Date is missing or not consistent with the onset of care

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Patient history – details SmartCloud Subjective Speed Note example:

Notice in the example that there is additional information in the “Complaint Freeform” tab related to the condition that the pre-set “buttons” do not cover. Return to the top.

Clinical examination – Objective Speed Note example:

Clinical examination – Examinations page example:

Clinical examination – Physical Exam page example:

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Patient Care Plan The header should include the case type (example: “Acute Care Plan” - see example below) to

guide the orders documented in the patient care plan.

Case Types and Management Plans

Acute Patient Presentation Public Health category of treatment: Secondary prevention – curing/resolving a problem that exists (in NMS terms, successfully treating radiculopathy or an episode of LBP, etc); the point of this care is to reduce PREVALENCE of a condition, so existing problems go away.

Acute Care Presentation Criteria: 1. New patient or Established Patient with new condition or similar condition with

moderate to severe symptoms 2. Initial onset <3 months (if greater than 3 months onset, but patient presents with

moderate to severe symptoms, then an acute treatment approach may be appropriate – see below).

3. Spinal condition is in scope of chiropractic care 4. No contraindications to chiropractic care found

Acute Care Plan must include:

Treatment type including who provides services (student or clinician).

Visit Frequency

Duration of care [Limiting factor: Therapeutic trial of up to 12 visits in 4 weeks]

Assessment date – if progress is documented through outcome measures, then further care may be warranted with expectations of resolution of the condition. If additional trials of care are indicated, supporting documentation should be available for review, including, but not necessarily limited to, documentation of complicating factors and/or comorbidities coupled with evidence of functional gains from earlier trial(s). Efforts toward self-care recommendations should be documented.

NYCC uses the term “Assessment of Patient Progress,” but SmartCloud uses “Re-examination.” Use this line in the Patient Care Plan to document the date of the assessment visit. This date should be consistent with the visit frequency and duration for the therapeutic trial or continued care.

Home/Work recommendations

Goals

Outcome Measures (OM) [Assess outcome measures < 1 month - with improving condition, OMs every 4 weeks thereafter and at discharge]

Chart documentation: - Initial visit history and exam essentials - Follow-up visit SOAP notes need to track the current condition and pertinent evaluation. During course of care: document condition change, dx test results, referrals, co-management, etc. Discharge expected at Maximum Therapeutic Benefit (MTB) within a 1 – 3 month period – document discharge and outcome measure scores.

Exacerbations/Recurrences (subset of acute care) 1 Document exacerbation

a) MTB reached and withdrawal from care documented b) Same or similar condition recurs within 30 days of discharge. Classified as Acute

Recurrence if similar condition is found after 30 days of discharge but needs to be treated in the acute-type care plan.

c) Moderate to severe symptom level d) Discharge at MTB expected as in Acute Care Plan

2 Exacerbation Care Plan (similar to Acute Care Plan with attention to active care and lifestyle modifications)

a) Trial of up to 12 visits in 4 weeks b) Active care recommendation and/or lifestyle modifications c) Consider dx tests, co-management or referral d) Monitor for MTB with Outcome Measures (OMs) e) May be heading for Chronic Care algorithm so discharge notation is necessary with

baseline outcome measures.

Chronic Care

Symptomatic aka Chronic Recurrent Care Public Health category of treatment: Transition from Secondary prevention (expect condition to resolve and a discharge of the patient) to Tertiary prevention (condition may not resolve but quality of life factors may be improved – see next section). 1 Defining characteristics of Recurrent symptom(s) for symptomatic chronic recurrent care

a) Mild symptom level b) Unplanned/unscheduled visit (more than 30 days since withdrawal of care) c) Often conditional discharge at same visit (consider diagnostic testing if progressive

changes noted over time) d) OM score may never reach zero, but should be monitored over time for significant

change that may indicate need for change in plan (may be headed for supportive care algorithm)

