Documentation Guidelines February 2018 NYCC Health Centers

Transcription

1 Documentation Guidelines February 2018 NYCC Health Centers This document is to be used as a guide for proper documentation and in conjunction with the File Review process by both students in the DCP and by clinicians as it relates to quality assurance. This guide describes proper documentation and location details that are expected in the SmartCloud EHR. Paper SOAP notes and other documentation items are expected to be present within the patient s case file in a similarly organized system. For evaluation and mentoring purposes, the draft version of SOAP notes submitted by chiropractic students should be utilized. [In SmartCould, the student s SOAP note submissions can be viewed by using the View Document History function.] Contents 1) Privacy practice ) Problem list The Problem Oriented Medical Record (POMR) ) Patient history ) Clinical Examination ) Diagnostic testing and diagnostic imaging ) Diagnosis ) Informed consent ) In-office treatment plan (Patient Care Plan) ) Self-care recommendations / Home Care recommendations ) Treatment goals ) Outcome measurements ) Progress notes ) Patient response to care per formal assessment of patient progress ) Management plan modification ) Documentation supports billing Appendix Privacy practice details Example of an executed Report of Findings (ROF) and Informed Consent (IC) form: Patient history details Clinical examination Objective Speed Note example:... 26

2 Clinical examination Examinations page example: Clinical examination Physical Exam page example: Patient Care Plan (Case Types) Example patient care plan in SmartCloud: Progress notes SmartCloud Plan Speed Note Discharge documentation: In-office treatment plan details Self-care recommendations - details Treatment goals details Outcome measurements - details Revised Oswestry Back Pain Disability Questionnaire Management plan modification details Documentation supports billing details... 42

3 1) Privacy practice The patient privacy verification is located on the back of the patient registration packet. The HIPAA Notice of Patient Privacy Practices may be provided to the patient upon request, unless emergency conditions make it impossible (the latter should be documented). The privacy verification should be signed by the patient on the first day they present to the health center and scanned into the patient record in the EHR. A form not dated the first day or signed by the patient (or a form not present at all) is a clear deficiency. Click here for detailed privacy practice information 2) Problem list The Problem Oriented Medical Record (POMR) POMR is a method of recording data about the health status of a patient in a problem-solving system. The POMR preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plan by all members of the health care team. The particular format of the system used varies from setting to setting, but the components of the method are similar. A data base is collected before beginning the process of identifying the patient's problems. The data base consists of all information available that contributes to this end, such as that collected in an interview with the patient and family or others, that from a health assessment or physical examination of the patient, and that from various laboratory and radiological tests. It is recommended that the data base be as complete as possible, limited only by potential hazard, pain or discomfort to the patient, or excessive assumed expense of the diagnostic procedure. The interview, augmented by prior records, provides the patient's history, including the reason for contact; an identifying statement that is a descriptive profile of the person; a family illness history; a history of the current illness; a history of past illness; an account of the patient's current health practices; and a review of systems. The physical examination or health assessment makes up the second major part of the data base. The extent and depth of the examination vary from setting to setting and depend on the services offered and the condition of the patient. The next section of the POMR is the master problem list. The formulation of the problems on the list is similar to the [assessment section of the SOAP note]. Each problem as identified represents a conclusion or a decision resulting from examination, investigation, and analysis of the data base. A problem is defined as anything that causes concern to the patient or to the caregiver, including physical abnormalities, psychological disturbance, and socioeconomic problems. The master problem list usually includes active, inactive, temporary, and potential problems. An excerpt from Mosby's Medical Dictionary, 9th edition. 2009, Elsevier. See sample Problem List

4 SmartCloud Location: Problem List Page The Problem List in the SmartCloud EHR is the starting point of the patient s initial and subsequent SOAP notes. Due to the functionality of the SmartCloud electronic health record, it is necessary to choose a problem (an ICD-10 code) in order to introduce the subjective history of a patient concern. It should NOT be considered the final diagnosis at this point since the highest level of understanding of the problem has not been determined at this time. In order to standardize the entries in the EHR, the subjective symptomatology should be entered by region of the body for musculoskeletal complaints. It is suggested that the regional joint dysfunction codes should be used to enter the subjective description or history of a problem for musculoskeletal complaints (M99.01 through M99.08). For visceral complaints, is suggested that the general unspecified codes be used to start the note (i.e. the R ICD-10 codes). Once the differential diagnosis or highest level of understanding of the patient s problem is determined, it will be entered into the problem list before the note is closed. When entering the problem in the problem list, use one of the macros in the comment box to direct the reader s attention to the regional area where the subjective description is already entered and no further details are necessary. Non-musculoskeletal codes such as hypertension (I10)and type 2 diabetes (E11) should be in the problem list, but not in the SOAP notes as a treated condition. 3) Patient history An appropriate, structured, complete history should be obtained and recorded at any clinical evaluation. Every clinical evaluation history should include: - Items relevant to the chief complaint and problems revealed during the evaluation - A review of medical, social, and family histories, appropriate to the complexity of the complaint and patient; each element should be noted - A review of relevant systems Various mnemonics are used to represent the core components of a patient history, some more common to specific regions or disciplines. These include: OPQRST (onset, provoking/palliative factors, quality, radiation, site, temporal factors LMNOPQRST (location, mechanism or medical history, new symptoms, other symptoms, provoking/palliative factors, quality, radiation, severity, timing) SOCRATES (site, onset, character, radiation, alleviating factors, timing, exacerbating factors, severity). While these can guide the taking of a structured, complete history, it is important that all relevant information is obtained and recorded, not only regarding the chief presenting complaint(s) (e.g. course/progression of the complaint, previous treatments and response to

5 prior care), but also for other problems revealed during the evaluation (e.g. headaches indicated on the systems review, an unreported surgical scar discovered upon examination). For chief complaint history, review of systems, family history, medical history, and social history, items should be relevant, obtained to sufficient degree to differentially diagnose, and recorded in sufficient detail to inform future care and allow third parties to render judgment on standards of care. Remember that SmartCloud has a separate system of entry for many of the past medical history and family history items. This includes the Meaningful Use (MU) requirements, including: Allergies Family history Medications Smoking history/tobacco use Vital signs (although not technically history, the vital signs are entered here) These items should be entered/updated and included in the SOAP note during an examination visit. In addition, there may be problems that are complicated by or associated with these items and need to be recorded in the problem list as such, i.e. hypertension, diabetes, etc. It is also appropriate to report that the patient reports no changes in family, past medical, or social history where these histories have been previously recorded. This statement should be in subjective freeform section of the subjective speed note in the EHR (Paper notes will require separate documentation). Remember that Meaningful Use (MU) reporting may require an update in the patient record (Histories Section of the EHR). SmartCloud Location: History Speed Note SmartCloud has the commonly asked questions on the History Speed Note page as easy entry buttons. It should be emphasized that these may not be able to portray the complete picture. There are both complaint and subjective freeform tabs. It is necessary to enter information that completes the history of a problem (in the complaint freeform tab) or general information that does not link to one of the problems being evaluated (in the subjective freeform tab). If the patient presents with more than one problem, then each problem needs a complete history unless there is a reference to a regional or visceral code (see starting a note in Problem List above). Whenever appropriate, a body diagram should be entered in the note with problem areas marked and labelled.

