FEATURE RECORD KEEPING Ongoing treatment notes Y What to write down when there’s nothing to say by dawn armstrong ou know who they are – they’re your “regu-lars.” They come in like clock-work, marking the passage of the months of the year, year after year. They love you because you “get them.” You understand what makes them tick, and you know just what to do to help them be healthier and happier. These pa-tients love you, and you love them right back, maybe be-cause it’s all so easy? You make some quick adjustments, and they positively glow. I have come to appreciate that the most challenging aspect of these “easy” patients is entering sufficient details in their chart. What do you do when they have no com-plaints? They say they are just there for a “tune-up” – their body language makes it obvious they’re impatient, ready to jump up on the table and not waste a minute of their scheduled treatment time with your questions or tests. If you make the same generic entry, month after month: (Chief complaint: None, tune-up. Treatment: Adjust-ments), then your record keeping for these beloved pa-tients could/should be assessed as sorely lacking and not one bit helpful in the quest to justify the care you are providing. Never forget that the quality of your work re-flects the quality of notes found in your patient files. Fortunately, there are some tricks of the trade that can DR. DAWN ARMSTRONG is a graduate of CMCC and has been in practice for over 30 years. She is currently focused on promoting life-long learning and professional development and has created a continuing education course – Clinical Record Keeping: A Hands-On Approach. Learn more at auroraeducationservices.ca. The standard in healthcare record keeping uses the SOAP format. If these answeres are documented, then notes are rated as “adequate.” help with your record keeping when a regular patient comes in with absolutely nothing to complain about. Remember, the standard in healthcare record keeping uses the SOAP format. If the answers to these questions are documented, then the daily notes are rated as “adequate.” S – Subjective: What did they say? O – Objective: What did you see? A – Assessment: What do you think is going on? P – Plan: What’s the treatment? What else can they do (self-care/referrals)? What’s next? General guidelines: – Make an entry under each of the four headings and be consistent throughout. If you are (for record keeping purposes) focusing on a particular area, all entries should relate to this area. Please keep it simple. – Be specific with any details. Which example is more useful? “Knee pain,” or “vague discomfort at the lateral aspect of the knee and proximal calf?” – Negative responses are just as significant as positive ones. They document the fact that you queried/checked spe-cific things. – Use abbreviations and the key to your abbreviations more effectively www.canadianchiropractor.ca 16 Canadian Chiropractor July/August 2019 Photo: Adobe Stock
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