2 Document:

a) OM at each visit (pain diagram/functional questionnaire may be necessary) b) Recurrence of previous condition (date and dx) (review any diagnostic testing reports

that may be available) c) Unscheduled visit (walk-in, call-in, etc.) d) Review active care/home recommendations e) Conditional discharge notation with instructions for follow-up only when necessary f) Monitor OM scores over time for significant deterioration (may be indication for plan

change)

Supportive Care aka Ongoing Chronic Care:

Public Health category of treatment: Tertiary prevention – managing a condition that is not curable/resolvable, but working with quality of life issues, management of comorbidities, etc (in NMS terms, this would be care that helps someone with spastic paralysis regain 5 degrees of ROM so they can continue to live independently, but tx is required weekly – or working with the patient who has MS and care is palliative and quality of life, etc); the point of this care is to reduce the MORBIDITY associated with a condition, but not to resolve the condition.

1 Defining characteristics of supportive care case type a) At least 2 withdrawals from care for a problem (example: low back pain) b) MTB documented (outcome measures recorded for baseline measurement)

- Functional assessment tool preferred c) Active care/lifestyle modification attempted d) Assess/consider risk of long term care e) Risk/Benefit ratio must be in patient’s favor f) Long term plan in place with future attempts at withdrawal from care g) Monitor for deterioration of condition or other health concerns – request and/or review

any diagnostic testing reports available 2 Document:

a) 2 withdrawals from care (dates & OM baseline) b) Medical necessity (OM score(s) above baseline) – see medical necessity criteria c) Active care &/or lifestyle modification attempts d) Alternative care consideration e) Risk of long term care assessment (risk/benefit – red flags) f) Set goals with future attempt at withdrawal from care (at 6-10 months) g) Individualized plan w/ long term assessment – visits scheduled appropriately h) Monitor for deterioration of condition – document any complicating factors such as

diagnostic test results that complicate the patient’s condition, for example: a degenerative IVD

Suggested Plan Template: Ongoing Chronic/Supportive care plan In the SOAP note, episodes of care/dates must be documented. Other significant notations should be clear:

Active care/lifestyle modifications recommended in past plans

OM scores at time of discharge(s)

Current OM scores

Red Flags or lack of In the Patient Care Plan notate the following: Date of Assessment and/or the last assessment date New informed consent if necessary Plan of care:

Treatment type/frequency

Active care/lifestyle modifications

Goal(s)

Monitoring method (OMs)

Expected trial withdrawal from care date

Follow-up instructions

Wellness visit/ Elective care (sometimes referred to as “Maintenance” or Preventive care): Public Health category of treatment: Primary prevention – preventing a problem from occurring in the first place (in NMS terms, this would be ergonomics consulting to prevent the overuse syndrome, the carpal tunnel syndrome, the ITB syndrome in a

runner, etc); the point of this care is to reduce INCIDENCE of a condition, so they don’t happen. 1 Goals (one of the following)

a) recognize and reduce the incidence of a condition (prevent overuse syndrome, etc.) b) optimize levels of function (ADLs not limited, but individual wants performance

enhancement) c) maximize performance (athletic activity enhancement/improvement) d) Maintain joint flexibility (correction of subluxation)

2 Methods a) Manipulation b) Nutritional counseling c) Exercise guidance d) Lifestyle modification / patient education e) Monitor health conditions f) Assess any need for referral or co-management

3 Parameters and documentation (Plan Template): a) Document individualized goals a) Consider individual health indicators – use AHRQ ePSS

http://epss.ahrq.gov/PDA/widget.jsp * - be sure to include appropriate “A” level recommendations are acted upon in the plan and SOAP notes.

b) Consider Health Promotion and Wellness Checklist (use BMI calculator, etc.) c) Indicate treatment types/management measures, frequency, outcome measures (if

possible).