6 This item is deficient if patient care documentation lack an appropriate, structured, and sufficiently comprehensive chief complaint, medical, social, and family history, and a review of relevant systems, all correctly documented. See sample history 4) Clinical Examination Clinical examination is necessary for all patients presenting to the clinic whether wellcare, health clearance or symptomatic. The clinician in consultation with the chiropractic student will need to decide the appropriate level of evaluation necessary to arrive at a working diagnosis. Further, this examination should also be used as a risk management tool (similar to a pre-surgical screening) so that any procedures we select in our treatment plan are safely delivered/modified for the individual patient. The examination must include minimal core components. Additional case specific components that will relate to significant findings are warranted on a case-by-case basis. The case specific examination will focus on the unique patient condition being examined that might not be evaluated by the minimum core components. The clinician may direct the student to perform or not perform specific exam procedures due to special circumstances unique to the patient both for the core or case specific examinations. The examination The clinician along with the chiropractic student must: a) Perform, interpret, and document appropriate clinical examination procedures. b) Order and use specific diagnostic tests when appropriate based on information obtained in the case Return history to and the other top. clinical examination procedures (see diagnostic imaging to review). c) Record a working diagnosis based on the highest current level of knowledge and understanding of the patient s case. Minimal core components of the examination (must be performed on all new patient examinations and usually performed on established patient examinations): Postural evaluation Spinal joint and soft tissue assessment Spinal range of motion Spinal screening orthopedic assessment Vital Signs includes: Neurological assessment o Ht., Wt., bilateral B/P, pulse, respiration and temperature o Screening of motor, sensory and reflex functions related to cervical/lumbar spine and upper/lower extremities o Pathological reflex

7 Case specific examination (determined by the history and area of the condition i.e. shoulder): o May require orthopedic and neurological exam of a peripheral joint/segment of the body. o Detailed segmental peripheral neurological examination and peripheral vascular examination to investigate complaints of tingling, numbness or weakness in an extremity. o Cardiovascular, cardiopulmonary, lymphatic, and/or abdominal examination may be required. o Specific physical examination procedures should be performed and evaluated when related to the area of chief complaint. o Record the results even when negative. Examples of inappropriate or unacceptable work that would indicate a deficiency: 1) Is not complete (missing key components necessary for diagnostic conclusion i.e. orthopedic and/or neurological tests not present for a radiculopathy diagnosis) 2) Lacks essential core examination components for a clinical evaluation of a new or existing patient missing one or more of the following: a) vital signs (includes height, weight, B/P, pulse, respirations and temperature) b) postural evaluation c) spinal ROM d) spinal joint and soft tissue assessment e) orthopedic assessment of the region (spinal screening) f) neurological assessment of the region (MRS) and other necessary assessment(s) 3) Lacks essential case-specific examination components depending on the case, certain exam procedures would be expected in order to determine the appropriate course for the patient. Example: Low back complaint does not include evaluation of the abdomen including auscultation of the abdominal aorta; or thyroid exam in a CTS case or weight issue. 4) Examination results are incompletely documented. 5) Missing/not documented SmartCloud Location: The examination information should be documented in the EHR: 1. Objective Speed Note page 2. Examination page 3. Physical examination page Paper notes must contain the same elements. This item is deficient if essential core or case specific items are missing, or if the documentation of the examination is not clear or absent. See sample Clinical Examination

8 5) Diagnostic testing and diagnostic imaging During each course of care, it must be determined whether or not a patient needs special testing procedures. Additionally, if a patient has already had testing completed, results should be requested and reviewed. These reports should be signed by the clinician and scanned into the patient record. This information may be utilized as part of the diagnosis and management plan. A summary statement should be documented indicating that the test results were reviewed. SmartCloud Location: A summary of the results of the diagnostic testing (including the place, date and if appropriate, the reason for testing) should be listed in the General Assessment section of the Assessment Speed Note. The actual report should be scanned into the EHR and the summary should be present in the student draft note. There are 4 possible outcomes: 1) imaging, lab work, or other special tests WERE critically required in management of the case and WERE ordered 2) imaging, lab work, or other special tests WERE critically required in management of the case, but WERE NOT ordered 3) imaging, lab work, or other special tests WERE NOT critically required in management of the case and WERE NOT ordered 4) imaging, lab work, or other special tests WERE NOT critically required in management of the case, but WERE ordered This item is deficient if outcomes 2 or 4 above are indicated in the chart. Outcome 2 represents gross under-management (including ordering the wrong test with information available at the time), and outcome 4 represents gross over-management. This item is also deficient if documentation of the review of testing is not noted, management modification if critically needed is not documented, or the results shared with the patient was not documented. 6) Diagnosis The diagnosis should be listed at the highest level of understanding. It should be supported by the patient s history and examination findings. The diagnosis should be clearly evident in the patient file in at least 4 places and on the Patient Encounter Form. The diagnosis/es should be:

