Maintaining Complete Records

protecting-your-practiceAccording to the Canadian Chiropractic Protective Association (CCPA), one of the hardest situations to encounter when legally defending a chiropractor is discovering that their record-keeping processes are not complete.

It’s tempting to take shortcuts in the clinic to save time, but these processes are crucial to patient care and thorough record-keeping. When you document your road map to care consistently, it is easier to defend your practice in times of legal dispute.

There are six key components in the road map to care: Patient history, examination, diagnosis and differential diagnosis, report of findings, informed consent and treatment/SOAP notes. A health record is only complete when all six components of the road map to care are present.

It is especially important that your records demonstrate that your examination and care aligns with the patient’s history and their stated concerns. The CCPA offers an example of this: If a patient came in with foot pain and the chiropractor only recorded examining their spine, this would make it difficult to defend the chiropractor effectively. Maintaining detailed records can protect your practice.

The Standard of Practice S-002: Record Keeping establishes the minimum requirements in Ontario.

Record Keeping and EHRs

Electronic Health Record (EHR) software can help you to ensure that your examination is congruent with what the patient has shared and that the examination record contains enough detail to show how you arrived at your diagnosis. It is important to consistently record your findings, and EHRs can help you specify how these findings align with the patient history, examination and your diagnosis.

In most EHRs there are also sections dedicated to SOAP notes, encouraging thorough note-taking that shows exactly what you’ve done and how it helps the patient’s health.

When your patient records are kept in an EHR, it is also easier for you to share these digital records with your legal counsel if you encounter a legal situation.

Informed Consent

Informed consent ensures that your patient understands your diagnosis and proposed treatment plan and has consented before you proceed. Using an appropriate informed consent process will protect you from legal trouble and protect your patients from misperception.

It is important to keep your informed consent forms current so you are sure your patients do not have unanswered questions. The CCPA advises practitioners to avoid stale documents by revisiting informed consent forms for every new condition that your patient is faced with or every two years.

There are four key components to informed consent:

  1. Listing the benefits of the treatment.
  2. Discussing the risks that may be involved.
  3. Providing alternative treatment methods.
  4. Obtaining a signature.

The CCPA suggests that you first allow your patient to read over the informed consent form. After they have read over the document, discuss the elements outlined in the text.

Remember to state how the prescribed treatment will benefit their condition but also the risks involved. Don’t look at discussing the risks as a deterrent. If you have an honest conversation with your patient, they are more likely to be comfortable with whatever the risks may be.

After you’ve discussed the benefits and risks, give your patient the opportunity to ask questions. They may need clarification no matter whether it’s their first appointment or they’ve been coming to you for years.

Once all of their questions are answered, offer alternate forms of treatment. If alternative treatments such as rest, exercise or other therapies could help your patient’s condition, it is important to share this information. This allows your patient to make an educated decision.

If your patient agrees to continue with the treatment you have suggested, they can date and sign the informed consent form.

The CCPA believes that the informed consent process is not effective if it is done without the practitioner present. Simply asking patients to read and sign the form while waiting for their appointment to start doesn’t promote a full understanding of their diagnosis or proposed treatment. For this reason, the CCPA advises practitioners to obtain informed consent in the treatment room after a discussion with your patient.

When reviewing your informed consent procedures, you may wish to consult the CCO’s Standard of Practice S-013: Consent.

Informed Consent and EHRs

EHRs make it easy to access the patient’s full history of informed consent. This history is extremely useful when dealing with legal situations because it shows that that the performed treatment was agreed upon by both the practitioner and the patient.

If an informed consent form has not been renewed recently, some EHRs will remind you to follow up with the patient.

More Information

The OCA would like to thank Dr. Greg Dunn and Dr. Dean Wright from the CCPA for their assistance with this article. For support and advice on record keeping and informed consent, the OCA and the CCPA are here for you:

OCA: or 1-877-327-2273 (local: 416-860-0070)
CCPA: or 1-800-668-2076 (local: 416-781-5656)

On-Demand Webinar

Protecting Your Practice and Electronic Health Records (EHRs)
The CCPA presents on how to mitigate risk and liability when using EHRs in your clinic. You’ll learn how EHRs can be used for informed consent, roadmaps to care, practice protection and consistently excellent patient care.

Article from ON Chiropractic – Issue: Spring 2016