I get this question all the time: “Who actually makes the rules for documentation?” The answer is…
Centers for Medicare and Medicaid Services
And that applies to all patients who are 18 years old or older, not just your Medicare patients. Most insurance companies are following the Medicare requirements, and most state boards are following the same plan. Some doctors yell at me with, “But I have a cash practice!”
I hear this all the time. I’ll just say this:
It. Doesn’t. Matter.
I don’t know why some chiropractors think it’s OK to document differently for a patient paying for their own care, versus an insurance company. The same rules apply, regardless of who is paying.
So, what do they want from us? It’s pretty simple, really.
The First Thing…
They require us to assess pain for each condition that we’re treating, and on every visit, but with a “standardized tool.” The standardized tool used to assess the patient’s pain must be documented in the medical record, except if you’re using the Numeric Rating Scale, like 5/10. For this, we don’t have to document the actual tool name when assessing pain for intensity.
Centers for Medicare and Medicaid Services (CMS) defines a standardized tool as “an assessment tool that has been appropriately normalized and validated for the population in which it is used.” Some examples of a standardized pain assessment tool include, but are not limited to, Brief Pain Inventory (BPI), Faces Pain Scale (FPS), Numeric Rating Scale (NRS), Visual Analog Scale (VAS) and the Verbal Numeric Rating Scale (VRNS).
So, Which One Should We Use?
The common denominator for all of these is that they are all measurable in some way. I think the easiest and most powerful one we can use is the Verbal Numeric Rating Scale (VRNS).
It seems easy enough to ask a patient to rate the intensity of their pain from 0 to 10, with 10 being the worst, but most patients don’t seem to understand that. I start by asking the patient if the pain is mild, moderate, or severe. I tell them that we reserve Severe for patients who have been to or are at or on their way to the hospital. That gets 99% of the patients saying, “Well, it's not THAT bad.” I suspect that most new patients who see a chiropractor will fall into the moderate category.
Then I define the scale for them. If they say that condition 1 is mild, I ask for a number from 1-3. If it's moderate, gimme a number between 4 and 7. And for the very few who are severe and are heading to the hospital once they leave your office, that's an 8-10. When we reduce the patient’s choices from 0-10 to 4-7, it seems to be much easier and manageable for patients to come up with a more accurate number.
But, wait…
If you’re only documenting the pain intensity, though, you may still run into a problem. As patients heal, the intensity of the pain may not actually change for a while. Imagine if the pain remains a 6/10 for a couple of weeks. In this scenario, your notes would be indicating no improvement. That leads us to the second part of Pain Assessment:
The Frequency
Many chiropractic records I’ve reviewed do not even mention the frequency, and the few that do note the ranges of Occasional (0-25% of the time), Intermittent (26-50% of the time), Frequent (51-75% of the time) and Constant (76-100% of the time). Many of the EHRs on the market even force you to document these ranges. I'm telling you right now...
Those do not work for us.
If you only see the patient once every few months, those ranges might be OK, but not for chiropractors who see patients more frequently.
I have two issues with these ranges. The first is the Constant category. In my world, the word “constant” is associated with only one number, and that’s 100%. Years ago, I asked my patients if their pain was “constant or on and off.” Many of the patients answered “constant,” but when I questioned them further, it turned out that they noticed the pain just 60% of the time. That’s not constant.
The second issue I have with these ranges is that they are each 25 points broad. That means that the frequency of the symptom could actually be improving, but they are stuck in the “constant” category for two months until they get to the next category.
Another way is to document an actual percentage of awake time for each condition. The problem with this, though, is when asking for the percentage of time, that’s too much thinking for some people. Since I don’t ask if the symptom is “constant or on and off” anymore, I simply ask the patient if they notice that symptom “every waking moment…or not.” It seems that everyone understands what “every waking moment” means.
If they answer that they feel the symptom “every waking moment,” I’ll document 100%. If they say, “no, not every waking moment,” I’ll ask them if they feel the symptom half the time, more than half or less than half. If they answer, “half the time,” I’ll document 50%. If they answer, “more than half the time,” I’ll ask them to tell me when to stop: “55, 60, 65, 70” and so on. If they answer, “less than half the time,” same idea: “45, 40, 35, 30” and so on. When we reduce the quantity of numbers for them to consider, it helps significantly.
Let’s say, on the initial visit, the patient states that they feel symptom #1 “every waking moment,” and you document 100% of awake time. On the next visit, the patient states that the symptom is not every waking moment now, but 95% of the time. On the next visit, it’s 90%, and so on. That shows improvement, even if the pain intensity remained the same for those visits.
Why are these metrics so important?
This could make or break the second half of your SOAP note.