Best Practices: PARQ in Clinical Record Keeping

Informed consent is a process involving verbal discussion as well as proper documentation. CHP recommends as a “best practice” that informed consent be fully documented and included in the clinical file.

One common option for documenting informed consent is noting the acronym “PARQ” which can be written in the patient’s chart indicating that the provider has explained the procedures (P), viable alternatives (A), material risks (R), if any, and has asked if the patient has any questions (Q). “PARQ” should be noted prior to the implementation of any treatment. If the patient requests further information or has specific questions, the provider can underline the PARQ chart notation to reflect the patient’s request. The provider should note the particular question and note the more detailed information provided. While this is an appropriate method of documenting that this process has occurred, there is no substitute for the patient’s written confirmation of those facts.

It is also recommended that the patient execute some document acknowledging that they have been part of an informed consent process, the material risks have been disclosed including a description of those risks and that the patient has agreed (“consented”) to the procedures understanding any risks inherent to that procedure. This could be accomplished using a prepared written consent form that must be signed by the patient and should be signed by the doctor. Again, it is important to note that practitioners should not rely exclusively on those forms and must communicate directly with the patients.

As new conditions occur that may require different evaluation procedures or different treatment procedures, additional informed consent should be obtained from the patient. In addition, consent given to one physician is not consent for any other physician unless the patient agrees to the substitute. This assent to the substitute physician should be noted in the clinical record.

The Minor Patient (In the US, minor is legally defined as a person under the age of 18)
As with all patients, informed consent is required for minor patients. There are different considerations required based on the type of provider delivering the service, e.g. DC, MD, as well as the services that are being provided, e.g. chiropractic adjustments, reproductive healthcare. For the purposes of Best Practices, it is recommended that the provider review the specific statutes or rules regarding obtaining informed consent from a parent/legal guardian or the minor patient, whichever is appropriate, that applies to the services rendered in the state in which they practice.

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.

Cigarette smoking is down among kids. What’s the bad news?

The only national survey of middle and high school students focusing exclusively on tobacco use demonstrates that cigarette smoking among kids is down but use of other tobacco produces is way up. According to Benjamin J. Apelberg, Ph.D., branch chief of epidemiology at FDA’s Center for Tobacco Products, “Middle and high school kids are using novel products like e-cigarettes and hookahs in unprecedented numbers, and many are using more than one kind of tobacco product.” What is the impact of these survey results for clinicians? Patient intake questionnaires should ask about use of tobacco products not just smoking.

Read more about this survey and the results here.

Best Practices: Documenting Informed Consent in Clinical Record Keeping

Documentation of informed consent in the patient’s chart is important from a number of perspectives: health care ethics, malpractices risk management, and effective patient management. The most important goal of informed consent is that the patient has an opportunity to be an informed participant in health care decision making. It is generally accepted that complete informed consent should be obtained from patients before carrying out any diagnostic or therapeutic procedure and includes a discussion of the following elements:

  • The nature of the treatment plan, procedure or diagnostic testing
  • Reasonable alternatives to the proposed intervention
  • The relevant risks, benefits, and uncertainties related to each alternative, including the risk of refusing care
  • Assessment of patient understanding
  • The acceptance of the intervention by the patient

Informed consent is the process by which fully informed patients can participate in choices about their health care. It originates from the legal and ethical right each patient has to direct what happens to their body and from the ethical duty of the physician to involve the patient in his or her health care. Fully informed patients have adequate foreknowledge or understanding of the recommended treatment and/or diagnostic testing, the anticipated outcomes and alternatives to it. It is the process of effectively communicating with patients in terms they understand, and then allowing them the opportunity to ask questions.

Malpractice Risk Management
Despite our best efforts as careful clinicians to do what is right, bad outcomes do happen. In an informed consent process, the potential risks of an adverse outcome are dealt with up front with each patient in a straight-forward and non-threatening manner. Having this conversation with patients first helps a great deal in those unlikely cases with a less-than-optimum outcome. What is more, patients who have access to open information exchanges are less likely to sue for malpractice.

To protect yourself in malpractice litigation, in addition to carrying adequate liability insurance, it is important that communication about the informed consent process itself be documented in the clinical file. Good documentation can serve as evidence in a court of the law that the process indeed took place. A timely and thorough documentation in the patient’s chart by the provider of the treatment can be a strong piece of evidence that the provider engaged the patient in an appropriate discussion.

Of the complaints that we receive at CHP, the most common is “the practitioner hurt me.” Often the patient goes on to describe an uncomfortable procedure (adjusting, massage, acupuncture needles) followed by post-treatment soreness, stiffness or other symptoms. The perception of an uninformed patient in this scenario boils down to “That practitioner hurt me.” and CHP gets a complaint. A complete “informed consent” discussion with that patient acknowledging the risk of discomfort with the procedure and the potential of post-treatment soreness may well have prevented this perception and prevented a complaint.

