Best Practices: Clinical Assessment of Pain Intensity

Pain is an individually experienced phenomenon producing a widely different sensory effect that cannot be easily measured by objective examination.  The importance of pain assessment however has led to the development of a number of validated clinical tools designed to measure the self-expression of a patient’s pain level.  These self-reporting tools are the gold standard of pain assessment and can be used to evaluate the severity of the pain, its effect on physical functions and the effect of treatment when measured serially.

Among the most commonly used and well known are the Visual Analog Scale (VAS) and Numeric Pain Scale (NPS).

The VAS uses an unmarked horizontal line of precisely 100mm on which the patient marks their pain level ranging from no pain to most pain. VAS

The NPS uses a horizontal line with a segmented scale of numbers marked from 0-10 where the patient is asked to place their mark rating their pain. The length of the line is not essential for this scale.NPS

These tools can be expanded to include multiple measures of pain, e.g. Quadruple VAS (QVAS) where pain is rated 1) present 2) average or typical 3) at worst 4) at best.

Another pain measuring tool that is often combined with a numeric pain scale and physical or functional capacity is the pictographic or Faces Pain Scale (FPS). This employs pictures of faces expressing levels of pain from no pain to most pain and was originally developed to assess the intensity of children’s pain. The CHP Group has developed a vertical pictographic FPS with an associated numeric pain level, verbal description of pain, physical capacity, and Spanish language translation. Click here to download the new CHP FPS

These scales can also be adapted to other physical symptoms, e.g. discomfort, stiffness, perception of breathing capacity for asthmatics.

When implementing these instruments, an initial evaluation of a new patient or existing patient with a new problem is appropriate and at intervals thereafter consistent with the type of condition and the patient’s response to care. For example, a more acute condition would likely see more rapid progress and re-measuring in days is reasonable compared to a chronic condition where change may occur more slowly and re-measuring in weeks may be more appropriate. Similarly, these numbers can be used to set treatment goals, e.g. reduce pain by 50% in 2 weeks.

Are you waterlogged or dehydrated?

“….and don’t forget to drink 8 glasses of water per day” has been admonished without question for the last 70 years. The evidence to back up the requirement is empty despite the progression of bottled water that started in 1977 with Perrier to the craze that is present today. As Aaron E. Carroll discusses in his article in TheUpshot, there is a story here.

Social Media and Healthcare Providers

As a healthcare provider, do you know the risks of using social media – both personally and professionally? A recent survey of more than 4,000 physicians survey found that over 90% used some form of social media personally and 65% professionally. If you use social media and want more information about how healthcare professionals are using it to interact with peers and patients, as well as what to watch out for, check out the following articles:

Social Media and Health Care Professionals: Benefits, Risks, and Best Practices (P.T. 2014 Jul; 39(7); 491-499, 520)

The Wisdom of Patients: Health Care Meets Online Social Media

Social Media: A Review and Tutorial of Applications in Medicine and Health Care

Best Practices: Documenting Labs & Diagnostic Imaging

Complete and thorough documentation of laboratory and diagnostic imaging studies is an important part of the clinical record. Laboratory and diagnostic imaging studies performed and/or interpreted by the provider must be documented. The clinical history and examination findings should document the indications for the lab tests and imaging that is ordered. Findings should have an impact on the clinical decision making process.

Reports of studies that are conducted within a provider’s office should always incorporate complete identifiers including:

  • Patient name, age/date of birth, sex
  • Facility name, address
  • Ordering provider name
  • Date of study
  • Views or tests obtained

In-house lab and imaging studies and interpretation of tests obtained from outside sources (facilities, other providers) should be an accurate description of all significant laboratory and diagnostic imaging findings. An “impression” contains a summary of important findings and should contribute to the diagnosis and guide the treatment plan. Recommendations for further imaging studies, other tests or specialty referral should be noted.

Studies that are conducted and interpreted at another facility should be documented by reports from that facility. If outside studies are not documented, interpretation should be obtained from a qualified clinician.

Initial or sign lab, X-ray, or consultants’ reports upon receipt as evidence of having reviewed them. A number of patient injuries and malpractice cases are traced to a provider’s failure to review and act upon abnormal laboratory and X-ray results. It is not fail-safe only to file these reports in the chart with the assumption the provider will review them the next time the patient is seen. For instance, if the patient does not return, as some patients do not, the doctor may not discover significant findings that require action until the patient suffers an injury.

