Shouda, Coulda, Woulda…. What Records to Keep on Your Patients???
by Honora Lee Wolfe
One of the things that many acupuncturists struggle with is what records they should keep on their patients and for how long. It’s actually quite a list and I will openly admit that it has never been my strongest suit! I think it’s something we all struggle with. Below I’ve written the basics of what you need, whether digital or hard copy. Everyone’s practice is different and, the truth is, if you are going to bill insurance regularly, then ALL of this is pretty much necessary. If not, you can ask your malpractice provider what their minimal requirements are….but I bet it’s pretty close to this. So create a system for yourself into which all this stuff is simply built in to your process. That way you don’t have to think about it each and every patient…it just becomes what you do.
If anyone thinks of something that should be on this list, I hope you send it to me! I’ve also given a short rationale for each of these, unless it’s so obvious as to not need explanation. If you use digital files, some of these instructions could change or be less relevant, which I will discuss as I go through these as well as I am able.
• The patient name should appear on all pages. While digital record-keepers could have the patients name connected with each relevant file, in paper files it’s best if the patient name is somewhere on each physical page. While there is no reason to think that you will mix up one chart with another…you never know. What if your moving guys were moving large file cabinet drawers and they dropped one?
• All pages secured into the treatment folder. It’s easy to purchase file folders with metal clasps or tabs that hold all the papers at the top of the file (Smeed Classic Fastener folders #14537). Both sides have the fasteners, so you can separate money/legal papers from treatment papers. Then, even if the clumsy moving guy drops the cabinet drawer, the papers are all secure inside!
• Organized chronologically (most recent date on top). This makes it easy for you to track what you did from one week to the next. This will be automatic with digital record keeping systems.
• Write legibly, be consistent, clear and concise. Easier said than done, but important. When your patient moves to New York and asks to have their chart sent to a new practitioner, it’s nice if you can be proud of what you are sending. Will what you have done and why you did it be clear and easy to understand?
• Maintain record in ink, use the same pen for each entry on the same day. This is important if your charts are ever subpoenaed in a legal case. If you are using only digital records, the software will know when entries were made.
• Do not alter the records, do not erase, use correction fluid, or use adhesive labels to cover up anything. If you made a mistake or need to make a correction, reference where it goes in the chart relevant to which date, and simply put it into the chart from where you are. Or, clip or staple a page onto the page that needs to be changed and reference the specifics.
• Fill in all blanks, do no skip lines or leave spaces, line through large blocks of space. In addition to conserving trees, which is certainly worthy enough, this rule keeps you or someone else from being able to go back and easily add erroneous information or change things in that day’s entries.
• Do not “squeeze in” notes and do not indent… same thing as above.
• Make additions and changes appropriately, on the page where you are, reference the page you want to change and why, or add a clipped note to the page that needs to be amended. In digital files, date any changes or additions to another day’s notes.
• Record all patient contact of every type
- a. Missed appointments are documented
- b. Telephone messages are documented
- c. Entries dated, timed and initialed by you
- d. Patient non-compliance is documented
- e. Faxes, emails are documented
• Initial all externally generated reports (X-ray, lab, diagnostic, consultant) before filing them
• Dictation and correspondence and reports proofread, initialed by you before filing. Keep dated copies of any item that you send anywhere for or about a patient.
• Maintain a legend for any codes or abbreviations used. This list should be in your employee manual, or procedures manual, or kept somewhere that employees can reference it if necessary or copy it to be mailed with any records that have to be sent anywhere.
• Document the reason for the visit. This should be done every time the patient comes in, even if it is just a short visit to reconfirm a diagnosis or an acupuncture follow up visit with no further diagnostic assessments.
• Document any unusual events. If the patient does or says anything unusual or alarming, or if there is a strange interaction between a patient and any staff member, this should be in absolute detail in the chart notes.
• Avoid or explain contradictions. If something about what you wrote some other visit is for any reason no longer correct, explain why this happened. If you take a complete u-turn in your treatment modalities with a patient, explain why. If you did something that you now think was wrong, explain why and what you will now do about that.
• Clinical findings (positive/negative) documented and the problem or complaint list is kept current. Don’t leave out diagnostic details, but be as concise as possible.
• Treatment plan documented. This is both the short term (today) and long term (series of treatments) treatment plan. This can and will change throughout the overall course of treatment.
• Entries are objective; do not get personal beyond what’s necessary to write up the case and what you did about it.
• Never criticize other providers or their treatment methods. You will get patients who have seen other practitioners, including other AOM practitioners. You may not agree with what others have done with your patient. You must, to the best of your ability, leave that past behind and simply do what you think is right for the patient in the present moment. It is unprofessional to criticize other practitioners’ work, even if you think they are a total idiot.
• Properly identify the file, the record keeper (you or your employee), the techniques employed in the treatment, the table and/or room used and the channels and points treated. When the patient comes back a few days later and says, “that was a great treatment; can you do that again?” you do not want to be in the situation of not remembering what treatment you gave and then find that you did not write it down!
• Patient instructions are documented. If you know what you asked the patient to do as homework, there is an engaged discussion to be had with the patient that makes them feel that you are paying attention to their case. If you don’t write it down, you won’t remember what you told them, unless you only have three or four patients in your practice!
• Document any patient non-compliance. If they did not do the homework, take the herbs, change their diet, whatever, they should not be complaining that they don’t feel any better!
• Informed consent is in the chart. This is one of the fundamental legal documents that you must have in order to legally stick needles in patients (or do moxa, or do whatever)
• Be certain that the “Release of Records Authorization” form in the chart is correct and valid. If you need the patient’s records from a previous practitioner, this form is vital.
• Referral letters from other practitioners are kept in the file. If you keep digital records, scan the letter or copy the email and store it.
• Prescription list is in the chart, both Western and Chinese. If the patient is taking western meds, that list needs to be in their chart. Whatever herbals or supplements you recommend must also be kept up to date.
• Herb list is current, when due to refill, reactions or allergies, or positive results documented.
• Keep financial and clinical information separate. In a digital record-keeping system, this is automatic. If you use paper records, the Smeed Classic Fastener file folders help you keep both sides of the chart (a. financial/legal and b. clinical) tidy and separate.
• Retain patient records forever because of the statue of limitations on malpractice cases is very, very long. If you have paper records, you may at some point want to scan them and keep them on a CD or in a back up system.
• Signature of the provider of services on each new treatment date in the chart. Each time the patient comes in, a new signature by you as treating practitioner or any acupuncturist-employee you hire to do treatments must be in the chart notes for the day you or they did the treatment. Every time.
Customize the forms you use for your specific clinic and style of work. Your forms should probably not be a clone of anyone else’s…unless you think that form is already perfect for you!
Again I repeat: Create a system for keeping your charts (whether paper or digital) that you always repeat the same way with each patient every day in clinic. Don’t vary this procedure once memorized. Teach your employees how to help you and where their participation is appropriate, legal, and vital, so you are not doing all this by yourself! This stuff is another good reason to have front desk staff.
The most important thing to remember about record keeping is this: if you did not document it, it never happened from a lawyer’s point of view.