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

2. Standards of Practice 1aº Statutory Law 1bº 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

3. 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”

4. Sub-standard
Minimal Standard
Better Practice
Best Practice

5. 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

6. 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%)

7. 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

8. 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:
• presentation of FCLB Model Practice Act regulations on Documentation & Record-keeping

9. 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

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

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

12. 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.

13. 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;

14. 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;

15. 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.

16. 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.

17. Record-keeping  legible and self-explanatory;
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;

18. 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.

19. Member Board - Action Steps
* require CE hours in documentation/record-keeping 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 in approving documentation/ record-keeping seminars (PACE-approved)
* impose uniform sanctions in documentation/ record-keeping based violations

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

21. Albert Stabile, Jr., D.C. New Jersey Board of Chiropractic
Kirk Shilts, D.C. Massachusetts Board of Registration of Chiropractors (617)
Albert Stabile, Jr., D.C. New Jersey Board of Chiropractic
Examiners
(201)