For those times when there’s nothing to say, here are some suggestions around: 1. Questions to ask 2. Physical exam screening tests 3. Assessment summaries 4. Treatment notes abbreviated 1. Questions to ask: Some are more appropriate for a patient you haven’t seen in a few months, some are more useful for your regulars. You generally want to rule out red flags, assess treatment effectiveness and show interest in their overall health/wellness. • Since your last visit have you had any falls or accidents? • Since your last visit have there been any changes to your health in general? • After the previous treatment, how have you been doing with (any complaint they had)? • Have you had any headaches? • Do you ever notice any weakness or tingling in your arms/ hands or legs/feet? • Are you sleeping well? • How are your energy levels these days? What about your stress levels? • Have you noticed any issues with your balance? • Any digestive disturbances like heartburn or constipation? • When you first wake up in the morning, do you have any stiffness or pain in your feet or hips or hands? • Do you notice any stiffness in your hips or low back when you get up after sitting for a while? • How much/what kind of exercise are you doing these days? 2. Tests to do: It’s handy if your daily notes form includes diagrams, charts and checklists. There should be a place for all of the things that as hands-on practitioners we are expected to notice – observations, ROM’s, palpation, spe-cial tests and vital signs • Posture • Gait • General appearance • Active ROM – eg. Apley’s scratch tests for the shoulder • Passive ROM – e.g. internal/external rotation of hips, flexion/extension of wrists • Resisted ROM – e.g. grip strength or foot dorsiflexion • Palpation findings – e.g. bony/soft tissue tender points, hypertonicities • Sensory screening – e.g. compare light touch along arm/ leg, right vs left • Pulse rate, body temperature • Learn a new test every so often and try it with all your regular patients 3. Assessment: Your impression of what is going on today. • Part of the ongoing treatment plan (3/10) • Chronic postural strain to pelvis/low back with short hip flexors/SI subluxation • Chronic periscapular/shoulder girdle dystonia secondary to desk work • Recurring cervicogenic tension headaches with chronic atlas subluxation www.canadianchiropractor.ca If you are (for record keeping purposes) focusing on a particular area, all entries should relate to this area. • Ongoing prevention of lateral epicondylitis (or plantar fasciitis) 4. Plan: For documenting the treatment provided today, it is helpful to link the specific details of your treatment to your physical examination findings, so if you can use one method (e.g. checklist or diagrams) to indicate both at the same time, you will save yourself some effort. You can also make extensive use of abbreviations and your abbreviations key. If there are certain things you al-ways do, find a way to create protocols. For example, you write down SP3. Your key clearly outlines that SP3 is “Shoulder Protocol number 3,” and it consists of…. These shortcuts will save you from repeatedly writing down all the exact details. What else can the patient do (self-care, exercises, refer-rals)? What’s next? Are there any issues you want to explore at the next scheduled visit? (TIP: You can slip in questions and tests as you go through the regular treatment. Make gait and postural observations as they walk in; checking vitals and comparing passive ROM’s or strength of a body part is done while the patient is on the table.) Re-assessments There comes a time when even the most regular of patients must be re-assessed. Schedule the appointment as a re-as-sessment and add some extra time. Ten to fifteen minutes should suffice. (Whether you charge more for the meeting is up to you and your patient.) Why? It is a requirement of all licensed HCPs When? At ‘regular’ intervals – every six months or annu-ally for patients who are generally well. How? Refer back to your notes from their first visits (or the notes from their previous re-assessment) for compari-son. Stick to the SOAP format. S – Take a history of their current status; question their goals for the coming year O – Cover all the bases – Observations/ROMs/Palpa-tions/Special Tests/ Vitals A – What’s going on now? What has changed? Is the current treatment working as well as you’d hoped it would? What are their current needs? P – What’s the plan for care going forward (next six months or year)? Include treatment frequency, type, refer-rals and self-care recommendations. July/August 2019 Canadian Chiropractor 17
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