Documentation Record-keeping FCLB Annual Congress April 29

Documentation & Record-keeping FCLB Annual Congress April 29, 2010 Baltimore, MD 1

Standards of Practice 1 aº Statutory Law 1 bº Board Regulation Federal Regulation (CMS) 2º Board Policy Guideline 3º Recognized Authorities: * CCE-accredited institutions * chiropractic organizations * accepted experts within profession 4º Consensus of what practitioners do 2

Minimal Standard Minimal “the smallest amount or lowest : limit” Standard: “something established as a measure or model to which other similar things should conform” Best Practice “the utmost/highest quality” : – “exercise of a profession” 3

Sub-standard Minimal Standard Better Practice Best Practice 4

FCLB Documentation/ Record -keeping Model Fall 2005 FCLB District Meetings • introduce June/2005 Federal OIG report which suggests poor chiropractic documentation practices Winter 2005/6: FCLB Board of Directors • educate state Boards to OIG findings • inquire from Boards about mandating CE hours in documentation as condition of relicensure • work with CCE, ACC, COCSA, ACA about developing acceptable documentation curricula 5

FCLB Documentation/ Record -keeping Model Spring 2006: FCLB Annual Congress • Resolution #2 -06: Request that state Boards require CE hours in documentation as condition of relicensure Winter 2006/7: Website Data Collection • 50 States; 4 had no web-sites • 46 States; 22 had statute or regulation that specifically pertain to record-keeping (48%) • 46 States; 2 had (non-enforceable) record-keeping guidelines (4%) 6

FCLB Documentation/ Record -keeping Model Spring 2007 & Fall 2007: FCLB Annual Congress & Regional Meetings • presentation of website findings, feedback & opinion Fall 2008: FCLB Regional Meetings • introduce draft doc. /record-keeping model outline • prioritize information, add/ amend material Winter 2008/9: Survey sent to all state board members • condense/ finalize model outline 7

FCLB Documentation/ Record -keeping Model Spring 2009: FCLB Annual Congress • FCLB Model Practice Act Committee acceptance Fall 2009: FCLB Regional Meetings • introduce doc. /record-keeping Model Act regulations Spring 2010: FCLB Annual Congress • presentation of FCLB Model Practice Act regulations on Documentation & Record-keeping 8

Patient Record Purpose: to memorialize a patient’s medical info. , clinical findings, provider recommendations, therapeutic actions and outcomes. Benefit: for the historical record itself. Two essential qualities: (1) What should the record contain? DOCUMENTATION (2) How should the record be maintained? RECORD-KEEPING 9

. . . a patient record is like a car, is has essential parts seat belts steering wheel engine fuel tank transmission tires 10

. . . a patient record is like a car, is has essential rules of maintenance registration age of operator change oil gasoline speed limits tire pressure 11

Documentation: 6 -items the patient’s identifying information, and identity of the treating chiropractor(s) and all care providers; the reason for the encounter, including any subjective complaints and pertinent history; the current objective findings and results of diagnostic studies; the diagnosis and/or assessment of the patient’s condition; a management and/or care plan, including the recommendations, intended goals, prognosis, modifications to the plan, and the procedures provided; evidence that the patient was informed of any material risk relative to a proposed procedure and consented to receive this procedure. 12

Documentation Each patient record shall, at a minimum, contain the following information: the patient’s identifying information, and identity of the treating chiropractor(s) and all care providers; the reason for the encounter, including any subjective complaints and pertinent history; the current objective findings and results of diagnostic studies; 13

Documentation Each patient record shall, at a minimum, contain the following information: the diagnosis and/or assessment of the patient’s condition; a management and/or care plan, including the recommendations, intended goals, prognosis, modifications to the plan, and the procedures provided; 14

Documentation Each patient record shall, at a minimum, contain the following information: evidence that the patient was informed of any material risk relative to a proposed procedure and consented to receive this procedure. All documentation items shall have an adequate and reasonable level of detail and pertinent clinical information. 15

Record-keeping: 5 -items legible and self-explanatory; contemporaneously constructed and chronologically organized; contain only accurate and reliable information, including any necessary amendment; maintained in a physically secure and confidential manner; accessible to the patient and treating doctor within a reasonable period. 16

Record-keeping Each patient record shall, at a minimum, be maintained in the following manner: legible and self-explanatory; contemporaneously constructed and chronologically organized; contain only accurate and reliable information, including any necessary amendment; 17

Record-keeping Each patient record shall, at a minimum, be maintained in the following manner: maintained in a physically secure and confidential manner; accessible to the patient and treating doctor within a reasonable period. 18

Member Board - Action Steps * require. CE hours in documentation/recordkeeping as a condition for license renewal * adopt. FCLB documentation/record-keeping model regulations as a policy guideline, and then a regulation in your jurisdiction * be mindful approving documentation/ in record-keeping seminars (PACE-approved) * imposeuniform sanctions in documentation/ record-keeping based violations 19

(insert FCLB common slide here) you must, you can, you are not alone! 20

Kirk Shilts, D. C. Massachusetts Board of Registration of Chiropractors (617) 277 -1344 dr-shilts@comcast. net Albert Stabile, Jr. , D. C. New Jersey Board of Chiropractic Examiners (201) 342 -6111 docbiker 728@optonline. net 21