Every liability insurer has had cases in which un-reviewed reports somehow managed to get filed in the record, but were never documented as having been reviewed by the responsible clinician. A safer approach is for the reviewing clinician to initial all reports as an indication that each item has been reviewed and taken into consideration in treatment planning.

Documentation of lab and imaging studies is important in quality patient care, appropriate clinical decision making and effective malpractice risk management. Tests conducted within a provider’s own office must be completely identified and significant findings documented. Lab and diagnostic imaging reports from outside facilities also should be clearly documented as having been reviewed by the responsible clinician.

Resveratrol and quercetin as cancer therapies?

In a recent press release, the Oregon State University College of Pharmacy released results of new research that identify resveratrol and quercetin as possible components for new cancer treatments. In a laboratory setting researchers created a system that allowed for injections of these compounds directly into the bloodstream to create very high levels of concentration in the body – much more than through oral intake.

As the press release notes “The resveratrol and quercetin then appear to reduce the cardiac toxicity of a very widely used cancer drug, Adriamycin. Although highly effective in the treatment of lymphomas, breast, ovarian and other cancers, Adriamycin can only be used for a limited time in humans because of it’s cardiotoxicity.”

Full findings on this research where published in the Journal of Controlled Release. To read the press release, click here. To read the research finding in the Journal, click here. (Purchase and/or membership may be required to read full article.)

Best Practices: Documenting Modalities & Procedures

Naturopathic and chiropractic physicians need to accurately record clinical information when providing or performing physical therapy modalities and procedures. Standards for “best practices” rely on these records to establish the clinical necessity and effectiveness of any given modality or procedure, aid in the determination of patient outcomes management, help with continuity of patient care, and aid in the reduction of malpractice risk.

These services are broken up into three broad categories:

  • Supervised (CPT codes 97010 – 97028) – these are limited to one unit per patient encounter per day regardless of time or region.
  • Constant Attendance (CPT codes 97032 – 97039) – these are time based and require the provider to be present during the administration, application, or performance of the modality.
  • Therapeutic Procedures (CPT codes 97110 – 97546) – these require direct patient – provider interaction; these are also time based.

Clinical documentation for these services should include a brief explanation of the necessity of the service, the nature of the modality or procedure (ultrasound, interferential electrical stimulation, massage, myofascial release, etc.), settings – if appropriate (e.g. pulsed vs. continuous ultrasound), location of application by region or segment (as specific as possible), duration, and result.

When billing any time-based modality or procedure, certain rules apply. While the AMA CPT Code Book defines time as a 15 minute unit, actual practice does not always fit such rigid parameters. Billing methods for time-based services, including physical therapy modalities and procedures allow for some flexibility. (CMS Physical and Occupational Therapy Billing Manual, Center for Medicare and Medicaid Services, 2010, 2012)

While one unit of time is 15 minutes, the individual service is allowed to vary between 8 minutes (just above the midpoint between 0 and 15) to 22 minutes (just below the midpoint between 15 and 30). Thus a single unit of service may be billed when the involved time reaches 8 minutes.

When more than a single unit is rendered or when other time-based modalities or procedures are performed during the same encounter, the provider must account for the total time involved in rendering these services. If two time-based services are performed sequentially, billing would be dependent on the total time of service. As an example, 8 minutes of ultrasound (CPT code 97035) followed by 8 minutes of attended electrical stimulation (CPT code 97032) totals only 16 minutes of time-based services. While if each were performed separately on different dates of service, one unit of time could be billed for each code. However, since the two procedures are performed in the same visit, only one unit (8 to 22 minutes) can be billed. In such a case, it would be permitted to bill for the modality or procedure with the higher associated fee. If the fees are the same, bill for the one requiring slightly more time than the other. If all aspects are equal, the decision is left to the provider to bill for one or the other; however, the clinical documentation needs to reflect the specific services performed during the patient encounter.

