By William E. Morgan, D.C.

Charting is the bane of every doctor's existence, and the more integrated you become, the more detailed your charts must be. In private practice, the only time that a doctor of chiropractic's charts are reviewed is when a third-party payer attempts to verify services or in response to a legal or board action. This lack of accountability may allow a doctor's documentation to insidiously regress to substandard level. DCs working in hospitals, colleges or government programs are required to have regular peer reviews of their charts and case management. Regular, objective peer review keeps charts and treatment plans in line with current standards of care.

If you plan to work in an integrated practice, you must maintain good records. Even if you do not practice in an integrated setting, you should maintain high-quality chart notes. You and your malpractice carrier may one day be glad that you did.

What common mistakes are found in chiropractic charts?

Inadequate Record of Normal Findings:

If you perform manual muscle testing, list all the muscles tested and the findings. Do not simply write "lower extremity muscle strength intact-5/5." Months later, if you note the patient has weakness in extension of the right great toe and you did not record it specifically, you would be hard-pressed to prove that this weakness did not occur under your care.

Biased Charting:

Try to record your findings in an objective manner, and do not attempt to "make a case" for a particular diagnosis. For example, if you record "right C8 dermatome distribution paresthesia," you are leading your diagnosis toward a nerve root lesion. The paresthesia could in fact be the result of an ulnar nerve lesion, vascular insufficiency, MS or one of many other possibilities. It is better to simply record the patient's symptoms in his own words: "He complains of a feeling of 'pins and needles' along his medial forearm." This helps you to remain objective in your decision-making.

Failing to Record All Communication:

Whenever you communicate with a patient-including telephone consults or e-mail-you should record the interaction. Similarly, keep all correspondence with your patient's other providers. If you receive e-mails from your patient, print the e-mails and place them in the patient's chart.

Unsupported Diagnosis:

Just because you went to a seminar last weekend that touted annular rents as a major cause of back pain, it does not mean that every patient who walks in your door on Monday should be diagnosed with a rent of the annulus. Your diagnosis should be logical and in line with the presentation, history and evaluation.

Unsubstantiated Treatment:

If no assessment of the cervical spine is recorded in the notes and yet it is treated, the obvious question of any reviewer is, "Why was this region treated?"

Charting Advice

Create your own customized forms, questionnaires and charts to make charting faster, easier and more accurate. If you work in a hospital, be prepared to have your forms reviewed by the "Forms Committee." (Hospitals have committees for everything.)

You can also seek assistance from your malpractice carrier. A good malpractice carrier will gladly help you with your charting and peer-review questions. It is your partner in risk management and good charting-peer review is as important to it as it is to you.

In the military, there is a saying: "If it's not inspected, it's neglected." If you want to ensure that your notes are up to standard, you must have a colleague review them with a critical eye. Remember to be humble, and prepare yourself for professional criticism.

For more information regarding charting and chart review and to learn how to utilize Microsoft Word to create Speed Notes, please review my article Speed SOAP Notes Using Microsoft Word™.