9 1) Written in plain and medically accurate language (not codes or abbreviations) on the informed consent form for the patient. See informed consent. 2) Written in the header of the Patient Care Plan both the case type and ICD-10 diagnosis code numbers. See Case Types in appendix. The diagnosis codes should be listed in the order used in the Plan Speed Note section of the SOAP note. Codes used for billing should be consistent with the patient encounter form (routing sheet). [Note: In order to be aware of possible complicating factors, the footer of the patient care plan should also include all critical review of systems, comorbidities, or other relevant past medical history findings as well as relevant family history.] If the diagnosis lacks important elements related to the chief complaint, review of systems, comorbidities, or other relevant findings, or if the diagnosis is inconsistent with significant findings, is not a sufficient level of understanding ( radiculopathy, site unspecified or headache instead of cervicogenic headache when these are indisputably clear), is not current (resolved diagnoses are still listed, or diagnoses that have been refined in the SOAP notes have not been refined in the care plan), or is missing, documentation in the chart is deficient. NOTE: The case type should be listed as a type of care plan to avoid student confusion (a problem may have been present for more than 3 months, but is being treated on an acute care basis, i.e. 3 visits per week for a period of time with expectations of resolution in a relative short phase of care). The care plan should be fairly consistent with the case type selected. NOTE: A wellness case type (non- medically necessary elective and generally non-third party reimbursable care) may have only subluxation diagnoses and codes without secondary diagnoses and codes. No other case types should have subluxation codes without secondary codes. There may be secondary codes for wellness care, but it is not required for elective, wellness-orientated care. Nonthird party reimbursable problems need to be coded, for student management, but not used in the billing. These problems should be evident in the adjustment page of the SOAP note with the modalities used to address them (usually student services and not the clinician s). 3) Coded in the Plan Speed Note. The Plan Speed Note should have all of the diagnosis codes entered that are in the header (these codes need to be within chiropractic scope of practice). They should remain consistent from visit to visit until the problem is resolved or there is a change, such as a diagnostic imaging revealing a finding or a new problem arises. 4) Coded in the Problem List. The problem list will also contain any other nonmusculoskeletal conditions of note such as hypertension, diabetes, etc.

10 5) The Patient Encounter Form. The form also known as the Routing Sheet should have the ICD-10 codes listed in the order for billing and consistent with the order in the header of the Patient Care Plan and the Plan Speed Note. Please refer to the case types document and case types decision tree for more detailed information related to diagnosis. SmartCloud location of diagnosis: 1. Problem list 2. Header of Patient Care Plan and in the Problems line in the Care Plan 3. Plan Speed note 4. Informed Consent form 5. Patient encounter form (Routing sheet not found in the EHR but same as Plan Speed Note) Click here for example diagnosis in the Plan Speed Note 7) Informed consent Informed consent must be obtained for all diagnoses and procedures, but must particularly address significant risk procedures. The informed consent is obtain during the report of findings procedure. It requires documentation of any health risks and management options considering the patient s health care needs and goals*. The diagnosis should be written out in plain language and highest level of understanding for the patient s benefit. Including only diagnosis codes and/or abbreviations on the informed consent form does not meet NYCC guidelines. The SOAP note should indicate that informed consent was obtained on the same day it was received. The patient care plan should indicate that informed consent was obtained. The treatment and diagnosis should be consistent across the SOAP, the patient care plan, and the informed consent. The patient and clinician should sign the informed consent form. Any new diagnosis, added treatment modality, or significant risk would require obtaining a new informed consent. An informed consent must be obtained by a licensed provider. In order to train the student, the following procedure and SOAP note documentation is suggested: the student discussed the report of findings and tenets of the informed consent with the patient while the clinician was present and the clinician confirmed that the patient understood. The patient and clinician signature are still required on the informed consent form that is scanned into the EHR. *CCE 2013 Accreditation Standards Meta competency Outcome The Informed Consent process and definition as per the Association of Chiropractic Colleges: a. Recognizing that all care including diagnostic studies and chiropractic care have some potential for causing injury to a patient, it is the recommendation of the Association of Chiropractic Colleges that, prior to performing diagnostic testing and prior to implementing chiropractic procedures, the patient should be informed about the

11 material and inherent risks and common options to the recommended care and the associated risks, including the risk of refusing care. If the patient wishes to continue he/she should give his/her consent. The Doctor should have a record in his/her clinical file documentation which confirms that consent was given by the patient to the diagnostic testing and/or the chiropractic procedure. b. Informed consent" is more of a process than a documented procedure. The Association of Chiropractic Colleges recommends that the Doctor engage in a thorough, verbal discussion with the patient, thus enabling the Doctor to be in a position to verify that he/she took the time to explain the material risks inherent in the recommended procedures and that the patient consented. Beyond this, the Association of Chiropractic Colleges recommends that the patient execute some document acknowledging that: (a) he/she has been part of an informed consent process; (b) that the material risks have been disclosed to the patient, including a description of those material risks; and (c) that the patient, after assessment, has agreed ("consented") to the procedures understanding any material risks which are inherent to that procedure. c. Whereas it is beneficial for the Doctor to have notations in the clinical records reflecting that the patient was advised of the material risks and consented to the treatment, there is no substitute for the patient's written confirmation of those facts. It is the Association of Chiropractic Colleges belief that the profession and the public interest are better served by an occasional patient refusing to execute an informed consent acknowledgment form as opposed to having licensed Doctors exposed to claims of informed consent violations when, in fact, informed consent was secured but not irrefutably documented and verified. It is the recommendation of the Association of Chiropractic College's to document the patient's consent to both the diagnostic procedures which the practitioner proposes to use, as well as to document the patient's consent to the "patient care plan" which lists the patient's diagnosis and identifies the particular procedures and/or modalities to be used. Resource: ACC Policy - Informed Consent Guidelines

12 Report of Findings (ROF) and Informed Consent (IC) process and documentation: The clinician or the student with clinician supervision is must discuss the following with the patient prior to rendering care. The report of findings will include: a) The clinical impression/working diagnosis(es) b) The management/treatment plan c) The risks and/or complications that may be apparent regarding the condition itself, or the treatment that may be given d) Any alternatives for the management of the diagnosed conditions e) The likely outcome of chiropractic care and management for the diagnosed conditions. After the patient is informed regarding the above items and related questions answered to his/her satisfaction, the clinician must obtain the patient s consent to initiate treatment as evidenced by the patient s and the clinician s signatures on the IC form. The diagnosis needs to be written out completely. There should be no abbreviations or codes used. The record needs to include a properly executed document indicating that the informed consent has been obtained from the patient. The signed document is not sufficient. A statement in the SOAP note acknowledging that the patient has understood and agreed to the care plan is necessary. Remember that the diagnosis on the IC form must be consistent with the diagnosis listed in the SOAP note(s). The treatment being provided in the SOAP note(s) must be consistent with the treatment indicated on the IC form. These must both be consistent with the Patient Care Plan. Indicators that initiate the need for an IC: Anytime there is a significant change in risk the IC should be obtained, signed, dated and noted on the date of the onset of care for a particular condition. As new complaints/diagnosis(es) arise requiring additional evaluation procedures or different care procedures additional informed consent(s) should be obtained from the patient and documented in the SOAP note(s). SmartCloud Location: 1. The signed Informed Consent form is scanned into the EHR. (see sample IC form) 2. A statement is listed in the Assessment Speed Note, General Assessment section indicating that the patient understood and consented to the treatment plan, health risks, management options considering the patient s health care needs and goals (a macro is available for this statement). 3. In the Patient Care Plan, in the Informed Consent Obtained line, indicate Yes and list the date. Do not delete prior dates if they exist. Diagnoses or significant risk procedures in the SOAP or patient care plan that are not consented to in writing by the patient are a clear deficiency. -