Patient Management
Informed patients make better health care decisions. Open discussion with patients about treatment plans, common alternative treatments that may be available, the risks that may be associated with them, including refusing care, and invitation to patients to ask questions and receive clarification are primary activities for all health care providers. Often dubbed the “PARQ” conference (an acronym for “procedures, alternatives, risks, and questions”), this open communication empowers each patient to obtain all necessary information, ask questions and to collaborate with the clinician in making decisions about care.

Patients who are able to make informed decisions are more likely to follow through on your treatment recommendations. They have demonstrably better clinical outcomes, are more satisfied with you and your care and they are more likely to refer their family and friends.

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.

Overactive bladder treatment may decrease fall risk for eldery

A recent analysis of Medicare claims presented at the American Urological Association 2015 Annual meeting reveals that treating an overactive bladder might help reduce the risk of falls for older patients. While chiropractic care has not been evaluated for an overactive bladder, many chiropractic physicians see improvements in this condition after lumbar and pelvic manipulations. To read the full text of the Medscape article, click here. (You may need to sign up for a free Medscape account to access this article.)

Low vitamin D level common in painful diabetic neuropathy

A study presented at the American Diabetes Association (ADA) 2015 Scientific Sessions indicates that vitamin D may have a role in the pathogenesis of diabetic peripheral neuropathy, a painful side effect of Type 1 and Type 2 diabetes. The authors of the study plan to do an intervention study to determine if this is a significant finding. For more information on the ADA 2015 Scientific Sessions  and this study click here. (You may need to create a free account to access Medscape articles.)

The chemistry of massage

The International Journal of Neuroscience recently published an article reviewing research about the effect of massage therapy on cortisol, serotonin, and dopamine levels. Unsurprisingly, massage has positive effects on all causing cortisol to drop and serotonin and dopamine to rise. Click here to read the full abstract and view options for obtaining the full article text.

Open access online resource for chiropractic research

If you are a chiropractor looking for research on a particular patient condition, a new resource sponsored by Council on Chiropractic Guidelines and Practice Parameters (CCGPP) is now available: This site collects the latest information on medical topics pertinent to chiropractic care and presents them free of charge as a resource for chiropractic physicians. Materials available include relevant and current peer-reviewed journal articles, either as abstracts or full-text, depending upon availability. Summaries and annotated bibliographies are available for each topic.

Best Practices: Provider & Patient ID in Clinical Record Keeping

One of the most basic elements of a clinical record is full and complete identification of the provider, the office, and the patient. Whether the record is paper to be scanned into an electronic medical record (EMR) or paper forms stored in a physical file, best practice is a complete ID on each and every page of the chart.

  • The provider should be identified by name, professional designation, physical address and telephone number.
  • The patient should be identified with a full name and date of birth or other unique identifier such as a health record number.
  • The author of the note should be clearly identified and include a verifying signature. Note: If forms are two-sided, each side should have complete identification.

Some providers complain, “Why the over-kill? I know who my patients are.” It’s true that, while the chart is in the provider’s office and under their control, everything may be clear. However, when copies are made for another health care provider, an insurance company, or even an attorney and the provider or patient’s ID is not on every side of the paper record, the receiver may not be able to tell for certain that a piece of the record is from the provider or pertains to their patient. A completely identified record with a full signature or validated electronic signature is an unassailable legal record. Also, mishaps happen. If records are vandalized, misplaced, or even just fall to the floor, proper identification of each page will allow successful reassembling of the files.

If you use an EMR system, check your software settings to ensure proper ID is printed on every page. If you are printing commonly used forms – such as a patient intake form – always allow space for the patient name and DOB or other unique ID on each page. Make sure that the clinic address and phone number is included on each page. In multiple provider offices make sure to identify the provider seeing that patient.

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.

CDC releases survey results for physical activity levels by age

The CDC has just released data from the 2013 National Health Interview Survey (NHIS) showing the percentage by age of survey respondents who say they meet US Preventive Services Taskforce recommendations for physical activity. Compared to the NHIS from 2008 the recent numbers show slight increases in all age groups, however in the most active age group (18-44), less than 25% of respondents met “both aerobic-activity and muscle-strengthening.” The guidelines recommend moderate-intensity physical activity for ≥150 minutes per week, vigorous-intensity physical activity for ≥75 minutes per week, or an equivalent combination of moderate- and vigorous-intensity activity, and engaging in physical activities specifically designed to strengthen muscles at least twice per week. Even fewer seniors (>65) meet activity goals with only less than 15% reporting adequate physical activity.

Read the QuickStats report here.

Cochrane review of percutaneous vertebroplasty

Osteoporosis is common among the elderly, especially women. Vertebral compression fractures are a painful sequel of an osteoporotic spine and the most common complication seen in osteoporosis. More than 700,000 new compression fractures happen in the US each year at a cost of $1.5 billion. (More here.) Integrative medicine providers may treat patients with pain from osteoporotic compression fractures.

A recent innovation in surgical treatment for these painful fractures is percutaneous vertebroplasty. The procedure involves injection of cement into the fractured vertebra which then hardens and supports the fracture. A recent Cochrane systematic review of this procedure however calls into question the effectiveness of the procedure. Given the cost of the procedure and the potential for complications, conservative non-surgical treatment approaches are a reasonable alternative.