Note: Maintenance treatments are an elective form of care. Medicare and many 3rd party payers do not cover it as a “medically necessary” treatment. It is thought of as preventive treatment where further clinical improvement is not expected (if Est. Pt.) Maintenance treatments are not covered by:

- Medicare - Most insurance contracts

* The Electronic Preventive Services Selector (ePSS) is an application designed to provide primary care clinicians and health care teams timely decision support regarding appropriate screening, counseling, and preventive services for their patients. The ePSS is based on the current, evidence-based recommendations of the U.S. Preventive Services Task Force (USPSTF) and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors. Available both as a Web-based selector and as a downloadable PDA application, the ePSS brings information on clinical preventive services that clinicians need - recommendations, clinical considerations, and selected practice tools - to the point of care. Source: US Department of Health and Human Services – Agency for Healthcare Research and Quality (AHRQ)

Annual Check-up Evaluation 1 Yearly physical examination (at appropriate E/M service code†) 2 Assess/identify health risks

a) Focus on spinal health

b) Review/evaluate general health (SF-36 ) 3 Provide advice and education:

a) Promote health – use BMI calculator, nutritional advice, blood pressure check, etc. b) Prevent disease – use AHRQ ePSS http://epss.ahrq.gov/PDA/widget.jsp to

recommend/make referrals 4 Similar to wellness care (but may be covered service for some insurance) CPT codes for Annual Physical Exam

Established Patient: 99395 / 18-39 years old 99396 / 40-64 years old 99397 / 65 years and older New Patient 99385 / 18-39 years old 99386 / 40-64 years old 99387 / 65 years and older

References: National Public Health Partnership, The Language of Prevention. 2006, Melbourne: NPHP website: http://www.nphp.gov.au/publications/language_of_prevention.pdf Baker GA, Farabaugh RJ, Augat TJ, Hawk C, “Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain,“ Topics in Integrative Health Care, 2012, Vol. 3(4) ID: 3.4007 http://www.tihcij.com/pdf/Vol3i4/algorithms-for-the-chiropractic.pdf Globe G, Farabaugh RJ, Hawk C, et al, “Clinical Practice Guideline: Chiropractic Care for Low Back Pain,” JMPT Vol 39(1):1-22, 2016 http://www.jmptonline.org/article/S0161-4754%2815%2900184-0/fulltext NCQA – BPRP definition of acute and subacute care programs, 2007 http://www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/BPRP%20Standards%20Slides.pdf U.S. Dept. HHS. National Guideline Clearinghouse, Best Practices & practice guidelines. Intervention and Practice considered: Spinal manipulation therapy (SMT) (frequency and duration), 2008 http://www.guidelines.gov/content.aspx?id=14231&search=chiropractic New York State Workers’ Compensation Board New York Mid and Low Back Injury Medical Treatment Guidelines http://www.wcb.ny.gov/content/main/hcpp/MedicalTreatmentGuidelines/MidandLowBackInjuryMTG2012.pdf

Ronald J. Farabaugh, DC, Mark D. Dehen, DC, Cheryl Hawk, DC, PhD. Management of Chronic Spine-Related Conditions: Consensus Recommendations of a Multidisciplinary Panel, J Manipulative Physiol Ther. 2010 Sep;33(7):484-92. Epub 2010 Aug 25. Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines) Dehen MD, Whalen WM, Farabaugh RJ, Hawk C. Consensus terminology for stages of care: acute, chronic, recurrent, and wellness. J Manipulative Physiol Ther. 2010 Jul-Aug;33(6):458-63. Dept. of Health and Human Services, CMS Misinformation on Chiropractic Services bulletin ICN 006953 October 2011 (updated on Aug. 28, 2012) http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractors_fact_sheet.pdf US Department of Health and Human Services – Agency for Healthcare Research and Quality AHRQ ePSS http://epss.ahrq.gov/PDA/widget.jsp

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Does the patient seek care for functional limitation or pain?

Yes

No

Initiate the “Wellness Care”

rubric.

Does the patient seek care to actively

achieve optimum health possible?

Is this the first time for this problem

and is the initial onset <3 months?

Is this the first time for this problem

and is the initial onset >3 months?

No

Yes

Yes

Yes

Suggest appropriate care or referral

outside of the clinic. STOP.

Yes

No

See the “Acute Care” rubric.

Did the patient’s symptoms resolve?

Yes

No

Is the goal resolution of the

(underlying) condition?