13 8) In-office treatment plan (Patient Care Plan) In the SmartCloud EHR, the In-office treatment plan is located in the Patient Care Plan page. The Patient Care Plan should contain all the relevant information for the comprehensive management of this patient including all treatment modalities and specifics of who delivers these modalities. In addition, all recommendations and factors that are needed to properly manage the case should be found in the Care Plan. This includes recommendations for lifestyle changes, exercise, nutrition, wellness and tracking of co-morbidities such as diabetes, and hypertension. Collaborative care and/or referrals should also be noted here. There should be dated ongoing notations tracking these recommendation or referrals. Nutrition handouts, rehab exercise handouts, patient education handouts and/or any correspondence or notes need to be documented and tracked as part of the plan. The plan: - Must not have treatment in areas of contraindications (such as manipulation of an anticoagulated patient whose INR is outside of therapeutic range or joint manipulation for patients with cancer), - Must be related to the diagnosis (there should not be a plan for lumbar manipulation for a patient with acute cervical torticollis), - should provide expected benefit to the patient - Must specify parameters (this must include specific location, parameters, settings, duration, treatment frequency and who applies the modality clinician or student). - Must have a planned assessment of patient progress (distinct from the plan end date these might be the same date, but there should be a planned assessment of patient progress noted. Note: NYCC uses the language assessment of patient progress while Smart Cloud indicates Reexamination in the Patient Care Plan. The SmartCloud line labelled Re-examination should be the location of the date of assessment of patient progress and what outcome measures are to be utilized. - Would promote patient dependence rather than work towards patient self-efficacy, (grossly excessive treatment frequency might be an example). - Needs to include all of the procedures used during treatment in the SOAP note, - Must include treatment that is appropriate for all chiropractic scope diagnoses and consistent with the overall patient presentation as well as any treatment/modalities used by the student for non-billable conditions/problems. - Includes all management for non-billable or non-musculoskeletal conditions. These plans may be for conditions that require tracking of collaborative care, referral or specific outcome measures. Each patient s case will be unique, but all problems should be addressed. Student draft versions of SOAP notes should have evidence of complete Patient Care Plans with the above mentioned components addressed. There must also be evidence of problem tracking and appropriate changes to the Care Plan as the case progresses.

14 Click here for a sample patient care plan 9) Self-care recommendations / Home Care recommendations Self-care recommendations are located in the Patient Care Plan listed as Home Care Recommendations. The recommendations should be consistent with best practices to reach a reasonable objective. There should be appropriate detail and/or parameters listed. There should be a typed in description or a scanned-in chart copy of all recommended self-care. SOAP notes should indicate that there was follow up with the patient relative to home care performance. If this is missing, the deficiency should be noted in the progress notes file review item. Work, school or sports restrictions must be noted in the Patient Care Plan. A scanned-in copy of any notes or correspondence in regard to these restrictions should be present in the patient s EHR. SOAP notes should indicate that there was follow up with the patient regarding any of these restrictions possibly with an additional scanned-in note. Example: a return to work note should be documented and scanned into the EHR. This item is deficient if the recommendations are: contraindicated, likely to produce no benefit (rather than maximally effective), lack needed detail and/or parameters, do not encourage patient self-efficacy and autonomy, or are absent. SmartCloud Location: Self-care/ home care recommendations should be located in the Home Care recommendations line in the Patient Care Plan page. These recommendation/orders should also be listed in the Plan Speed Note freeform section on the day the recommendations/orders were given indicating the patient understood and agreed with the plan. Click here for detailed self-care recommendation information

15 10) Treatment goals Treatment goals are located in the Patient Care Plan. Goals should be listed and have corresponding outcome measures. Generally, most conditions can be evaluated with a subjective measure and a separate objective measure. If not possible to use the accepted and valid outcome assessment tools (OATs), then SMART goals should be used, or a combination of SMART goals and OATs. SMART is a mnemonic for Specific, Measurable, Achievable, Relevant and Timed ( data/assets/pdf_file/0010/27595/clinical-frameworksingle.pdf ). In either case, it is necessary to be specific with goals and have an expected date of achievement as well as what is expected in the short term as appropriate for the case if not resolution of the problem. The long term goals (if appropriate for the case) should be the best estimate prediction of the objective being reached in fairly specific time frame. The time frame is determined by the case type being used (acute or chronic see Case Types in the appendix). SmartCloud Location: Goals are located in the Patient Care Plan of SmartCloud. There are both short term and long term sections in the Care Plan. Reasonable goals as outline above need to be entered into these sections unless it is expected that there is only one goal, short term. It is necessary to link the outcome measures with each goal. The outcome measures are listed directly after the goals in the Care Plan. Goals should be adjusted as they are or not met. Student draft notes should show evidence of evaluation of patient goals as the case progresses. Note: Goals listed at the end of the Patient Care Plan are the patient s goals noted on the intake form. These are not necessarily the short or long term goals listed above. They may be physical, health or activity related. They are listed and should be tracked as the case progresses over time. This item is deficient if any element of the goals are not in SMART format, if the goals do not include a functional component (if appropriate to the case), or are absent. Two example goals are provided here in poor and in SMART format other examples are in detailed treatment goal information. Poor goals: Reduce hypertonicity Poor goals: Be more active SMART goals: No trigger point in upper trapezius will produce pain greater than 2/10 on palpation within 3 weeks. (Even better than this, goals will focus on function see the following) SMART goals: Patient will perform minutes of moderate aerobic activity 3 days per week within 4 weeks General tip: The following terms should not be considered sufficiently specific or measureable: Amount of hypertonicity (unless a non-subjective measure of detection is included), number of joint restrictions, ROM in degrees unless double inclinometers are used in the SOAP/clinical

