Proper record keeping for chiropractors -- Part 2

Part 1 discussed the importance of proper recordkeeping from a risk management perspective, and listed several important "rules" every doctor of chiropractic should follow. They included recording only the facts about your patient and the case, tailoring your records and forms to be congruent with your type of practice, and taking and documenting a comprehensive chiropractic history.

Doing those few things will greatly improve your recordkeeping procedure, but they're not enough to "bullet proof" your records. Here are several other steps to take to make sure your records protect you and your practice in case of lawsuits and/or board complaints:

Conduct and document a thorough chiropractic exam. The standard of care requires that the doctor make a reasonable chiropractic diagnosis under the circumstances. Recording a thorough exam, including range of motion, postural checks and palpation can help to establish that the assessment and plan were reasonable, based on those findings, even if there is a misdiagnosis.

Document all patient non‑compliance. Every chiropractor has encountered patients who fail to comply with a care plan. They may, for instance, fail to keep appointments, skip doing the "prescribed" exercises, or refuse to take time off work as recommended. A patient's failure to participate in his or her own care should be fully documented. "DNKA" (did not keep appointment) is one way to chart a patient's failure to keep a scheduled appointment. Likewise, the patient's failure to follow your advice should be specifically noted, even if it conflicts with the patient's interests in maximizing recovery from a third party.

Never release original records. Patients often stop by their chiropractor's office and ask for their records. They may claim to need them for another health care practitioner, or for some insurance practice. Since your office staff wants to accommodate all patients, they may be tempted to hand over the X‑rays, notes or other original records, particularly if they are busy.

However, your CAs should be instructed never to give out any original record, X‑ray or other material, which documents a patient's care. This doesn't mean you shouldn't provide copies of the requested material. In fact, most states have laws giving patients the right to copies of their record. When a request for records is made, simply follow these procedures:

• Have the patient sign and date an authorization to release records. This can be a very simple form with the statement: I authorize you to furnish (name) or bearer, with a complete copy of my chiropractic record including records of office visits and care rendered, diagnostic test results, and X‑ray reports.;
   
• Keep this form in the patient's record;
   
• Provide copies only of the requested records (a reasonable fee may be charged if considerable copying is required);
   
• Make a note in the patient's file as to which records were requested and to whom and when they were sent.

Be aware that some attorneys may coach their clients on how to request records from a chiropractor and how to convince staff members to break the rule about releasing original material. No matter how much you might wish to oblige a patient, keep steadfast in this rule.

Never alter records. When faced with a lawsuit or threat of litigation, it's natural to review your records on the case. Never be tempted to "improve" those records by adding a few notes you forgot to include at the time, or to clarify a few points you think might be unclear. Some doctors have even totally rewritten their notes in order to make them more legible. However, you should never add, delete or change anything on a patient record once you become aware of the potential for litigation.

Note that the law does not require you to document perfectly. But it does require that you correct your mistakes in a way that preserves the integrity of the original record.

Guidelines

Doctors and their staff should observe the following guidelines:

1. If a mistake needs to be corrected, draw a single line through the error, write the word "error" above the incorrect entry, then date and initial the correction. Do not erase anything, use liquid correction fluid or do anything else to conceal the original entry.

2. Additions should be made very infrequently and only if information subsequently remembered is important to the patient's care. Label the new material as "addendum" and date the new entry using the date the addition was made. Remember that additions made shortly after the original note have far more credibility than information added weeks, months or years after the fact. Do not make any additions after legal action is threatened or commenced. Do not add obviously self‑serving notes after an adverse patient care event.

Any change made after the facts, no matter how minor or "innocent," will be considered suspect in a court proceeding and can damage your credibility beyond repair. In any lawsuit, the job of the plaintiff's attorney is to find and exploit even the smallest weaknesses in your records. This has been the Achilles heel of many chiropractors and is the main reason they lose cases.