Yes

No

Yes

Yes

Does the patient seek care to

actively achieve optimum health

possible?

Is care still appropriate?

No

Yes

Yes

Suggest appropriate care or referral

outside of the clinic. STOP.

Yes

Yes

Consider another trial (if

appropriate), withdrawal, or the

“Supportive Care” rubric.

Case Types Decision Tree – Based on Case Types – 1/21/2014

Yes

Not first TX for presentation. Were

symptoms quiescent for <30 days?

No

Yes

Yes

Is goal to manage symptoms of an

unresolvable underlying condition?

Follow the “Supportive Care” rubric

Yes

No

Yes

Yes

No

Yes

“Exacerbation”

“Recurrence”

Is the “acute care” rubric still

appropriate? (No contraindications,

<2 documented care withdrawals,

modifiable factors?)

Suggest appropriate care or referral

outside of the clinic. STOP.

Yes

See the “Acute

Care” rubric.

No

Yes

Yes

See the “Chronic

Care” rubric.

Is the visit expected to be for the

occasional flare up? (<1 visit/month)

No

Yes

Yes

Yes

Follow the “Symptomatic Care”

rubric

Is goal to manage symptoms of an

unresolvable underlying condition?

No

Yes

Yes

Yes

Example patient care plan in SmartCloud:

Note that the above plan contains all of the pertinent information about the diagnosis and management of the patient including problems within the scope of practice and conditions that need to be tracked or determined to fall into the realm of collaborative care. Return to the top.

Progress notes – SmartCloud Plan Speed Note Sample Plan Speed Note:

Notice that the diagnosis codes are listed in the order of billing and the procedure code is listed

for the billing. The response to treatment/follow-up recommendations are noted in the

‘Freeform’ section.

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Discharge documentation: Note that a patient discharge (or change in care type) would indicate that the day’s visit is

expected to be the last visit for that complaint. The student and clinician will indicate that the

condition is resolved after that visit. The Care Plan must then indicate that the condition is

resolved after the date of visit and no further care is warranted – or – the case type is changing

and a new plan is indicated (for example: acute to chronic).

The student at the direction of the clinician may decide to create a brief non-visit chart entry

with a Freeform SOAP note indicating resolution of the problem for reporting to outside

healthcare professionals. That short discharge summary non-visit chart entry note is the

documentation that the patient is released from care and may be necessary for some 3rd party

payers.

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In-office treatment plan – details NYCC does not use the “Treatment Plan” pages of SmartCloud due to the inconsistent

functionality of the page in the program. Use freeform entry spaces in the “Plan Speed Note”

and/or “Adjustment” section in SmartCloud for any specific treatment details associated with

that day’s visit.

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Self-care recommendations - details Self-care recommendations: Self-care is personal health maintenance. It is any activity an

individual can perform with the intention of improving or restoring health, or treating or

preventing disease.

http://en.wikipedia.org/wiki/Self_care

All details of the self-care should be appropriately stated in the Patient Care Plan. Self-care or

home recommendations may include exercise (location, duration, settings, frequency, reps, sets,

or other parameters), nutritional recommendations (dietary changes/advice), activity

restrictions (work or sports), or simply asking the patient to remain active. All details of the

active care exercise should be appropriately stated in the Patient Care Plan with the date

started.

http://medical-dictionary.thefreedictionary.com/Exercise

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Treatment goals – details Goals should be:

1) In SMART format, and ideally functional (Outcome Assessment Tools such as Oswestry or Bournemouth Questionnaires may work as measures of these goals) 2) Present for all diagnoses 3) Tailored for the specific patient SMART format:

Additional detail:

Specific and measureable goals:

The following terms should not be considered sufficiently specific or measureable: Amount of

hypertonicity (unless a non-subjective measure of detection is included), number of joint

restrictions, ROM in degrees unless double inclinometers are used in the SOAP/clinical exam, or

items such as “reduce pain” unless quantified (such as “reduce pain per VAS from 3/10 to

1/10”), etc. A goal is more likely to be specific and measureable by reliable and valid means if

someone unfamiliar with the patient (and even someone clinically untrained) could verify the

status on the goal with the patient without any previous interaction with the patient.