16 exam, or items such as reduce pain unless quantified (such as reduce pain per VAS from 3/10 to 1/10 ), etc. A goal is more likely to be specific and measureable by reliable and valid means if someone unfamiliar with the patient (and even someone clinically untrained) could verify the status on the goal with the patient without any previous interaction with the patient. 11) Outcome measurements Outcome measures are described in the Patient Care Plan and evaluation of this item requires assessing the plan, as well as care notes to determine if they were used. When outcome measure scores are obtained, they should be noted in the SOAP note in the General Assessment section of the Assessment Speed Note. There should be a comparison to previous outcome assessment scores if previously done. In addition, the scores should be noted in the Outcome Assessment line in the Patient Care Plan with the date acquired for easy reference in future SOAP notes. When used longitudinally, the scores should be related to the achievement of goals. This item is deficient if outcome measures are: incorrectly scored or interpreted, not valid or reliable, not correspondent to the goals (every goal should have a way to measure it), not used as planned to assess progress, not appropriate to the diagnosis (a headache questionnaire used for low back pain), not signed, and missing. NOTE: A measure should only be marked missing if it was done and mentioned in the note, but the score or outcome was not recorded. If the outcome measure simply wasn t done at all and should have been, mark that it was not used longitudinally for purposes of this review. NOTE: You may be aware of a better outcome measure than the one that was used, or you may have an outcome measure you prefer. If an outcome measure was used that does work for the diagnosis and is reasonable, even if not ideal, do not mark it as deficient. See OAT details SmartCloud Location: Outcome Measure Scores and/or SMART goal objectives must be documented: 1. On the date obtained, in the General Assessment section of the Assessment Speed note (with comparison to past scores if a longitudinal assessment). 2. In the Outcome Measures line of the Patient Care Plan with the date the scores were obtained for easy reference in future SOAP notes. Click here for detailed outcome measurement information

17 12) Progress notes Daily progress notes or SOAP notes track the patient s progress during the course of care. They tend to be brief compared with examination visits or formal assessment of patient progress visits. There are some minimal requirements that will change depending on the patient s condition: - Essential subjective information: How the patient is doing today, how the patient responded to the prior treatment, if the patient is doing homecare, if there is anything new. Key case specific information should be present if needed. For example: Are neurologic symptoms progressing? Did a needed follow-up with an outside provider occur as recommended? Etc. - Essential objective information: Any treated area should be appropriately examined prior to treatment (this may simply be observation, palpation, and/or range of motion in simple cases), and findings during and after care should be reported as appropriate. For Medicare and other documentation as needed, two elements of PART must be recorded, one of which is A or R (see below). - Essential assessment information: Diagnoses for the visit must be recorded in plan speed note. Response to care must be recorded here or in the Plan Speed Note Freeform section. Case specific assessment information should be present if critical. It is helpful, but not required for this file review, that each note indicates the patient s response to that day s treatment while still in the office. - Essential treatment information: All treatment and clinical reasoning for the visit should be recorded. For example, if a certain treatment was not rendered per plan, the rationale should be noted. If care is changed, rationale should be noted. If the treatment indicates hot pack and does not state per plan (with the patient care plan elsewhere detailed enough to follow easily) or does not state location, duration, and setting information in that section of the SOAP, it is deficient. The same is true for CMT-D it should indicate per noted restrictions, or list restrictions and soft tissue manipulation should include indication of muscles, regions, techniques, or other details that will render the day s treatment reproducible and understandable. Referrals, new homecare provided, recommendations, suggestions, and all clinical reasoning should be captured. Additional information is available from the NCQA website - GUIDELINES FOR MEDICAL RECORD DOCUMENTATION: ew.pdf Progress notes are located in the patient s record in the EHR and usually labelled SOAP notes. Each note during the review period needs to be assessed by reviewers. Minimal documentation requirements is governed by the PART mnemonic: P Pain or problem A Alignment

18 R Range of motion T Tissue texture/tension At least two of the above components must be present in the SOAP and one of them must be the A or the R. The progress or follow-up SOAP notes should track the patient s progress during a care plan. It is expected that brief description of the patient s current problem(s) be documented along with significant examination findings (as noted in PART). SmartCloud Location: Progress notes should include the PART notation in the Subjective and Objective Speed Notes of the EHR. The Assessment Speed note should contain pertinent or new information such as imaging or lab reports, or reports from outside healthcare providers. These may affect the prognosis and should be noted. There are additional buttons that are generally used during an Assessment of Patient Progress visit, example: Benefits are lasting longer. The Plan Speed Note must have the diagnosis listed exactly as in the Care Plan Header. The procedure codes should be consistent with the Patient Encounter Form (Routing sheet). Any procedure(s) performed by the student and not billable should be described in either the Adjustment page comments section or in the Plan Speed Note freeform (both contain macros for ease of documentation). The student should insert the Patient Care Plan in the progress note to ensure care is guided properly. This item is deficient if the progress notes do not capture essential subjective, objective, assessment, or treatment information, or if the notes are not signed or are absent. See sample Plan Speed Note 13) Patient response to care per formal assessment of patient progress This is determined and documented in an Assessment of Patient Progress visit, which should occur consistent with the Patient Care Plan and case type. The following guidelines constitute the Assessment of Patient Progress (APP) credit for all clinic courses and evaluated in the APP CRW in ExamSoft. The APP is not a complete examination, but a review of the patient s progress at a predetermined date. The date of this assessment may be changed if the patient presentation warrants. Components of the APP should include any outcome measures previously used in the case both subjective and functional, i.e. pain diagram with VAS, Oswestry or Back Bournemouth forms. ROM, orthopedic and neurological tests may be included if relevant from the onset of the case. The student and clinician should decide what measures are necessary to update the Patient Care Plan. The APP procedure requires enough information to determine if the patient requires additional care, home recommendations, referral or discharge. There needs to be evidence of decision making with regard to the care plan and future treatment planning.

