by R. J. Hammett, D.C.

 

            Dr. Hammett is a chiropractor in private practice in Kenosha, Wisconsin. After graduating from Life College in 1979, he completed several post-graduate programs in Physical Impairments, Diagnostic Imaging and Rehabilitation. He completed his Juris Doctor in 1995. He has written articles for several Journals and has lectured to numerous Chiropractic groups on the topics of Practice Management and Risk Prevention.

Clinic documentation has been both a blessing and a curse to chiropractors. In 1979, when I graduated from Life College, the only documentation necessary for daily visits was the date of the adjustment and the levels adjusted. Subjective information was not necessary, and we as chiropractors were not supposed to be treating symptoms, only subluxations.

            By the mid eighties, things had changed. With better third party coverage came the demand for more and more reasons to justify your care. In my mind, the right documentation is actually a good thing. For example, documenting what the reason was for giving an adjustment on any given visit just makes sense. Documenting what was adjusted and how, also makes sense, especially if you need to refer back to what you did the last visit that worked so well for the patient.

            The problem though, within our profession, is what constitutes proper chiropractic documentation. Most, if not all, colleges and boards require soap notes at this time. The reason is simple; one chiropractor in California receives records from a chiropractor in Wisconsin, the chiropractor in California should be able to tell what the treatment plan was, treatment performed, and the results of the treatments just from the Wisconsin chiropractor’s records. But, here lies the real problem. Many, if not all of you, have received records from other D.C.’s. Some of you have had your records reviewed by IME’s and R.N.’s. Most of you have been told at one time or another, that your records do not demonstrate “Medical Necessity” for care.

            The problem is, whose guidelines are they using? What is the true indication of the need of care in chiropractic? Is it the same as in medicine? As in physical therapy? Just what constitutes a base line for justification of necessity of chiropractic care? When does documentation demonstrate a corrected vertebral subluxation complex?

            Well, that depends on whom you accept as “the” authority. In one camp of chiropractic, orthopedic, and neurological tests and their results are the necessity for care. In another camp, only those tests that indicate the presence of a vertebral subluxation complex are necessary for validity of chiropractic care. So, who's right?

            Well, actually both. As you well know, there are five components of the vertebral subluxation complex. These components have been accepted by all the national organizations. Each component has a corresponding test or tests to indicate the presence of one of the components of vertebral subluxation complex. It is important that at least three of the five components be tested and documented to provide a base line of the necessity for care.

            Your initial examinations and x-ray procedures should focus on the probable corresponding vertebral subluxation complex level of the patient’s presenting complaints. The primary focus of any chiropractic examination is to find the primary vertebral subluxation complex first; then plan out a course of care to correct what was found. Tests such as posture, weight and balance, palpation, range of motion and others are long standing indicators of vertebral subluxation complexes. There are, of course, some orthopedic and neurological tests that are also useful in confirming a component of the vertebral subluxation complex.

            Additionally, at each office visit, what are you using to confirm or deny the presence of the vertebral subluxation complex? Leg length? Posture? Range of Motion? Palpation? Also important are periodic re-examinations (every 10 to 15 visits). These re-examinations are utilized to both question the patient subjectively, and second to re-check all your initial indications of vertebral subluxation complexes.

            Remember, it should be important to you to prove the presence of subluxation in your patients. Whether or not any insurance company or a “hired” IME says there is a need for care or not, is irrelevant. Most of the third party opinions are purely money motivated and not directed to improving patient’s health or well-being.

            So, in final, learn to document the true indicators for the necessity of care in your office, based on long standing tests that show you where the nerve interference is. Quit letting third parties dictate to you what you already know to be true, that your patient has nerve interference, this is where it is, and this is how you're correcting it.

 

            ‘Til next time. . .