Achievable goals:

The goals should be able to be achieved by the patient given patient’s status and compliance. A

goal can provide a “stretch”, but should be achievable based on data provided about the patient

in the documentation.

Relevant goals:

The goals should reflect what the patient hopes to be able to accomplish – goals should

therefore reflect the patient’s involvement in goal setting.

Timed goals:

A realistic and appropriate time element should be included. Not providing a time element

would be an error. A time element that is clearly too short based on documentation would be

an error. A time element that is clearly too long (ie, the goal would have been reached well

before the provided time, based on documentation) would be an error. The Case Types

document may helpful in predicting an appropriate time frame.

Poor goals: Reduce hypertonicity SMART goals: No trigger point in upper trapezius will

produce pain greater than 2/10 on palpation within 3

weeks. (Even better than this, goals will focus on

function –see the following)

Poor goals: Reduce cervical ISD SMART goals: Patient will display full, painless, active

cervical range of motion within 4 weeks

Poor goals: Improve posture SMART goals: Patient will utilize sound ergonomics at

work (demonstrated in the office) and do hourly body

awareness checks while at work within 2 weeks.

Poor goals: Eat better SMART goals: Patient will increase vegetable intake to 3

servings/day within 2 weeks and 5 servings/day within 4

weeks

Poor goals: Be more active SMART goals: Patient will perform 30-50 minutes of

moderate aerobic activity 3 days per week within 4

weeks

Poor goals: Quit smoking SMART goals: Patient will move from pre-contemplative

stage to contemplative stage of quitting smoking based

on motivational interviewing within one month

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Outcome measurements - details Outcome Assessment Tools (OATs) should be accepted and validated. A resource for OATs is the

Chiro.org website: http://www.chiro.org/LINKS/Outcome_Assessment.shtml#Functional

Some accepted OATs:

Revised Oswestry Disability Index (ODI)

Neck Disability Index (NDI)

Back Bournemouth Questionnaire

Neck Bournemouth Questionnaire

Roland Morris Questionnaire

Rand SF-36

Headache Disability Index

Disabilities of the Arm, Shoulder and Hand (DASH)

Lower Extremity Functional Scale (LEFS) Other OATs exist and may be required by 3rd party payers, such as Back Index and Neck Index that resemble the ODI and NDI respectively. Additionally, there are Psychosocial Outcome Questionnaires such as:

Fear-Avoidance Beliefs Questionnaire (FABQ)

Keele STarT Back Screening Tool An example of a completed ODI follows

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Revised Oswestry Back Pain Disability Questionnaire

This questionnaire has been designed to give your chiropractor information as to how your low back pain

has affected your ability to manage in everyday life. Please answer every question by placing a mark in the

one box that best describes your condition today. We realize you may feel that two of the statements may

describe your condition, but please mark only the box that most closely describes your current

condition.

Name: Maya B. Herts Date: 7/31/16

PAIN INTENSITY [] I can tolerate the pain I have without having to use pain

medication. [] The pain is bad, but I can manage without having to take pain medication.

[] Pain medication provides me with complete relief from

pain. Pain medication provides me with moderate relief form

pain.

[] Pain medication provides me with little relief from pain. [] Pain medication has no effect on my pain.

PERSONAL CARE (e.g. Washing, Dressing) [] I can take care of myself normally without causing increased pain.

[] I can take care of myself normally, but it increases my

pain. It is painful to take care of myself, and I am slow and

careful.

[] I need help, but I am able to manage most of my personal care.

[] I need help everyday in most aspects of my care. [] I do not get dressed, wash with difficulty, and stay in bed.

LIFTING [] I can lift heavy weights without increased pain.

[] I can lift heavy weights, but it causes increased pain.

[] Pain prevents me from lifting heavy weights off the floor,

but I can manage if the weights are conveniently positioned (eg, on a table).