When multiple units of service are billed, only the last unit of service is subject to the range of time adjustment. All other units billed are based on the 15 minute definition. Two units of service would require 15 minutes for the first unit; the second unit could range between 8 and 22 minutes (total time of service would be from a low of 23 to a high of 37 minutes). Three units of service would require 30 minutes for the first two units; the third unit could range between 8 and 22 minutes (total time of service would be from a low of 38 minutes to a high of 52 minutes). The same method of calculation is used as additional units of modalities or procedures are added.

It is incumbent on the provider to document the time elements described above in such a manner that allows easy determination of when threshold parameters are met.

Containing Healthcare Costs with Integrative Medicine

For anyone looking to understand how integrative medicine can help stem the tide of rising healthcare costs, the “Health and Medical Economics: Applications to Integrative Medicine” white paper, published in 2009, offers insight into both clinical care and overall cost effectiveness as well as societal loss when populations require nursing care and/or drug treatment intervention. This 97-page white paper – commissioned for the IOM Summit on Integrative Medicine and the Health of the Public – takes into consideration cost-benefit analyses of many aspects of health and medical care. Definitions of ‘direct vs indirect cost’ are explained in table 2, page 13. This explains why one must not only look at the direct cost of specific medical care for a disease but also the indirect cost to the patient and society. As the paper notes “Chronic conditions are on the rise across all age groups, and it is expected that in the near future, conditions such as diabetes, heart disease, and cancer will tax employers more heavily as they provide medical benefits for employees and absorb the costs of absence, short term disability (STD) and long term disability (LTD) costs (Thorpe, 2006).” The objective of integrative medicine is to broaden the array of evidence-based interventions that are selectively available through an integrated, collaborative network of providers while producing better patient outcomes, reducing disability, time loss and medication costs.

Best Practices: The Anatomy of a SOAP Note

In a previous post, we reviewed the necessity of basic best practices for SOAP notes including legibility, identification, and dated chart entries. In this post, we review the proper structure and contents of a SOAP note.

The acronym SOAP stands for Subjective, Objective, Assessment, and Plan. Each category is described below:

S = Subjective or symptoms and reflects the history and interval history of the condition. The patient’s presenting complaints should be described in some detail in the notes of each and every office visit. Using the patient’s own words is best. Routine use of one-word entries or short phrases such as “better”, “same”, “worse”, “headache”, “back pain” is usually not sufficient. In follow-up notes, “S” is a reiteration of the chief complaints elicited during the initial evaluation of the patient. The complaints should reflect change over time. The patient’s responses to the previous treatment, resumption of daily or occupational activities, intervening injuries, and exacerbations are also noted in “S.”

“S” should also describe improvement in the patient’s activities and physical capacities in the interim since the last treatment. Also included in this section are explanations for any hiatus in treatment and the patient’s compliance with recommended home care.

O = Objective or observations. This section includes inspection (e.g., “patient still walks with antalgic gait”) as well as a more formalized reevaluations such ranges of motion, provocative tests, specialized tests (fixations, tongue, pulse, BP, labs). The extent of the reevaluation at each office visit is determined by the information gathered in “S” together with the original positive clinical findings as well as changes in “O” at previous office visits. Usually only the critical indictors need be repeated. Findings should be qualified and quantified in order to be able to ascertain progress/response to care over time. Indicators for treatment should always be identified in order to document necessity of the treatment provided and described in “Plan” section of the note, for example motion palpation findings, stagnation of blood and chi, or abnormal lab values.

A = Assessment. Initially this is the diagnostic impression or working diagnosis and is based the “S” and “O” components of SOAP. On follow-up visits the “A” should reflect changes in “S” and “O” as a response to time, treatment, and other interim events (e.g., “Cervical strain, resolving” or “exacerbation of right sacroiliac pain”). “A” should be continually updated to be an accurate portrayal of the patient’s present condition. Other components of “A” may include the following where appropriate: patient risk factors or other health concerns, review of medications, laboratory or procedure results, and outside consultation reports.

P = Plan or Procedure. The initial plan for treatment should be stated in “P” section of the patient’s first visit. A complete treatment plan includes treatment frequency, duration, procedures, expected outcomes and goals of treatment. An initial treatment plan may be for an initial trial of treatment over a short interval with a re-assessment and further treatment planning at that later time.

