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:
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.
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.)
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.
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.
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.
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.”
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.
- The patient’s chart must reflect subjective findings that are consistent with a lesion, injury, or condition.
- 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.
- The management of the case or treatment rendered must be considered appropriate for the condition.
- 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.
Over the last several years, there has been an trend toward patient participation in medical decision-making. Known as “shared decision-making’, this model puts emphasis on involving the patient in their treatment decisions with input from the physician. However, when the patient is faced with the prospect of an invasive medical produce, many feel nervous and anxious; they may have a harder time thinking of questions to ask their provider or surgeon about the procedure and their options.
If one of your patients is scheduled to have surgery or another medical procedure, one way to help them relieve their anxiety about it is to help them learn all they can about the procedure. The following list of questions is based on information from Questions to Ask Your Doctor page on the Agency for Healthcare Research and Quality website. The AHRQ provides basic questions as well as a question generator that patients can use to print a personalized question list.
Encourage patients to use a list of questions like this. They may also benefit from having a family member or a friend at their doctor’s or surgeon’s appointment. Such ones can help speak for your patient and may also be able to help them remember all of the information the doctor or surgeon provides.
Why do I need surgery?
Find out the purpose of the surgery and how it relates to the diagnosis of your condition. For example, is the procedure designed to relieve pain? Reduce symptoms? Improve function?
What type of surgery are you recommending?
Often, there are different types of surgery available for a given condition. Ask your surgeon to explain the procedure and describe to you exactly what is going to be done. Ask if any instrumentation (hardware such as screws, plates, stents, or cages) will be used and how large your incision will be.
Your surgeon may be able to draw a picture, show you a diagram, give you written information or refer you to other resources such as books, videos, or websites that can help you better understand the procedure.
Are there alternatives to surgery?
For some musculoskeletal conditions, surgery is considered only after conservative, or non-surgical, treatments have been tried. Talk to your surgeon about other options to see if there is any reason to try a different treatment option first or to just postpone surgery. If you have tried various conservative treatments, tell your surgeon about them and why they did or did not help your condition.
What are the benefits of having the operation?
Find out what you will gain from the surgery. Ask how long the benefits will last or if you will need another operation at a later date.
What are the risks of having the operation?
All surgeries carry a risk of complications, such as infection, excessive bleeding, reactions to anesthesia and injury. Be sure you understand all of the possible complications before you agree to have any surgical procedure. Also, talk to your surgeon about any side effects after the surgery, such as swelling, soreness, and pain and how these will be managed. What will my capacity for activity be like?
What if I choose not to have this operation?
After you have learned about the risks, ask your surgeon what would happen if you chose not to have the surgery. Will your condition get worse? Will you have more pain?
Where can I get a second opinion?
Getting another doctor’s opinion about whether or not to have surgery is a great way to ensure you are making the right decision. Many health insurance plans cover getting a second opinion. Call your insurance company to see if your plan will pay for a second opinion.
What has been your experience with this procedure?
Ask your surgeon how many of these surgeries they have performed. Get a feel for their experience with your condition. Ask your surgeon if they can refer you to someone who has also had this operation.
Where will the operation be done?
Most surgeons work out of more than one hospital. Find out where your procedure will be performed. If you have a choice, choose the facility that has the most experience and the highest success rate in treating your condition. Talk to your doctor about whether or not your procedure will require you to stay in the hospital and for how long.
Asking these straight forward questions empowers patients to make collaborative decisions with their caregivers. Empowered patients tend to have better outcomes from any treatment, especially in the case of a major surgery.
In a previous post, we discussed the need for providers to stay up-to-date on the latest evidence-based medicine so that they can help patients make the best decisions for the healthcare. At the same time, we acknowledged the fact that the sheer volume of material available makes it difficult for providers to keep up-to-date on the latest research. These research tools and databases can assist providers by producing current summaries of the evidence about a wide variety of clinical topics.
TRIP Database – www.tripdatabase.com
The TRIP Database is described as a “clinical search engine designed to allow users to quicly and easily find and use high-quality research evidence to support their practice and/or care.” Access to the site is through a free registration. Searches on the database bring up links to the source articles on any particular topic. While TRIP is not focused on integrative healthcare (IH), many topics relevant to an IH practice do include citations of mainstream medical literature that report on such care.
Natural Medicines – www.naturalmedicines.therapeuticresearch.com
Natural Medicines (formerly Natural Standard) is self-described as the “The most authoritative resource available on dietary supplements, natural medicines, and complementary alternative and integrative therapies.”
For each therapy covered by Natural Medicines, a research team systematically gathers scientific data and expert opinions. Validated rating scales are used to evaluate the quality of available evidence. Easy to understand grading scale and cross-indexing by condition is available to save your time. All data is incorporated into comprehensive monographs which are designed to facilitate clinical decision making. All monographs undergo blinded editorial and peer review prior to inclusion in Natural Medicines databases. In addition to now-familiar symptom checkers and calculators, the NM database offers comparative effectiveness tables, drug/natural medicine interactions and drug and natural medicine depletion guides.
Natural Medicines is “impartial; not supported by any interest group, professional organization or product manufacturer.”
Natural Medicines is a fee-based product. They also offer a free monthly newsletter “covering news and events on herbs, supplements, exercise, nutrition, complementary and alternative medicine modalities, practices, and policy.”