Pain prevents me from lifting heavy weights, but I can

manage light to medium weights if they are conveniently positioned.

[] I can lift only light weights

[] I cannot lift or carry anything at all

WALKING [] Pain does not prevent me from walking any distance. [] Pain prevents me from walking more than 1 mile.

[] Pain prevents me from walking more than ½ mile.

Pain prevents me from walking more than ¼ mile. [] I can only walk with crutches or a cane.

[] I am in bed most of the time and have to crawl to the toilet

SITTING [] I can sit in any chair as long as I like.

[] I can only sit in my favorite chair as long as I like. Pain prevents me from sitting for more than 1 hour.

[] Pain prevents me from sitting for more than ½ hour

[] Pain prevents me from sitting for more than 10 minutes [] Pain prevents me from sitting at all.

Other Comments:

STANDING [] I can stand as long as I want without increased pain.

[] I can stand as long as I want, but it increases my pain. Pain prevents me from standing more than 1 hour

[] Pain prevents me from standing more than ½ hour.

[] Pain prevents me from standing more than 10 minutes. [] Pain prevents me from standing at all.

SLEEPING [] The pain does not prevent me from sleeping well [] I can sleep well only by using pain medication

[] Even when I take pain medication, I sleep less than 6 hours

Even when I take pain medication, I sleep less than 4 hours

[] Even when I take pain medication, I sleep less than 2 hours

[] Pain prevents me from sleeping at all

SOCIAL LIFE [] My social life is normal and does not increase my pain. [] My social life is normal, but it increases my level of pain.

[] Pain prevents me from participating in more energetic

activities (e.g.) sports, dancing) Pain prevents me from going out very often

[] Pain has restricted my social life to my home

[] I have hardly any social life because of my pain

TRAVELING [] I can travel anywhere without increased pain. [] I can travel anywhere, but it increases my pain.

[] My pain restricts my travel over 2 hours.

[] My pain restricts my travel over 1 hour. My pain restricts my travel to short necessary journeys

under ½ hour

[] My pain prevents all travel except for visits to the physician/chiropractor or hospital

EMPLOYMENT/HOMEMAKING [] My normal homemaking/job activities do not cause pain. [] My normal homemaking/job activities increases my pain,

but I can still perform all that is required of me.

I can perform most of my homemaking/job duties, but pain prevents me from performing more physically stressful

activities (e.g., lifting, vacuuming).

[] Pain prevents me from doing anything but light duties. [] Pain prevents me from doing even light duties.

[] Pain prevents me from performing any job or homemaking chores.

Examiner: E. U.

Score: 27/50 x 100 = 54%

Management plan modification – details As the status of the patient changes it may become necessary to alter the Patient Care Plan. Any changes should have a documented reason for such change. Changes in the plan should be based on outcome assessment scores, diagnostic testing results, SMART goals, or the need for referral, changed therapies, therapy frequency and/or a transition to active care. Documentation of medical decision making should be located in the general assessment section of the Assessment Speed note. To track these changes, it is necessary to indicate the date and the change in the Treatment Plan Modifications line in the Patient Care Plan. These changes may be part of the formal Assessment of Patient Progress procedure or at any visit where appropriate. The plan modification changes and reasoning for such changes should be evident in the student draft as well as the final SOAP note signed by the clinician.

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Documentation supports billing – details

ICD and CPT codes entered on the Patient Encounter form (Routing Sheet) should be the same codes in the patient care plan, the plan speed note, and correspond to the diagnosis listed on the informed consent form. An example of a completed patient encounter form is provided here. Billing diagnoses should be consistent with the care plan diagnosis even if there are minor day-to-day changes. The diagnosis on the patient encounter form should not be changed unless a code is being resolved or added in which case, the clinical rationale should be evident in the general assessment of the SOAP note. If a new code is being added, an informed consent form likely needs to be added as well. An example of a completed Patient Encounter form follows:

Deficiencies include:

SOAP notes do not match the billing record

CPT codes in the billing record do not match the SOAP notes

ICD-10 codes in the billing record do not match the SOAP notes

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