19 The following process may be helpful: 1. Indicate in the history how the patient is doing now compared to intake and document the comparison. 2. Re-administer or re-obtain OATs that were listed in the Care Plan, compare to previous scores and report conclusions. Document the comparison in the General Assessment section of the SmartCloud as well as the Care Plan. 3. Indicate if goals were met, whether they should remain the same or be revised. This should be documented in the Care Plan. 4. If a re-examination of the patient is necessary, did it reveal pertinent positives and/or negatives (of prior ROM, ortho or neuro tests)? Compare the current to the findings at intake and document the comparison. 5. A revision of the diagnosis may or may not be in order. The student in consultation with the clinician will make the appropriate changes (if any) in the Care Plan, Plan Speed note for that day and the Problem List (some APP visits, but not all will rise to the level of E & M coding: Established Patient Evaluation depending on the case specific needs). 6. If there is to be a continuation of care, then the dates of future assessment and possible change to the end of care date need to be included in the modified Care Plan. Indicate the date of last assessment to the right of the start date. Do not change the original start date unless there is a new condition. SmartCloud Location: An Assessment of Patient Progress SOAP note should contain all of the elements of a Progress SOAP note with the addition of: Review of any pertinent testing (ROM, orthopedic or neurological findings) if positive at onset Documented evidence of longitudinal outcome measure scores (OATs) / SMART goal assessments and comparison with earlier scores / assessments. Evidence of medical decision making in an updated Patient Care Plan including diagnosis and any changes, continued care with or without changes noted, discharge at MTB or referral. This item is deficient if formal assessment of patient progress occurred, but needed information cannot be ascertained from the documentation or was not gathered. This item is also deficient if a formal assessment of progress should have occurred during one of the recorded visits, but the lack of formal assessment of progress is not satisfactorily explained. Click here for detailed patient response to care information

20 14) Management plan modification This is documented in the patient s SOAP notes and would be most likely seen on the assessment of patient progress (APP) visit or thereafter. However, this could occur at any visit as clinically warranted. The Patient Care Plan must be modified to be consistent with any change that is expected to continue on in future visits. A dated notation of such change should be entered in the Care Plan s Treatment Plan Modifications line, i.e. change of a modality such as cold laser, electric stimulation or rehabilitation exercises. The necessary documentation items are noted above in the Assessment of Patient Progress box above. The Treatment Plan Modifications line in the Care Plan must be dated with the specific changes (changes in procedures such as added treatment modalities or stopped modalities). This item is deficient if the plan is not modified when critically needed (patient harm or violation of patient autonomy* would result). Examples would be a patient who recovers and becomes symptom free who is not released from care or transitioned deliberately and with their consent to wellness care; or a patient who is not responding and whose management is left unchanged after a reasonable trial (up to 4 treatments for most uncomplicated scenarios, with perhaps as few as 2 treatments in very clear cut scenarios, such as uncomplicated low back pain). * Patient autonomy is the right of a patient to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient. Click here for more management plan modification information 15) Documentation supports billing This is assessed by comparing plan speed note codes with the documentation supplied from the ledger. This item is deficient if CPT codes in the billing and note do not match, the SOAP does not support the level of CPT code billed, the ICD codes in the billing statements and the billing ICD codes in the note do not match, or the number of billing records do not match the number of notes (with the sole exception of non-visit chart entries). Click here for detailed documentation/billing information Click here for a sample Patient Encounter Form (Routing Sheet)

21 Appendix Privacy practice details The patient should have a properly executed acknowledgement section of the Patient Intake form from the first visit. This form should be scanned into the patient s EHR in Smart Cloud or be present in a paper chart. Example of executed HIPAA Privacy Example of an executed Report of Findings (ROF) and Informed Consent (IC) form: Example IC form follows:

22 NYCC Health Center INFORMED CONSENT FOR TREATMENT Patient s Name Maya B. Herts Date 7/31/16 Diagnosis Sciatica left side associated with lumbar degenerative disc and joint dysfunction. Cervicalgia with cervicothoracic joint dysfunction. Treatment Modalities (circle all that apply) Instrument Assisted Adjusting/Activator Chiropractic Adjustment/Manipulation Cold Laser Therapy Cryotherapy/Ice Pack Electric Muscle Stimulation Exercise/Stretching Hot Moist Pack (HMP) Ultrasound Instrument Assisted Soft Tissue Massage (IASTM) Manual Soft Tissue Massage Other: I have received information from my doctor about my condition and proposed chiropractic treatment program, including the anticipated benefits, the reasonably foreseeable risks and side effects of the treatment, and alternatives to the proposed treatment, including no treatment. I understand that, as in all health care, there are some risks to chiropractic treatment. The risks include but are not limited to bruising, soreness, worsening of symptoms, muscle strains, sprains, fractures, dislocations, disc injuries, and strokes. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I have had the opportunity to ask questions about my condition and the recommended care, and my doctor has answered all questions to my satisfaction. I understand that I may ask further questions at any time. Comments (optional): Maya B. Herts 7/31/16 Patient/Guardian Signature Date Doctor s Signature Doc Ed Ucator 7/31/16 Date

23 Example of SmartCloud Problem List: Notice that I10 Hypertension is listed in the Active Problem Records, but is not listed in the Problem Records in Current Note section. The subjective description of the patient s symptoms is listed in the in the M99.03 Segmental and somatic dysfunction of the lumbar region. The M54.42 Lumbago with sciatica, left side was added once the history and examination determined this to be the highest level of understanding diagnosis. The Onset Comments to the right of the diagnosis codes directs the reader of the note to the segmental dysfunction where the subjective description was originally recorded. Return to the top

24 SmartCloud Assessment Speed Note example including IC statement: The informed consent statement is present in a macro for ease of entry. For additional help, the following is a list of common errors with informed consent (it is not necessarily all of the possible errors): Form is missing from case Abbreviated, missing or incomplete diagnosis Diagnosis codes listed with no words (missing diagnosis) Diagnosis is inconsistent with diagnosis being treated in SOAP note(s) Treatment is not listed or incompletely listed Treatment modalities are inconsistent with the plan and/or SOAP note(s) Patient s name and/or signature is missing Doctor s signature is missing Date is missing or not consistent with the onset of care

25 Patient history details SmartCloud Subjective Speed Note example: Notice in the example that there is additional information in the Complaint Freeform tab related to the condition that the pre-set buttons do not cover.

26 Clinical examination Objective Speed Note example: Clinical examination Examinations page example:

27 Clinical examination Physical Exam page example: Patient Care Plan The header should include the case type (example: Acute Care Plan - see example below) to guide the orders documented in the patient care plan. Case Types and Management Plans Acute Patient Presentation Public Health category of treatment: Secondary prevention curing/resolving a problem that exists (in NMS terms, successfully treating radiculopathy or an episode of LBP, etc); the point of this care is to reduce PREVALENCE of a condition, so existing problems go away.

