Editor's Note: Part 1 of this article appeared as a digital exclusive in the December 2018 issue.
Standard of Care and Documentation (Cont.)
I save (print and scan in file) all emails and texts to and from patients regarding any recommendations of care, follow through of therapies, and especially urgent or emergency care recommendations.
All of my clinical documentation, SOAP notes, treatment notes of three months, emails and texts were reviewed (subpoenaed) by all parties involved. I was not sued, but the MD involved from another facility was. The case was settled in less than 11 months. *Many claims can take between 4-6 years.)
After I take the simple initial lateral view in this typical sample scenario, I would do a report of findings explaining the results. This usually encompasses C5-6 mild to moderate degeneration or lower lumbars, osteophyte spurring, spondylolithesis (ligament laxity analysis, which is quantified per AMA guides), desiccated or diminished disc space.
During the ROF, I always correlate the patient's symptoms with the X-ray, give a treatment plan for the next 1-4 months, and my mindset of ordering an MRI to further diagnose the discogenic lesions involved either in a period of time (number of visits) without seeing clinical results or asap. I tell the patient that the MRI will tell us how many discs are involved and how severe the discs are. In addition, the MRI will tell us if there are any curve balls involved, such as severity of disc lesions (migrating or worse) that I would not typically expect in these types of cases.
After I get the MRI, we will correlate the symptoms with the discogenic levels involved and decide on a second-opinion referral to help us out with breaking the inflammatory cycle (and another doctor with another set of eyes to optimize your patient's success). Then the treatment begins if the patient and I are on the same page.
Paper Trail: Key Recommendations
But wait, we are not done. We need to document the initial exam and patient's file for our paper trail, especially if the patient never comes back to our office for follow-up care. From all my reviews of case files and my trial experience with court testimony, I have come up with some suggested recommendations that will help with clinical competency and patient care. My suggested recommendations (when necessary depending on the patient's file, and case scenario) are the following:
1. Explain the patient's current condition utilizing spinal models, the patient's X-rays, current symptoms, treatment options, diagnostic recommendations to further analyze the patient's condition, and follow-up with primary / ortho / surgical consult for further evaluation.
2. X-ray studies of the lumbar and cervical regions are medically necessary based upon signs, symptoms, and patient presentation to rule out instabilities, degeneration and osteophytic formations. Stress views are recommended if indicated by initial set of lateral views to quantify instability (document when necessary).
3. MRI studies of the lumbar and cervical regions are medically necessary based upon signs, symptoms and patient presentation to rule out disc herniations in 4-8 consistent visits or asap. [I recommend selecting an avenue (time frame) when you are ordering advanced imaging based on symptoms, patient presentation, history, etc.]
4. Recommend second opinion for evaluation (possible injections, further diagnostic testing) with ortho, surgical consult, or primary based upon symptomatology and patient consultation with initial X-rays and current MRI findings.
Your Best Defense: Great SOAP Notes
A defense attorney I have multiple cases with tells me constantly, "The best defense I have to walk into court with is competent, complete and legible SOAP notes from the doctor." The four SOAP note recommendations above will aid in showing medical necessity, your decision-making mindset, your clinical expertise, and your patient's well-being.
At the end of the day I want to provide competent and compassionate care to increase the credibility of our profession, decrease liability in our practices, and increase clinical excellence in our communities.
Dr. Todd Cielo, a graduate of Life University, has practiced in Tampa, Fla., for 14 years, specializing in ligament laxity analysis, digital motion X-ray and objective impairment rating. For more information, visit www.cielochiropractic.com.