Documenting Phases of Care

Let us take a few minutes to talk about phases of care.  I get a lot of questions on documenting treatment, I had a call the other day where the doctor actually asked is there any research that shows how long we should be treating a condition.  This is an interesting question because there is no way truly to formally “research” how long you should be treating somebody.  Let us take an example of somebody that is on heart medication.  All the research on this topic tries to show what type of intervention will have an effect normalizing blood pressure as an example, but there is no research that says how long you should be on blood pressure medication.  It is really difficult to say because once you withdraw the medication, that patient’s high blood pressure is going to come back.  So, the intervention is as long as it is needed and the way that you determine that is by your re-examinations. 

In chiropractic, there are the typical three phases of care.  We have the acute intervention when the patient first walks in that is really sort of a corrective and pain reduction sort of intervention.  Reduce pain, reduce muscle spasm, and correct the biomechanical abnormality or subluxation is the goal of this phase, that should be outlined in your notes. 

The second phase is stabilization which now we are stretching and strengthening muscles while we are giving the patient home exercises, etc.  And then finally, you have the health maintenance phase which is the maintenance of the item that you stabilized and corrected.  The health maintenance phase is the proper terminology because that is what the research uses when describing such terms of care.  You are maintaining the health of their spine which is dependent on the “condition it is in” [DDD. DJD etc].  It is no different than medicine for diabetes or high blood pressure or kidney disease or anything like that.  We do not use the term “wellness” when you are communicating with the medical community or researchers because we are the only profession that uses it.  So, when you look at health maintenance care, the important component of that is that it is documented as such.  So the patient comes in for a re-evaluation, they are stable, they are doing well, they are getting back to their life activities, now, you are doling out maintenance care and that could be for reduction of pain or it could be maintenance of that biomechanical problem.  When you are treating people long term for health maintenance, it is critically important to have a significant objective finding to base your care plan on.  That could be ligamentous laxity, it could be an old fracture, they could have degenerative disc disease, they could have loss of lumbar lordosis, all of those things are critical biomechanical issues that justify long-term care. 

So, when you are taking a patient that has these conditions, spend the time properly documenting your first case because those words that you use in your note can simply be a macro for the rest of the patients that are similar.  Remember, things do not vary much between patients when it comes to spine problems.  Just like a cardiologist or an endocrinologist, we are seeing all the same stuff.  So, when you make you macro, do not make is specific to a patient by using their name or surgeon by using their name.  Use the patient or the surgeon in general.  That way, your macro can be used between patients. 

I hope that helps.