28 Acute Care Presentation Criteria: 1. New patient or Established Patient with new condition or similar condition with moderate to severe symptoms 2. Initial onset <3 months (if greater than 3 months onset, but patient presents with moderate to severe symptoms, then an acute treatment approach may be appropriate see below). 3. Spinal condition is in scope of chiropractic care 4. No contraindications to chiropractic care found Acute Care Plan must include: Treatment type including who provides services (student or clinician). Visit Frequency Duration of care [Limiting factor: Therapeutic trial of up to 12 visits in 4 weeks] Assessment date if progress is documented through outcome measures, then further care may be warranted with expectations of resolution of the condition. If additional trials of care are indicated, supporting documentation should be available for review, including, but not necessarily limited to, documentation of complicating factors and/or comorbidities coupled with evidence of functional gains from earlier trial(s). Efforts toward self-care recommendations should be documented. NYCC uses the term Assessment of Patient Progress, but SmartCloud uses Reexamination. Use this line in the Patient Care Plan to document the date of the assessment visit. This date should be consistent with the visit frequency and duration for the therapeutic trial or continued care. Home/Work recommendations Goals Outcome Measures (OM) [Assess outcome measures < 1 month - with improving condition, OMs every 4 weeks thereafter and at discharge] Chart documentation: - Initial visit history and exam essentials - Follow-up visit SOAP notes need to track the current condition and pertinent evaluation. During course of care: document condition change, dx test results, referrals, comanagement, etc. Discharge expected at Maximum Therapeutic Benefit (MTB) within a 1 3 month period document discharge and outcome measure scores. Exacerbations/Recurrences (subset of acute care) 1 Document exacerbation a) MTB reached and withdrawal from care documented b) Same or similar condition recurs within 30 days of discharge. Classified as Acute Recurrence if similar condition is found after 30 days of discharge but needs to be treated in the acute-type care plan. c) Moderate to severe symptom level d) Discharge at MTB expected as in Acute Care Plan 2 Exacerbation Care Plan (similar to Acute Care Plan with attention to active care and lifestyle modifications)

29 a) Trial of up to 12 visits in 4 weeks b) Active care recommendation and/or lifestyle modifications c) Consider dx tests, co-management or referral d) Monitor for MTB with Outcome Measures (OMs) e) May be heading for Chronic Care algorithm so discharge notation is necessary with baseline outcome measures. Chronic Care Symptomatic aka Chronic Recurrent Care Public Health category of treatment: Transition from Secondary prevention (expect condition to resolve and a discharge of the patient) to Tertiary prevention (condition may not resolve but quality of life factors may be improved see next section). 1 Defining characteristics of Recurrent symptom(s) for symptomatic chronic recurrent care a) Mild symptom level b) Unplanned/unscheduled visit (more than 30 days since withdrawal of care) c) Often conditional discharge at same visit (consider diagnostic testing if progressive changes noted over time) d) OM score may never reach zero, but should be monitored over time for significant change that may indicate need for change in plan (may be headed for supportive care algorithm) 2 Document: a) OM at each visit (pain diagram/functional questionnaire may be necessary) b) Recurrence of previous condition (date and dx) (review any diagnostic testing reports that may be available) c) Unscheduled visit (walk-in, call-in, etc.) d) Review active care/home recommendations e) Conditional discharge notation with instructions for follow-up only when necessary f) Monitor OM scores over time for significant deterioration (may be indication for plan change) Supportive Care aka Ongoing Chronic Care: Public Health category of treatment: Tertiary prevention managing a condition that is not curable/resolvable, but working with quality of life issues, management of comorbidities, etc (in NMS terms, this would be care that helps someone with spastic paralysis regain 5 degrees of ROM so they can continue to live independently, but tx is required weekly or working with the patient who has MS and care is palliative and quality of life, etc); the point of this care is to reduce the MORBIDITY associated with a condition, but not to resolve the condition. 1 Defining characteristics of supportive care case type a) At least 2 withdrawals from care for a problem (example: low back pain) b) MTB documented (outcome measures recorded for baseline measurement)

30 - Functional assessment tool preferred c) Active care/lifestyle modification attempted d) Assess/consider risk of long term care e) Risk/Benefit ratio must be in patient s favor f) Long term plan in place with future attempts at withdrawal from care g) Monitor for deterioration of condition or other health concerns request and/or review any diagnostic testing reports available 2 Document: a) 2 withdrawals from care (dates & OM baseline) b) Medical necessity (OM score(s) above baseline) see medical necessity criteria c) Active care &/or lifestyle modification attempts d) Alternative care consideration e) Risk of long term care assessment (risk/benefit red flags) f) Set goals with future attempt at withdrawal from care (at 6-10 months) g) Individualized plan w/ long term assessment visits scheduled appropriately h) Monitor for deterioration of condition document any complicating factors such as diagnostic test results that complicate the patient s condition, for example: a degenerative IVD Suggested Plan Template: Ongoing Chronic/Supportive care plan In the SOAP note, episodes of care/dates must be documented. Other significant notations should be clear: Active care/lifestyle modifications recommended in past plans OM scores at time of discharge(s) Current OM scores Red Flags or lack of In the Patient Care Plan notate the following: Date of Assessment and/or the last assessment date New informed consent if necessary Plan of care: Treatment type/frequency Active care/lifestyle modifications Goal(s) Monitoring method (OMs) Expected trial withdrawal from care date Follow-up instructions Wellness visit/ Elective care (sometimes referred to as Maintenance or Preventive care): Public Health category of treatment: Primary prevention preventing a problem from occurring in the first place (in NMS terms, this would be ergonomics consulting to prevent the overuse syndrome, the carpal tunnel syndrome, the ITB syndrome in a

31 runner, etc); the point of this care is to reduce INCIDENCE of a condition, so they don t happen. 1 Goals (one of the following) a) recognize and reduce the incidence of a condition (prevent overuse syndrome, etc.) b) optimize levels of function (ADLs not limited, but individual wants performance enhancement) c) maximize performance (athletic activity enhancement/improvement) d) Maintain joint flexibility (correction of subluxation) 2 Methods a) Manipulation b) Nutritional counseling c) Exercise guidance d) Lifestyle modification / patient education e) Monitor health conditions f) Assess any need for referral or co-management 3 Parameters and documentation (Plan Template): a) Document individualized goals a) Consider individual health indicators use AHRQ epss * - be sure to include appropriate A level recommendations are acted upon in the plan and SOAP notes. b) Consider Health Promotion and Wellness Checklist (use BMI calculator, etc.) c) Indicate treatment types/management measures, frequency, outcome measures (if possible). Note: Maintenance treatments are an elective form of care. Medicare and many 3 rd party payers do not cover it as a medically necessary treatment. It is thought of as preventive treatment where further clinical improvement is not expected (if Est. Pt.) Maintenance treatments are not covered by: - Medicare - Most insurance contracts * The Electronic Preventive Services Selector (epss) is an application designed to provide primary care clinicians and health care teams timely decision support regarding appropriate screening, counseling, and preventive services for their patients. The epss is based on the current, evidence-based recommendations of the U.S. Preventive Services Task Force (USPSTF) and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors. Available both as a Web-based selector and as a downloadable PDA application, the epss brings information on clinical preventive services that clinicians need - recommendations, clinical considerations, and selected practice tools - to the point of care. Source: US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) Annual Check-up Evaluation 1 Yearly physical examination (at appropriate E/M service code ) 2 Assess/identify health risks a) Focus on spinal health

