In the CCOA’s third webinar, Roadmap to Better Clinical Records moderated by Registrar Dr. Todd Halowski, Dr. Shima Shahidy, Director of Claims, Canadian Chiropractic Protective Association (CCPA) and Dr. Katy Pedden, Chair of the CCOA Competence Committee, discussed how record keeping is essential to competent practice, how it supports your patients and helps you maintain your professional commitment to the standards of the profession.
The importance of taking and writing thorough histories for your patients
Dr. Shahidy opened the webinar with the statement that chiropractors, by and large, are excellent communicators. To be the best practitioners they can be, chiropractors must have a natural and easy rapport with their patients. The patient is always welcome and encouraged to ask any questions about their care, or carry on conversation that highlights potential problem areas. However, the concern exists that this rapport is not accurately recorded, and instead internalized within the practitioner. For example, Dr. Shahidy shares that, “often very interesting things pop up on an intake form. When you look at it after the fact, you're like, wow, that's serious. Did anyone ask any questions about that?”
Sometimes the answers are lacking. It is important to ask yourself, and record what other red flags may have been discussed. What other underlying conditions? Did the patient give their informed consent for this care? How and why does the treatment evolve through your relationship with the patient?
Dr. Pedden adds, “chiropractors are excellent at addressing the issue that a patient might enter their practice for.” However, issues may arise when, in a haste to provide relief to the patient, missing data on the in-between steps can leave the clinical record sparse. “For example, if a patient is entering your practice with a low back complaint, you have a very thorough history on that.” Dr. Pedden explains. “And we can read that and see that you've asked all the important questions. However, two treatments in, you're now treating their neck and there's very little (information in their health record).”
As well, the patient may request a copy of these visit notes be made available for their own records, or those of their other appropriate health care providers. It is then doubly important that these notes be filled as complete as possible, both for their own information, as well as their other health care providers.
Why keeping a clinical record updated is important
The clinical record is one of the chief ways of protecting the practitioner in case of complaint or review. “If a doctor has contemplated a particular diagnosis, have they done an adequate array of tests to rule in and rule that out?” Dr. Shahidy asks. “If you've done them and you've shown that, then there's a pathway to see, well, there was nothing preventing the doctor in treating this person at this time. There were no red flags.”
If this natural progression of the treatment is not accurately documented though, this pathway does not exist and the practitioner could face problems in the future. The panelists also wanted to stress the importance of testing, even if a negative result is expected. The diagnosis could change in the future, and accurate testing, even negative results, narrows the pool of possible results. An accurate clinical record of all routes explored, and tests conducted, not only ensures the practitioner operated correctly, but promises the best standard of care for the patient.
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