Objective – Hands-on practitioners will take note of observations, palpation, ranges of motion, special tests and vital signs Assessment – ‘Mechanical low back pain’ or ‘Inflamed right lumbosacral junction associated with hypertonic right iliopsoas and quadratus muscles, second-ary to subluxations at the thoracolumbar junction and L5’ Plan –Treatment provided / recom-mended follow-up and self-care Whether you make use of electronic records or paper and pen, the forms you use should provide sufficient space for the right information. Make liberal use of ROM charts, body diagrams, headings and checklists for easy entry of details. seconds, not minutes, to jot down brief comments, draw a few lines on a ROM chart and check off some boxes. It should just take another minute to commit to what you believe is going on and decide what’s to be done. The better the form you use for ongoing treatment records, the better the information you get on file and the quicker you can accomplish the task. the patient. We can do both -help people who are suffering and keep good notes to prove it. WHAT IF? WHEN SHOULD CHARTING BE DONE? HOW MUCH TIME DOES IT TAKE? Not as much as you might think, but more than you probably do. With electronic tools we can now col-lect vast quantities of information, but it’s really the quality that matters. If you make use of the right forms, it takes Contemporaneously. Ideally, you should do it right now, during the visit and after the visit, before you start with your next patient. It is acceptable to complete your clinical notes before you go home for the day. They should definitely be done be-fore the file goes back into the drawer for the night. Attention to clinical record keeping doesn’t have to be accomplished at the expense of attention to the whole patient. On the contrary, good record keeping is concrete evidence of our connection to What if you were to drop dead next week? Would another practitioner be able to safely and effectively take over the care of this young man and all your other patients? What if you could begin to appreci-ate record keeping – not as a burden but a tangible asset and a tool to facil-itate practice excellence? Proof of safe, high-quality care is the greatest gift you can give your patients. What if better record keeping be-came a bigger priority for every doctor of chiropractic? Then we’d all be better at this health care detective business – asking the right questions and helping to solve big problems, better able to reassure our young patient with the bad back that he will return to work – and he can look forward to more canoe trips in the future! www.canadianchiropractor.ca CC_MatrixHalf_JulyAug17_CSA.indd 1 September 2017 Canadian Chiropractor 23 2017-06-26 9:20 AM
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