On each follow-up visit, “P” should indicate modalities and procedures performed that day, continuation or changes in the overall treatment plan. “P” should also describe what the patient is to do between office visits, what the expected course of treatment is, what further tests might be ordered (e.g., “Obtain cervical MRI if upper extremity paresthesia persists”), and the disposition of the case (discharge, referral, etc.). It is also appropriate to include in this section any comments with respect to the patient’s compliance.

Other items or events to be charted include:

  • Any phone or personal contact with the patient.
  • Missed appointments, rescheduled appointments, or when the patient is significantly late for an appointment.
  • The receipt of important correspondence regarding the case.
  • Requests for medical records sent or received.
  • Transmittal of records, correspondence, etc.
  • X-rays and other imaging studies, lab work, consultation reports.

Chiropractic care to be covered for Oregon Medicaid population

A new randomized clinical trial just published in the medical journal Spine compared medical care of prescribed medications to chiropractic spinal manipulation. The study results revealed that 94% of patients receiving chiropractic manual-thrust spinal manipulations had a 30% reduction in low back pain at week four while only 56% of those receiving medical care (prescribed medications, avoidance of lengthy bed rest, and staying physically active) achieved a 30% reduction in pain. This is consistent with the research reviewed by OHSU’s Center for Evidence-based Policy and the State of Oregon Health Evidence Review Commission that resulted in the 2012 State of Oregon Evidence-based Low Back Pain Management Guidelines. Based on the scientific evidence, those guidelines recommend spinal manipulation as the only non-drug treatment for all three phases of low back pain: acute (four weeks for less), subacute (four to eight weeks duration), and chronic (eight weeks or longer). As a consequence of the mounting evidence in favor of chiropractic manipulation for low back pain, a recent task force consisting of representatives from the Oregon Pain Management Commission, the Oregon Health Authority, and the Health Evidence Review Commission, made a policy change for Oregon’s Medicaid population. Beginning January 1, 2016, for the first time in Oregon’s history, Medicaid patients will have access to chiropractic treatments for their back and spinal pain conditions.

Dr. Vern Saboe, Director of Governmental Affairs for the Oregon Chiropractic Association, noted: “We chiropractic physicians look very much forward to working with our local medical doctors in hopes of providing the best possible care for our mutual low back pain patients.”

Best Practices: Problem-Oriented Medical Record and SOAP Notes

In 1968, Lawrence Weed, MD, developed the problem-oriented medical record (POMR) “… to develop a more organized approach to the medical record…” (Weed L. Medical records that guide and teach. NEJM Vol. 278, No. 11 & 12. 1968.) SOAP notes (Subjective, Objective, Assessment, Plan) – although only one component of the entire POMR – have become the standard in clinical record keeping for daily chart notes in ambulatory settings. Proper record keeping using the SOAP method improves patient care and enhances communication between the provider and other parties: claims personnel, peer reviewers, case managers, attorneys, and other physicians or providers who may assume the care of your patients.

The purpose of this post is to review accepted methods of clinical documentation using the SOAP format. CHP does not require, but strongly encourages the use of the SOAP format. If SOAP itself is not used, the elements embodied in SOAP must be recorded.

Basic best practices for SOAP format and other chart notes include:

  • Legibility: Chart notes must be legible, preferably typed. If handwritten, they must be easy-to-read.
  • The provider’s identification (name, address and phone) and patient’s name and unique identifier such as date of birth (DOB) or record number must be indicated on each side of each page of notes.
  • Every chart entry must be dated. Each entry must be signed by the person entering the note (this includes office personnel who make entries in the chart).
  • Standard abbreviations are acceptable as long as they are easily understandable and interpretable by the reader.

There are many styles of chart notes that can be effective. Narrative notes in SOAP format are the clinical standard. Effective chart notes must reflect the four criteria required to document medical necessity.

  1. The patient’s chart must reflect subjective findings that are consistent with a lesion, injury, or condition.
  2. The examination must confirm the existence of a lesion, injury, or condition that is consistent with the patient’s complaints and the exam findings must be documented in the chart.
  3. The management of the case or treatment rendered must be considered appropriate for the condition.
  4. The patient chart should reflect overall improvement over the course of treatment.

The best practices described here are endorsed by many health care organizations, regulatory agencies (e.g., NCQA) and state authorities. Want more information on record keeping or other best practices for integrative healthcare providers? Search “best practices” on this site to read more in this series of articles.