Charting and Peer Review

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 chiropractor’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.   Chiropractors working in hospitals, colleges or in government programs are required to have regular peer reviews of their charts and case management.   This regular objective peer reviewing keeps charts and treatment plans in line with current standards of care.

If you plan to work in an integrated practice you need to maintain good records.  But 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 record simply “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 while 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 due to 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 will help 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 emails from your patient, print the emails 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, does not mean that every patient that 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, more accurate and easier.  If you work in a hospital be prepared to have your forms reviewed by the Forms Committee. (Hospitals have committees for everything)

Seek assistance from your malpractice carrier.  A good malpractice carrier will gladly help you with your charting and peer-review questions.  They are your partner in risk management and good charting.  Peer review is as important to them as it is to you.  

In the military there is a saying, “If it’s not inspected, it’s neglected.”  If you want to insure that your notes are up to standard, you need to have a colleague review them with a critical eye.  This will require you to humble yourself and be prepared for professional criticism. 

Finally, schedule time for quality case reflection and charting.