Using dynamic functional capacity testing for outcome assessments is an important visual tool for documenting patient care

During disciplinary actions with state boards, national data banks, individual state data banks, and litigation, accurate documentation is critical. We, as chiropractors, need to defend our treatment plans and show reasonable and necessary medical care.

Currently, there are a variety of requirements in place that mandate meeting minimum standards in patient care. All states have a broad basis for tort law called negligence. Here,liability may be imposed for results that were not intentional. but with fault by the defendant who failed to perform a duty required by law. It is immaterial that the defendant believed in good faith that he or she was careful, but that a foreseeable person of ordinary prudence would have acted under the same circumstances. The greater the foreseeable risk of harm, the greater care is required. Depending on the state statutes and circumstances, there may be either or both of two types of duties owed: 1) The duty to conduct oneself as a reasonable person would under the same or similar circumstances; 2) The duty of due care, or special duty, imposed by statute or case law, which may be in addition to, or in place of the duty of due care.

All states require DCs to meet minimum record keeping requirements. Most include retaining a case history, an examination, x-rays, a treatment plan, daily progress notes, any and all past history records by other physicians, diagnostic tests, and medical consents.

If we fail to meet these standards, then we may be disciplined by the state board, or if patients perceive any injuries, we can face malpractice suits. With the new Health Insurance and Portability Accountability Act (HIPAA), which deals with patient confidentiality and privacy issues, we face new state and federal laws concerning patient care and documentation.

Take Careful Note
While examining patients, each individual differs in the length of time for treatment and should receive care appropriate for his or her condition. Since there is such a difference and no definite determination as to treatment duration of individual cases, the judicial system has been required to address these issues in litigation. Remember, you must be able to defend not only your records in court, but also your opinions as to the care of your patients. One such way is clear, accurate, and legible record keeping that demonstrates reasonableness and medical necessity in patient care from the first day to the day of discharge.

The most effective way is through outcome assessments, which should be attached to every patient case. An outcome assessment is a procedure of measuring a change in the patient’s condition over a period of time to determine whether the condition has improved, remained the same, or worsened. Keep in mind, the diagnosis must change as the patient’s condition dictates. Often, the same diagnosis is used through the entire treatment plan, which is a red flag. In addition, charting these changes in your progress notes is essential to the medical-legal arena.

Critical areas I have noticed while reviewing medical malpractice cases are: poor and illegible record keeping, continued treatment without medical necessity or documentation, and a lack of an informed consent in the majority of medical malpractice cases. Your records are vital to your defense in a malpractice action against you. They will either defend or prosecute you.

Outcome assessments relate to your treatment of the patient on a day-to-day basis. In addition to your chart information, diagnostic testing—when necessary—can help you with the treatment of the patient, as well as in your outcome assessment. With the proper type of testing, you can establish medical necessity and document the need for further care. This is important in cases involving personal injury or workers’ compensation cases. I place great emphasis on the proper diagnostic test that would be necessary for the condition, but also yield the most information to document patient progress and show the need for care.

Put to the Test
From a medical-legal standpoint, especially involving personal injury cases, documentation is extremely important for settlement purposes and litigation. In recent years, there has been a decline in settlements in personal injury cases and reimbursement issues for doctors. Most of the time, there is a lack of documentation to support the soft tissue injury. In some cases there is no testing done, or the testing done comes back negative or normal.

Knowing the biomechanics and how the mechanism of an injury occurs will help you understand what is needed to document your case. A diagnostic visual tool of injuries, which is supported by more than 30 years of research, is of great value in your soft tissue injury cases. Most of the research has been through the University of Michigan, Ann Arbor, and the National Institute for Occupational Safety and Health. Few doctors use this biomechanical video analysis diagnostic tool, and many do not realize it is available.

This type of testing can be performed in your office or on the job site. The test can measure each joint angle during any given task, and it allows for measurement of the range of motion (ROM) through the entire sequence of any task. The analysis tracks ROM of each joint during the task and predicts the weakest points where the individual is injured. This can be displayed in picture form on the report. This type of testing can document your cases, identify critical risk factors associated with unrestricted dynamic movements following an injury, and objectively measure the severity of soft tissue injuries. This test is accepted in the medical community and court with more than 500 published articles to attest to the validity and reliability of the results.

If you perform diagnostic testing, choose wisely to make sure it gives you the most objective data that will document your case. There are many legal statutory changes on the horizon that will affect health care, both from a state and federal standpoint. All of these changes will have civil remedies attached to them, but some will also have criminal penalties. Most changes involve privacy, confidentiality, medical records, and documentation issues that will affect outcome assessments.

The ability to document your cases and visualize the soft tissue injury through testing can be of tremendous value to you, the attorney, and in litigation. In addition you can determine strength, return-to-work status, safe lifting limits, and chance of re-injury. From a medical-legal standpoint, this type of testing will increase your ability to compete effectively in the personal injury and workers’ compensation market. CP

Kenneth S. Ross, DC, JD, MBA, LHRM, is a retired criminal law enforcement officer. He practices chiropractic in Orlando, Fla, and is a member of the Orange County Bar Association. Ross is a faculty member of Texas Chiropractic College, teaches tort law, and conducts a national expert witness certification course. He can be reached at 407-682-6041, or via his website: www.medicallawjd.com.