Diagnosis, Clinical Impression & Assessment

No matter your personal philosophical views about chiropractic, the first thing you want to do is review your states’ law, rules, regulations and board policies concerning diagnosis, clinical impression, assessment and your responsibility as a chiropractor.

Because if the state says you had a responsibility to do something and didn’t do it – you’ve got a problem and if the state says you can’t do something but did it anyway – you’ve got a problem.  So check this out first.

Beyond that there are many things that chiropractors do that you are expected to do even if its not explicitly stated in the law, rules or policies of the board. These amount to what any “reasonable” chiropractor would do in your situation or a similar situation. They also arise from what has become the defacto standard of care within the profession.

Some things to review in terms of your procedures or process for patient management include: Do you appropriately interpret the intake form, case history and examination findings in determining the appropriate application of chiropractic care within the overall needs of your patients? 

Do you develop and document a clinical impression, analysis or diagnosis for your patients? Don’t get too caught up on terminology here – remember if it’s in the law the board won’t care about your personal philosophy. If you don’t like the terminology then you are going to have to either change the law or risk losing your license.

Do you develop and document a care plan for your patients? This is definitely a standard of care issue and you are going to have a challenge convincing anyone that you didn’t need one.

Do you consider contraindications to chiropractic care? Notice I said “consider” – it does not mean that just because a patient has something that is a contraindication to an adjustment or manipulation can’t receive chiropractic care. But it does mean that you have to consider it and perhaps use a different technique, not adjust that particular area etc.   

Do you work with your patient to develop and document short term, intermediate and long term goals? “You gotta have goals” according to Zig Ziglar and this applies to health care as well. Working with your patient or practice member to develop a goal oriented care plan is not only going to help them realize all they can from the chiropractic care you are providing but its also going to lessen your risk because this process involves communication. And the better the communication between you and your practice member the less likely they are to sue you - period.

Do you work with your patient to develop and document functional goals? If a patient is able to go about their activities of daily living as a result of your care but absent that care they have deficits in this regard – then your care is necessary. Document these and discuss them with your patient.

If you are managing vertebral subluxation do you have a minimum of a biomechanical and neurophysiological component documented on each visit?

Since every operational model of vertebral subluxation and the standards of care and practice guidelines for management of vertebral subluxation these are generally considered the minimum components necessary to document its existence. If you are managing vertebral subluxation make sure your per-visit reassessment includes at least one analytical procedure previously used. 

If you are caring for Medicare patients are you using the PART Guidelines appropriately?  Don’t skimp on this as you don’t want to be caught in a Medicare audit and not be able to substantiate your subluxation diagnosis.

If you are managing vertebral subluxation do your records contain descriptions of any unique method or technique system? Different technique systems have different parameters, care plans, goals etc. Document what technique(s) you are using.

Further, if you are managing vertebral subluxation do your notes indicate the level(s), type, positions, listing, coordinates of the subluxation(s) you are managing? Again, different techniques may have different ways of doing this.

Do you use standard abbreviations and if not do you provide a legend of your abbreviations?

Are you aware whether or not your state specifically requires the use of a SOAP note format?

If you are using electronic records are you using “canned notes” that are essentially the same each visit?

Do you determine the patient’s progress on a per-visit and periodic basis?

This means you should be doing re-examinations on a regular basis. This is especially true for complicated cases, long term care etc. The last thing you want to have happen is you’ve taken care of a family of four over a period of 5 years and now there is a problem and you never did re-exams because they were “wellness” cases.

Have you developed an outcomes assessment plan? 

Are you using patient-reported quality of life instruments, mental health surveys, and general health surveys as part of the outcomes assessment plan? 

Are you using analysis of data from these sources to change or support continuation of a particular regimen of patient care?

If you are focusing your care on vertebral subluxation have you considered whether or not the patient needs co-management with some other type of provider? 

If you are focusing your care on vertebral subluxation and/or other types of neuromusculosketal disorders have you considered whether or not the patient needs co-management with some other type of provider?

Have you considered whether or not you are managing a patient beyond your knowledge, skill, or scope of practice?

Reviewing your state law, rules and regulations in the first step in making sure you set up procedures and process in your office that are compliant. The last thing you want is to find out you were not compliant after you are served with a lawsuit or after the state board comes knocking on your door.

As always I look forward to your feedback, comments and suggestions.