32 b) Review/evaluate general health (SF-36 ) 3 Provide advice and education: a) Promote health use BMI calculator, nutritional advice, blood pressure check, etc. b) Prevent disease use AHRQ epss to recommend/make referrals 4 Similar to wellness care (but may be covered service for some insurance) CPT codes for Annual Physical Exam Established Patient: / years old / years old / 65 years and older References: New Patient / years old / years old / 65 years and older National Public Health Partnership, The Language of Prevention. 2006, Melbourne: NPHP website: Baker GA, Farabaugh RJ, Augat TJ, Hawk C, Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain, Topics in Integrative Health Care, 2012, Vol. 3(4) ID: Globe G, Farabaugh RJ, Hawk C, et al, Clinical Practice Guideline: Chiropractic Care for Low Back Pain, JMPT Vol 39(1):1-22, NCQA BPRP definition of acute and subacute care programs, U.S. Dept. HHS. National Guideline Clearinghouse, Best Practices & practice guidelines. Intervention and Practice considered: Spinal manipulation therapy (SMT) (frequency and duration), New York State Workers Compensation Board New York Mid and Low Back Injury Medical Treatment Guidelines rymtg2012.pdf

33 Ronald J. Farabaugh, DC, Mark D. Dehen, DC, Cheryl Hawk, DC, PhD. Management of Chronic Spine-Related Conditions: Consensus Recommendations of a Multidisciplinary Panel, J Manipulative Physiol Ther Sep;33(7): Epub 2010 Aug 25. Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy Guidelines) Dehen MD, Whalen WM, Farabaugh RJ, Hawk C. Consensus terminology for stages of care: acute, chronic, recurrent, and wellness. J Manipulative Physiol Ther Jul-Aug;33(6): Dept. of Health and Human Services, CMS Misinformation on Chiropractic Services bulletin ICN October 2011 (updated on Aug. 28, 2012) MLN/MLNProducts/downloads/Chiropractors_fact_sheet.pdf US Department of Health and Human Services Agency for Healthcare Research and Quality AHRQ epss

34 Case Types Decision Tree Based on Case Types 1/21/2014 Does the patient seek care for functional limitation or pain? Yes No Is this the first time for this problem and is the initial onset <3 months? Does the patient seek care to actively achieve optimum health possible? No Yes No Yes Is this the first time for this problem and is the initial onset >3 months? See the Acute Care rubric. Suggest appropriate care or referral outside of the clinic. STOP. Initiate the Wellness Care rubric. No Yes Did the patient s symptoms resolve? Yes No Yes Yes Not first TX for presentation. Were symptoms quiescent for <30 days? Is the goal resolution of the (underlying) condition? Is care still appropriate? Does the patient seek care to actively achieve optimum health No Yes No Yes No Exacerbation Recurrence Is goal to manage symptoms of an unresolvable underlying condition? Suggest appropriate care or referral outside of the clinic. STOP. Is the acute care rubric still appropriate? (No contraindications, <2 documented care withdrawals, modifiable factors?) No Yes Consider another trial (if appropriate), withdrawal, or the Supportive Care rubric. Follow the Supportive Care rubric Yes No See the Acute Care rubric. See the Chronic Care rubric. Suggest appropriate care or referral outside of the clinic. STOP. Is the visit expected to be for the occasional flare up? (<1 visit/month) No Yes Yes No Is goal to manage symptoms of an unresolvable underlying condition? Follow the Symptomatic Care rubric

35 Example patient care plan in SmartCloud:

36 Note that the above plan contains all of the pertinent information about the diagnosis and management of the patient including problems within the scope of practice and conditions that need to be tracked or determined to fall into the realm of collaborative care. Progress notes SmartCloud Plan Speed Note Sample Plan Speed Note: Notice that the diagnosis codes are listed in the order of billing and the procedure code is listed for the billing. The response to treatment/follow-up recommendations are noted in the Freeform section.

37 Discharge documentation: Note that a patient discharge (or change in care type) would indicate that the day s visit is expected to be the last visit for that complaint. The student and clinician will indicate that the condition is resolved after that visit. The Care Plan must then indicate that the condition is resolved after the date of visit and no further care is warranted or the case type is changing and a new plan is indicated (for example: acute to chronic). The student at the direction of the clinician may decide to create a brief non-visit chart entry with a Freeform SOAP note indicating resolution of the problem for reporting to outside healthcare professionals. That short discharge summary non-visit chart entry note is the documentation that the patient is released from care and may be necessary for some 3 rd party payers. In-office treatment plan details NYCC does not use the Treatment Plan pages of SmartCloud due to the inconsistent functionality of the page in the program. Use freeform entry spaces in the Plan Speed Note and/or Adjustment section in SmartCloud for any specific treatment details associated with that day s visit. Self-care recommendations - details Self-care recommendations: Self-care is personal health maintenance. It is any activity an individual can perform with the intention of improving or restoring health, or treating or preventing disease. All details of the self-care should be appropriately stated in the Patient Care Plan. Self-care or home recommendations may include exercise (location, duration, settings, frequency, reps, sets, or other parameters), nutritional recommendations (dietary changes/advice), activity restrictions (work or sports), or simply asking the patient to remain active. All details of the active care exercise should be appropriately stated in the Patient Care Plan with the date started.

38 Treatment goals details Goals should be: 1) In SMART format, and ideally functional (Outcome Assessment Tools such as Oswestry or Bournemouth Questionnaires may work as measures of these goals) 2) Present for all diagnoses 3) Tailored for the specific patient SMART format: Additional detail: Specific and measureable goals: The following terms should not be considered sufficiently specific or measureable: Amount of hypertonicity (unless a non-subjective measure of detection is included), number of joint restrictions, ROM in degrees unless double inclinometers are used in the SOAP/clinical exam, or items such as reduce pain unless quantified (such as reduce pain per VAS from 3/10 to 1/10 ), etc. A goal is more likely to be specific and measureable by reliable and valid means if someone unfamiliar with the patient (and even someone clinically untrained) could verify the status on the goal with the patient without any previous interaction with the patient. Achievable goals: