AN OVERIVIEW OF
CLINICAL DOCUMENTATION
FOR THE CHIROPRACTIC
PROFESSION
Steven G. Yeomans, DC, FACO
404 Eureka Street
Ripon, WI 64971-0263
920-748-3644 (Ph)
920-748-3642 (Fax)
s@yeomansdc.com
Course Objective:
TO BULLET-PROOF YOUR DOCUMENTATION AGAINST AN
ADVERSARIAL REVIEW PROCESS
Table of Contents
Content
ACA Recommendations (2001)
Page #
3-4
WCA Recommendations (1996)
Intro & Acknowledgements ………………………………………………...
5-8
Chapter 1: Documentation recommendations ………………………….…..
9-18
Chapter 2: Commonly used mechanisms of record keeping ……….………
19-21
Chapter 3: Commonly used outcome assessment measurements ………….
22-24
Chapter 4: A primer on chiropractic listings ……………………….………
25-26
Chapter 5: Glossary ………………………………………………………..
27-28
Chapter 6: Commonly used abbreviations ………………………….………
29-32
Appendix A: HCFA Guidelines for Patient History Level Selection ………
33
Appendix B: Bibliography …………………………………………………
34-35
Chart Audit
36
Yellow Flags (psychometrics)
37-38
CPT Codes
39-40
Bibliography
41-44
2
Ref: ACA Today, March 2001 The Newsletter of the American Chiropractic
Association
CLINICAL DOCUMENTATION KEY TO REIMBURSEMENT FOR
CHIROPRACTIC CLAIMS
ARLINGTON, VA – During its recent meeting, the American Chiropractic
Association (ACA) House of Delegates passed a resolution to assist doctors of
chiropractic in successfully being reimbursed for necessary patient care by insurance
companies. ACA is now committed to disseminating the recommendations contained
in the resolution to doctors of chiropractic, chiropractic organizations and chiropractic
colleges nationwide.
Last year, representatives from 13 of the largest insurers in the United States met with
ACA representatives during the second meeting of the ACA-sponsored Claim
Solutions Work Group. Based on the suggestions made during this meeting and on
recent trends, ACA recommends certain basic requirements be considered as
appropriate clinical documentation in patient record keeping. Some of the insurers
present at the meeting agreed that using these practices will also reduce clinical
record requests by 50 percent.
“The mutual goal of the insurers and doctors of chiropractic at this meeting was to
simplify the claims process,” explained Pat Jackson, vice president of professional
development for ACA. “This way, chiropractors can reduce administrative costs and
get paid for more covered claims, and insurers can reduce claims expenses.”
According to Ms. Jackson, many insurers are already adopting the recommended
guidelines resulting from the meeting in order to educate their claim personnel on
appropriate requests for chiropractic clinical documentation.
The ACA also contends that a concerted effort by the chiropractic profession to
standardize clinical documentation will improve reimbursement experience
exponentially for doctors of chiropractic. For this reason, a special effort will be
made to share this information with chiropractic colleges so it can be incorporated
into the curricula.
ACA recommends the following documentation procedures:
1. The nationally accepted HCFA billing 1500 form must be completed in detail.
This means all required fields must be completed.
2. Subjective, objective, and treatment (if rendered) components should be
incorporated into patient records on each visit. A customized format is not
needed but these elements must exist consistently. Any significant changes in the
clinical picture (e.g. significant patient improvement or regression) should be
noted.
3
3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be
validated in the patient chart and coordinated as to the diagnoses and treatment
code descriptors.
4. Uniform chiropractic language should be used within the profession for
describing care and treatment. Non-standard abbreviations and indexes should be
defined.
5. Documentation for the initial (new patient) visit, new injury or exacerbation
should consist of the history and physical and the anticipated patient treatment
plan. The initial treatment plan, except in chronic cases, should not extend
beyond a 30-45 day interval.
Subsequent patient visits should include significant patient improvement or
regression if demonstrated by the patient on each visit. As the patient progresses,
the treatment plan needs to be reevaluated and appropriately modified by the
treating doctor of chiropractic (chiropractic physician) until the patient can be
released from care, if appropriate.
6. If the patient is disabled, a statement(s) on the extent of disability and activity
restriction is needed at initial and subsequent visits as appropriate over the course
of care.
7. Records can be attached to each billing to pre-empt requests; however, it is not
mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP
insurers may require records every visit while health insurers may not).
8. All records must be legible and understandable, released within the authority
given by the patients, in a secure, confidential manner and in compliance with
existing state (or federal) statutes.
9. The patient name and initials of the person making the chart notation (especially
in multi-practitioner offices) should appear on each page of the medical record.
10. If the above recommendations have been met, then the answers as to why the
necessity for continuing treatment are answered.
11. The insurance industry must improve their claim adjusting procedure by using
chiropractic consultants. The ACA can use its resources to assist in this initiative.
Contact the American Chiropractic Association Office of Professional Development by
phone at (800) 986-4636, ext. 222, or by e-mail at pjackson@amerchiro.org for more
information.
###
4
Wisconsin Chiropractic Association

Recommendations
for
Chiropractic Documentation
(1996)
Wisconsin Chiropractic Association
Recommendations for Chiropractic Documentation
5
General Disclaimer
This document contains recommendations for the clinical documentation of chiropractic
care. These recommendations are intended for educational and instructional purposes
only and do not constitute a standard of care for any specific clinical situation. These
recommendations, which may need to be updated, are intended to be flexible.
In is not the purpose of this document, which is advisory in nature, to take precedence
over any federal, state or local statute, rule, regulation or ordinance which may affect
chiropractic practice.
This document may provide some assistance to third parties in the evaluation of
chiropractic care, but it is not by itself a proper basis for evaluation. Many factors must
be considered in determining clinical or medical necessity.
Methods of chiropractic documentation must be sufficiently flexible to allow for
variations in practice methods, as well as differing complexities of individual cases.
Further, these recommendations will require constant re-evaluation as additional
scientific and clinical information becomes available.
6
Wisconsin Chiropractic Association
Recommendations for Chiropractic Documentation
Table of Contents:
Acknowledgments
Introduction
Chapter 1: Documentation recommendations ……………………………… 8-17
 Format
 Legibility
 Patient consent
 Initial entry: Subjective
 Initial entry: Objective
 Initial entry: Assessment
 Initial entry: Treatment plan
 Daily notes
 Progress notes
 X-ray reports
Chapter 2: Commonly used mechanisms of record keeping ……………… 18-20
Chapter 3: Commonly used outcome assessment measurements …………. 21-23
Chapter 4: A primer on chiropractic listings ………………………….…… 24-25
Chapter 5: Glossary ……………………………………………………….. 26-27
Chapter 6: Commonly used abbreviations ………………………………… 28-31
Appendix A: HCFA Guidelines for Patient History Level Selection ……… 32
Appendix B: Bibliography ………………………………………………… 33-34
Acknowledgments:
The Wisconsin Chiropractic Association is indebted to chiropractic colleges and insurers
who provided valuable background information for the work of the Committee, and also
to the Committee members for their diligent effort on this project.
7
Introduction:
Over the past decade, chiropractic has occupied a constantly growing position in today’s
complex health care delivery system. Chiropractors in Wisconsin now work routinely
with a myriad of parties who are interested in assessing the quality of clinical work
performed by the chiropractor.
The principal method through which other parties attempt to assess the quality and
necessity of a chiropractor’s work is through submitted clinical documentation. The
clinical records of Wisconsin chiropractors are now examined with an increased amount
of scrutiny. Many different payors and agencies have the right to access a chiropractor’s
clinical records, including:







insurers who wish to determine whether a claim is a covered benefit under the
terms of their contract with the patient
managed care organizations who conduct reviews of clinical record keeping as
part of their quality assurance and utilization review programs
attorneys who utilize clinical documentation as evidence in personal injury
litigation
attorneys who represent patients in malpractice suits against chiropractors
other health care providers who may request records in order to coordinate
interprofessional patient care
other chiropractors who assist with treatment for a patient
state regulatory agencies, who investigate consumer complaints, review
payment for government programs, etc.
Methods of chiropractic documentation must be sufficiently flexible to allow for
variations in practice methods, as well as differing complexities of individual cases.
Because chiropractic practice patterns vary from medical practice patterns,
recommendations for chiropractic documentation necessitate additional modifications
when compared to generally accepted medical record keeping formats.
8
Chapter 1:
Wisconsin Chiropractic Association
Recommendations for Clinical Documentation
1. General information:
The purpose of these recommendations are:
A. to serve as an informational source to doctors. These recommendations
represent well-accepted, contemporary views on documentation issues as
reported in the biomedical literature. Some of the source materials include:
 Health Care Financing Administration documentation guidelines
 Record keeping standards for the National Committee on Quality
Assurance.
 chiropractic and medical textbooks
 peer-reviewed journal articles
 submissions from chiropractic colleges
 input from insurers
B. to serve as voluntary guidelines for chiropractors to use when developing
documentation systems for their offices.
C. to encourage more uniform and more understandable clinical documentation,
which should serve as a benefit to patients, providers, and insurers.
The Wisconsin Chiropractic Association recognizes that the management of every
individual patient is unique. Different styles of practice, or areas of clinical
specialization, may prompt the doctor to vary the clinical information to be gathered and
recorded.
Documentation performed within the intent of these recommendations need not be
rigid and inflexible, but should be adapted to the needs of a particular case. These
guidelines are intended to provide a common framework for patient records which
allows for more consistent reporting and improved communication.
2. Format:
A SOAP format is regarded across the country as the most widely accepted method for
keeping clinical records. This format records information about subjective complaints,
objective findings, the doctor’s assessment and treatment plan in an organized manner.
Used less frequently are recognized derivatives of the basic SOAP schema, such as
POMR, SORE or SNOCAMP.1 2 3
1
Journal of Family Practice, Oct. 1995 41:4
Jordan E. St. Anthony’s guide to E/M coding and documentation. St. Anthony’s Publishing, Reston, VA
1995
2
9
An organized format [whether it is classic SOAP or a modification of the SOAP format]
allows information to be recorded in a predictable, repetitive manner. Proprietary or “inoffice” systems of documentation are, by definition, difficult or impossible for a reviewer
to understand.
Abbreviations: The proper use of accepted abbreviations [such as those listed in these
recommendations] can facilitate the documentation process by saving both record space
and time. However, the use of non-standard abbreviations can lead to confusion in the
interpretation of clinical records. Doctors who choose to utilize non-standard
abbreviations should “translate” those abbreviations prior to the records being submitted
to a third party.
Methods: The methods used to complete clinical record keeping is a matter of preference
for each practitioner. The doctor may prepare documentation by using dictation and
transcription, narrative-style writing, pre-prepared forms or other methods preferred by
the doctor.
Documentation of evaluation/management services: During the course of a
complicated case, the chiropractor may be presented with clinical situations which
require varying complexities of decision making and/or the services required. The level
of detail contained in the documentation will often increase as the complexity of the
decision making or the complexity of the provided services increases.
For example:

at the onset of the complicated case, or at other critical time periods during the
patient’s treatment, the chiropractor often functions at a specialist level.
When functioning at that level, a corresponding increase in the detail of
documentation is typically expected to fully detail the patient’s symptoms,
findings, diagnosis and treatment plan. The chiropractor will usually choose
to utilize a higher level [99204, 99205, 99214, 99215]
evaluation/management code when performing these specialist-level services.

at other times during the same case, the chiropractor may serve on a level very
similar to a general practitioner. The level of documentation typically
expected at this level is sufficient to tell the story of the patient, but may not
include the full level of detail expected of the specialist-level documentation.
The chiropractor will often use a mid-level [99202, 99203, 99212, 99213]
evaluation/management code when performing these general practitionerlevel services.
3
Vernon H. Clinical note: S-O-R-E, a record keeping system for chiropractic treatment visits. Can Chir
Assoc J. 1990;34:93.
10

on a daily treatment basis, the doctor is applying the treatment which has been
fully described in the most recent treatment plan. Therefore, the
documentation for daily visits will be much more concise.
Chart organization: Clinical notes consist of three distinct elements:
1. Initial entry. The initial entry generally includes:
 pertinent baseline information about the patient
 the patient’s chief complaint[s]
 the results of initial physical examination
 the chiropractor’s assessment
 the recommended treatment plan
2. Daily note. The daily note represents a concise record of pertinent changes in
the patient’s condition and treatment on that day. A series of daily notes will
show changes on a visit-to-visit basis. The daily note is used most often to
document:
 adjustment or manipulation
 physical modalities
3. Progress note. At different points in a case, a progress note is used to document
additional patient services. These services may include:
 reevaluations
 reexaminations
 counseling
 coordination of care
One respected author in the field of chiropractic documentation4 has described the initial
entry as “SOAP-ing” the patient. He then explains that the progress note can be thought
of as a kind of “midi-SOAP”, or a somewhat abbreviated version of the original SOAP
work-up. This so-called “midi-SOAP” retains the same database format, yet is not
necessarily as detailed as the original evaluation. The notation for a daily or routine visit
is described as a “mini-SOAP”, displaying the same general organizational scheme of the
of the initial evaluation, but on a significantly smaller scale.
3. Legibility:
Clinical documentation should always be legible. If patient records are hand written, it
is especially important that the handwriting is legible to the reviewer. If the handwriting
is not legible to the reviewer, the provider should be informed and given the opportunity
to transcribe the information.
4. Documentation of patient consent:
Doctors should review with their legal counsel their responsibilities5 to obtain written
proof of the patient’s consent in the following critical areas:
4
Mootz RD. Maximizing the effectiveness of clinical documentation. In: Top Clin Chiropractic 1994
1[1] p. 60-65. Aspen Publishers, Gaithersburg, MD.
5
Campbell L, Ladenheim CJ, Sherman R, Sportelli L. Informed consent: a search for protection. Top
Clin Chiropractic 1994; 1 (30): 55-63.
11



general consent to examine and treat: Many doctors will have the patient
complete this written consent as part of their initial patient questionnaire.
informed consent: if any proposed treatment procedure poses a meaningful
risk to the patient, the doctor is expected to disclose that risk to the patient and
to document that the patient has consented to proceed with the proposed
treatment. [In some cases in which the patient has significant difficulties
communicating, such as Alzheimer’s disease, stroke victims or the mentally
impaired, the informed consent should be obtained from a family member.]
parent’s consent to examine and treat minor children: generally
recommended before evaluating or treating any child under the age of 18.
5. The initial patient entry
The initial entry generally includes pertinent
baseline information about the patient, the patient’s chief complaint[s], the results of
physical examination, the chiropractor’s assessment, the recommended treatment plan.
An initial patient entry may be made anytime a patient presents with a new chief
complaint.
5a. Subjective: Initial New Patient History
This section forms the subjective area of the documentation. HCFA has recently defined
elements which may be included in the subjective portion of the patient records6.
The complexity of the patient’s health problems will determine which of these elements a
chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing
problems of greater severity will generally include more of the these elements. It may
not be necessary to include many of these elements in the records of patients with less
severe problems.
These elements of the subjective portion of clinical record keeping include the
following:
History of the present illness: [HPI] HCFA has defined the following factors
to constitute a complete history of the present illness:
 history of trauma
 description of the chief complaint[s]
 onset of symptomatology
 palliative factors
 provocative factors
 quality of pain (burning, numbness, tingling)
 radiation of pain
 severity of pain (scale of 1-10)
 frequency or timing of complaint
 previous episodes of chief complaint.
Reported in: St. Anthony’s Physician’s Claims and Billing Manager. St. Anthony’s Publishing, Reston,
VA Vol. 3, No. 6, March 1995
6
12
As an alternative, the elements of the history of the present illness can be
represented by the use of the mnemonic “O, P, Q, R, S, T”7.
 O = onset of symptoms
 P = provocative or palliative factors
 Q = quality of pain
 R = radiation
 S = severity of pain
 T = timing of pain
When using this mnemonic, many doctors add an additional element to indicate
whether the patient has experienced prior episodes of the chief complaint:
 U = previous episodes [have you ever had this problem before?]
Past history:
 prior major illnesses and injuries
 prior operations
 prior hospitalizations
 current medications
 allergies (food or drug)
 age appropriate immunization status
 age appropriate feeding/dietary status.
Social history:
 current employment
 occupational history (discretionary)
 use of drugs, alcohol, and/or tobacco
 other relevant social factors.
Family history:
Significant health factors which may be congenital or familial in nature should be
noted.
Review of systems: [ROS] HCFA has defined the following fourteen areas for
review of systems:
 constitutional symptoms [fever, weight gain or loss, fatigue, etc.]
 eyes
 ears, nose and throat
 cardiovascular
 respiratory
 gastrointestinal
 genitourinary
7
Foreman S, Croft A. Whiplash injuries; the cervical acceleration/deceleration syndrome. 2 nd ed.
Williams and Wilkins, Baltimore, 1995.
13







musculoskeletal
integumentary [skin/breast]
neurologic
psychiatric
endocrine
hematologic/lymphatic
allergic/immunologic
Appendix A includes the requirements from HCFA for the proper coding of
evaluation and management codes by the number of included elements from the
elements of the history above.
5b. Objective: Initial New Patient Physical Examination
This section forms the objective area of clinical documentation. The complexity of the
patient’s health problems will determine which of these elements a chiropractor will
choose to use in the patient’s record. A chiropractor’s records detailing problems of
greater severity will generally include more of these elements. It may not be necessary to
include many of these elements in the records of patients with less severe problems.
The elements of the objective portion of the patient records may include the following:
 Vital signs
 height
 weight
 blood pressure [age dependent; recommended at initial exam, followup depending on condition]
 pulse [recommended at initial exam, then prn]
 respiration [if indicated by symptoms]
 temperature [if indicated by febrile symptoms]
 observation
 auscultation [if indicated by symptoms]
 percussion [if indicated by symptoms]
 palpation
 range of motion [Note that range of motion can be measured using many
different methods, such as actively (AROM), passively (PROM) or active
assisted (AAROM). In addition, range of motion can be measured visually,
with a goniometer or a manual or electronic inclinometer. The doctor may
wish to note the methods used to measure range of motion.]
 reflexes
 deep tendon: use of Wexler [0-5] scale
 superficial [if indicated by symptoms]
 pathologic [if indicated by symptoms]
 vascular examination [if indicated by symptoms]
 provocative orthopedic tests
 neurologic testing [if indicated by symptoms]
14





cranial nerves
station, gait and balance
sensory testing
muscle strength testing: may be tested manually or with the use of
various machines. When tested manually, most doctors use a modified
Lovett scale, which assigns a number grade to the muscle strength8.
 The most common usage of this system uses 5 to indicate
“normal”.
 Grades 4+, 4, and 4- are used to indicate decreasing muscle
function within the “good” category, which is defined as the
ability to raise the part against gravity and some resistance.
 Grades 3+, 3, and 3- are used to indicate decreasing muscle
function within the “fair” category, which is defined as the
ability to raise the part against gravity only.
 Grades 2+, 2, and 2- are used to indicate decreasing muscle
function within the “poor” category, which is defined as the
ability to raise the part only with gravity eliminated.
 Grade 1 means that the muscle contraction can be felt, but there
is no joint movement. Grade 0 means no contraction is felt.
the use of various types of instrumentation, leg length tests or other objective
measurements which the chiropractor judges to be relevant to the case.
5c. Assessment: Initial New Patient Assessment


Diagnostic impression in a narrative or descriptive format.
Assessment of risk factors, if applicable.
5d. Plan: Initial New Patient Treatment Plan
The complexity of the patient’s health problem will determine which of the following
elements a chiropractor will choose to include in the patient’s record. It is not necessary
to include all of these elements in the records of patients with less severe health
problems. The elements of the treatment plan may include the following:






Diagnostic treatment plan: describes the need for further tests, including
reexamination, etc.
Therapeutic treatment plan: describes the frequency and duration of
adjustments and in-office therapies and modalities.
Educational treatment plan: home exercises, modification of daily or work
activities
Short and long term goals
Referral for other necessary services
Coordination of care with other health professionals, if applicable
8
Legg AT, Physical therapy in infantile paralysis. In Mock. Principles and practice of physical therapy.
Vol. II. Hagerstown, MD: WF Prior, 1932:45
15
6. Daily notes:
The daily note represents a concise record of pertinent changes in the patient’s condition
and treatment on that day. A series of daily notes will show the significant changes in
the patient’s condition and treatment which occur over a period of time. The daily note
is used most often to document ongoing treatment, such as adjustments/manipulation or
physical modalities.
After the initial entry, each subsequent office visit will usually be documented by a daily
note, until the next specified reevaluation. If the initial entry clearly states the
assessment and plan, it is not usually necessary to reevaluate the patient on a daily basis
or to reiterate the assessment or the treatment plan. Any significant modification of the
treatment plan should be recorded in the daily note.9
Because of its brevity, the daily note will list only the most important changes in the daily
presentation of the patient, and the management of the case. Therefore, the treating
chiropractor is best qualified to decide which objective and subjective elements of the
case should be recorded via the daily note.
7. Progress notes
At many different points in a case, a progress note is often used to document additional
patient services. These services may include:
 reevaluations
 reexaminations
 counseling
 coordination of care
7a. Re-examination frequency:
Periodic reexaminations of the patient are an important element of case management, and
are used to assess the effectiveness of treatment. It may be appropriate to reexamine a
patient or reevaluate a patient’s condition anytime there is a significant change in the
patient’s symptoms or response to treatment.
Reexaminations are especially important when a patient exacerbates their injury or if the
clinical condition of the patient changes, which may indicate the need for the doctor to
reassess the treatment plan. The following chart which describes typical frequency of reexaminations for established patients:
9
Bronston LJ. Record Maintenance and Narrative Writing. In: Ferezy JS. The Chiropractic Neurological
Examination. Aspen, Gaithersburg MD, 1992, p. 153.
16
Patient type
Definition
Acute


Chronic

Supportive

Maintenance 
or
preventative
Symptomatology is present less
than six weeks
Acute exacerbation of a chronic or
recurring condition.
Symptomatology present more
than 18 weeks
Symptomatology is present due to
a known, permanent deficit; a full
recovery is not expected.
No active symptomatology.
Typically, a reexamination is
performed within:
30 days or 12 visits or as
clinically indicated
3 months or 18 visits or as
clinically indicated
Six months to one year or as
clinically indicated
As clinically indicated
A re-examination for an established patient is particularly appropriate in the following
circumstances:
 a patient who presents with a new chief compliant
 a patient who presents with a new, distinct episode of a recurring condition.
 a patient who presents with symptoms, and has not received treatment for 90
days or more
8. Documentation of x-ray findings:
X-ray documentation is usually produced on the day the film was read and/or billed.
These x-ray findings may be in the form of a separate report, or may condensed to the
major findings, and included with the objective portion of the patient’s documentation.
Just as the “SOAP” format is used to methodically prepare patient records, formal x-ray
reports often follow a repeatable format. When preparing formal x-ray reports, the
following format has been advocated by Yochum and Rowe10:
Introductory Information
Letterhead Information
 Name of physician
 Clinic name and address
Patient information
 Full name and address
 Date of birth
 File identification
Radiographic information
 Views submitted
 Dates and location of films taken
10
Yochum TR, Rowe, LJ. Essentials of Skeletal Radiology, 2nd Ed. Williams and Wilkins, Baltimore,
1996, p.1371-1396.
17

Technique factors [optional]
Report
Clinical information
 Chief complaint
 Key clinical findings
 Reason for study
 Numbered summary of pertinent findings
Radiologic findings
 Descriptive narrative of findings
 Findings are usually listed in the order of alignment, bone, cartilage, soft
tissue, which can be easily remembered by the mnemonic “ABCs”.
 Conclusions
Recommendations
 Indications or contraindications to treatment
 Follow-up procedures indicated
Signature and qualifications
18
Chapter 2:
Mechanisms of documentation
There are many different mechanisms that a chiropractor may successfully use to keep
excellent clinical documentation. Some of the most commonly used methods are
discussed below:
Dictation and transcription:
Dictation of clinical records remains the benchmark against which all other forms of
record keeping are measured. Dictation has many obvious advantages:
 impeccable legibility
 the ability to use as much detail as may be needed
 there are no restrictions imposed by the format itself
 transcriptionist does not need special computer training
There are also minor disadvantages of the dictation/transcription method:
 labor intensive, therefore tends to be relatively costly
 dictation tapes can break or be lost
 digital dictation systems can lose data
Computer-assisted record keeping [commercial programs]:
These systems are available in many different formats. Various methods of inputting
information to the computer have been devised, each claiming to be the most efficient.
Information may be input into the computer via voice or through the use of keyboard,
light pens, scanning sheets, touch screens, bar code readers or other devices.
These systems have the advantages of:
 automating some of the repetitive aspects of patient records
 a comprehensive approach to inputting clinical data.
Disadvantages may include:
 relatively high purchase cost
 relative difficulty of editing your copy from the pre-defined format in some of
the products
 lost data if the system is not “backed up” frequently.
With new technology comes intriguing new ethical questions. For example, some of the
programs will automatically vary the verbiage to avoid the appearance of repetitive notes.
There are computer programs which will “write” a narrative report or “calculate” a
disability rating. Only the individual practitioner can decide if a particular product truly
represents a time-saving tool in completing the patient’s documentation, or a clinically
unacceptable “short cut”.
19
Word processing programs:
All of today’s computer word processing programs have the ability to be easily
programmed by the user to perform repetitive functions. These special, user-defined
commands are usually called a macro. With the use of a macro, it is possible to
automate many of the repetitive tasks required in patient record keeping, such as typing
the clinic name, patient name, date and other commonly required data.
In addition, a macro can generate frequently used text, often called boilerplate text. This
can enable the doctor to add significant depth to records without expending much time.
For example, complete instructions can be prepared for a routine of lumbar extension
exercises. When a patient’s clinical condition indicates that these particular exercises are
appropriate, the entire exercise routine can be added to the patient’s records with the
touch of the macro button.
The advantages of this type of system are:
 low cost
 system may be adapted completely to your needs and changed at any time
The disadvantages of this type of system are:
 set-up is labor intensive
 professional assistance is seldom available
 doctors and staff must thoroughly understand the system they have devised
 data may be lost if not “backed up” frequently
Hand written records:
It is possible to keep excellent quality patient records by hand writing each record.
However, many doctors will simply not be able to utilize hand written records because
they possess illegible or poor quality handwriting. In addition, the sheer volume of
information required in a quality patient record often lends itself to some sort of
mechanization, especially in a busy practice.
If hand written entries are to be part of clinical records:
 make sure that the handwriting is clearly legible
 be sure that the areas of the record reserved for handwriting are not cluttered
with other information
 use only common, standardized abbreviations, such as those listed in these
Wisconsin Chiropractic Association documentation recommendations.
Proprietary or “in-office” chiropractic record keeping systems:
Over the years, many chiropractors have developed proprietary [non-SOAP] formats or
shorthand systems for various aspects of their patient records. These may include the use
of abbreviations or symbols which are not well recognized within the chiropractic
profession.
The use of these types of devices within records can often be confusing to other parties
who wish to review the patient’s records. This potential problem can often be avoided
20
by the use of standardized abbreviations and conventions, such as those described in
these recommendations.
Chapter 3:
Outcome Assessment Measurement Devices
Pain is the primary complaint for 80% of all office visits to physicians each year in the U.S.
[National Center for Health Statistics, 1986]. It is important to use the proper measurement
device in order to get meaningful data of a patient’s baseline status. The measurement must then
be reapplied to get meaningful data of a patient’s improvement. The testing device must be
comprehensive enough to give a reliable clinical picture, simple to understand, easy to score, and
able to be administered at a low cost.
The devices listed in bold are used very commonly within the chiropractic profession, and it is
recommended that you become familiar with these outcome assessment devices. Unfortunately,
copyright restrictions do not allow for the reproduction of these materials within these Wisconsin
Chiropractic Association recommendations. Generally, you may access the original articles and
use any of these devices in your office for the treatment of your individual patients.
A. General health questionnaire
1. Health Status Questionnaire v.2.0 [Health Outcomes Institute, 1993]11
2. SF-36 [Stewart, 1988; Interstudy, 1990]12
3. RAND 36 [RAND Corporation, 1986]13
4. Dartmouth COOP charts [Nelson, 1987]14 15 16
5. Sickness Impact Profile [Bergner, 1981]17
6. Nottingham Health Profile18
B. Pain
1. Visual analog scale [VAS] [Huskisson, 1982]19 20 21 22
11
Health Outcomes Institute. Health Status Questionnaire 2.0. Health Outcomes Institute, Bloomington,
MN
12
Interstudy: An introduction to Interstudy’s outcomes management system development plans. October,
1990. Interstudy, Excelsior, MN.
13
Rand 36-item health survey 1.0. Rand Health Sciences Program, Santa Monica, CA: RAND; 1986,
1992.
14
Johnson D. Dartmouth COOP Project. Hanover, NY: Dartmouth Medical School, 1989.
15
Nelson E, Berwick D. The measurement of heath status in clinical practice. Medical Care 1989 27
[3]:S77
16
Kraus N. The Dartmouth primary care cooperative [“COOP] information project. Interstudy Qual Edge,
1991; 1:33-39.
17
Bergner M, Bobbitt R, Carter R, Carter W, Gilson B: The sickness impact profile: Development and
final revision of a health status measure. Medical Care 1981, 19 [8]:787.
18
Reviewed in: Deyo RA. Measuring the functional status of patients with lower back pain. Chiropractic
Technique. 1990;2[3]:127-137.
19
Huskisson S. Measurement of pain. J Rheumatol 1982, 9:768
20
Merskey H. The perception and measurement of pain, J Psychosom Res. 17:251-155, 1973.
21
Ventafridda V, DeConno F, DiTrapani P, Gallico S, Guarise G, Rigamonti G, and Tamurini M. A new
method of pain quantification based on a weekly self-descriptive record of the intensity and duration of
2.
3.
4.
5.
6.
Numerical pain scale [NPS] [Jenson, 1986]23
McGill/Melzak pain questionnaire [Melzack, 1975]24
Pain drawing [Mooney and Robertson, 1976] 25 26
Pain Disability Index [Tait, 1987]27
Dallas Pain Questionnaire [Lawlis, 1989]28 29
C. Disability: lower back pain
1. Modified Oswestry Low Back Pain Questionnaire [Fairbank, 1980]30 31
2. Roland-Morris Disability Questionnaire ROL-SIP [Roland, 1983]32
3. Low Back Pain TyPE Specifications [Health Outcomes Institute, 1992]33
4. Million Disability Questionnaire [Million, 1982]34
5. Waddell Disability Index [Waddell and Main, 1984]35
D. Disability: cervical or headache
1. Neck Disability Index [Vernon-Mior, 1991]36
2. Headache Disability Index: HDI [Jacobson, 1994]37
E. Pychometrics
pain. In Bonica JJ, Lindblom U Iggo A eds: Advanceds in pain research and therapy, Vol 5: Proceedings
of the Third World Congress on Pain.
22
Jensen MP, Koroly P, O’Riordan EF, et al: The subjective experience of actual pain: an assessment of
the utility of 10 indices. Clin J. Pain 5:153, 1989.
23
Jensen M, Karoly P, Braver S. The measurement of clinical pain intensity: A comparison of six methods.
Pain 1986, 27: 117.
24
Melzack R: The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1975, 1:277.
25
Mooney V. Robertson J. The facet syndrome. Clin Orthop 115:149, 1976.
26
Rainsford AO, Cairns D, Mooney V. The pain drawing as an aid to the psychologic evaluation of
patients with lower back pain. Spine 1:127-134. 1974.
27
Tait R, Pollard C Margolis R, Duckro P, Krause S. Pain disability index: psychometric and validity
data. Arch Phys Med Rehabil 1987, 68:438.
28
Review in: White A, Schofferman J. ed. Spine Care. Mosby, St. Louis, 1995. P. 919-922.
29
Lawlis GF, Cuencas R, Selby D, et al. The development of the Dallas Pain Questionnaire for illness
behaviour. Spine 14:511, 1989.
30
Fairbanks J, Davies J, Couper J, O’Brien J. The Oswestry low-back pain disability questionnaire.
Physiotherapy 1980, 66:271.
31
Hudson-Cook N, Tomes-Nicholson K, Breen A. The revised Oswestry low back pain questionnaire.
Thesis, Anglo-European College of Chiropractic, 1988.
32
Roland M, Morris R. Study of natural history of back pain, part I: development of a reliable and
sensitive measure of disability in low back pain. Spine 8:141; 1983.
33
Health Outcomes Institute. Low Back Pain TyPE Specifications. Health Outcomes Institute,
Bloomington, MN
34
Million R, Nilsen K, Jayson MIV, et al. Evaluation of lower back pain and assessment of lumber corsets
with and without back supports. Ann Rheum Dis 40:449, 1981.
35
Waddell G, Main C: Assessment of severity in low-back disorders. Spine, 1984, 9:204.
36
Vernon H, Mior S. The neck disability index: a study of reliability and validity. J Manip Physio Ther
1991, 14 [7]:409.
37
Jacobson GP, Ramadan NM et al. The Henry Ford Hospital Headache Disability Inventory [HDI].
Neurology 1994;44:837-842.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Psychosocial Pain Inventory [Heaton, 1980]38
Illness Behaviour Questionnaire [Pilowsky, 1976]39
Health Status Questionnaire 2.0 40 [Questions 37-39: depression screens]
Waddell Non-Organic LBP signs [Waddell, 1980] 41
Somatic Amplification Rating Scale [Korbon, 1987]42
Modified Zung Depression Index 43 44
Modified Somatic Perception Questionnaire MSPQ [Main, 1983]45
Minnesota Multiphasic Personality Inventory [MMPI]46 47
Fear-Avoidance Beliefs Questionnaire FABQ [Waddell, 1993]48
F. Patient satisfaction:
1. Patient Satisfaction Questionnaire [Ware, 1983]49
2. GHAA Consumer Satisfaction Survey [Ware, 1991]50
3. Low Back Pain Patient Satisfaction [Deyo, 1986]51
4. Chiropractic Satisfaction Questionnaire [Coulter, 1994]52
38
Heaton RK, Lehman RAW, Getto CJ. Psychosocial Pain Inventory, Odessa, FL, 1980, Psychological
Assessment Resources.
39
Pilowsky, I, Spence ND. Illness behaviour syndromes associated with intractable pain. Pain 2:61-71,
1976.
40
Health Outcomes Institute. Health Status Questionnaire 2.0. Health Outcomes Institute, Bloomington,
MN
41
Waddell G, McCulloch J, Kummel E, Venner R. Non-organic signs in low back pain. Spine 5:117,
1980.
42
Korbon GA, DeGood E, Schroeder ME, et al. The development of a somatic amplification scale for
lower back pain. Spine. 1987;12[8]: 787-791.
43
Zung W. A self-rating depression scale. Arch Gen Psychiatry. 1965;32:63-70/
44
Review in: Ahles TA, Yunus MB, Mari AT. Is chronic pain a variant of depressive disease? The case
of primary fibromyalgia syndrome. Pain, 1987; 29: 105-111.
45
Main C. 1983 Modified somatic perception questionnaire. J. Psychosom Res. 1983;27:503-514.
46
Hanvik LJ. MMPI Profiles in patients with lower back pain. J. Consul Psychol. 15:350-353, 1951.
47
Hathaway SR, McKinley JC. Minnesota Multiphasic Personality Inventory: manual for administation
and scoring. Psychological Corporation, New York, 1967.
48
Waddell G, Newton M, Henderson I, et al. A fear-avoidance beliefs [FABQ] questionnaireand the role
of fear avoidance beliefs in chronic low back pain and disability. Pain 1993:52:157-168.
49
Ware J, Davies AR. Defining and measuring patient satisfaction with medical care. Eval and Program
Plan. 1983;6:247-263.
50
Davies AR, Ware JE. GHAA’s consumer satisfaction survey and user’s manual. 2 nd ed. Washington,
DC: GHAA: 1991.
51
Deyo R, Diehl A. Patient satisfaction with medical care for low back pain. Spine 1986, 11:28.
52
Coulter I, Hays R, Danielson C. The chiropractic satisfaction questionnaire. Topic in Clin Chiropractic.
1994; 1[4]: 40-43.
Chapter 4:
A Primer on Chiropractic Listings
Chiropractors use a variety of different systems to indicate the deviation of a motor unit
from its normal position. While a comprehensive survey is far beyond the scope of this
document, the following information should prove helpful to anyone attempting to
understand a chiropractic listing.
Spinal segments:
The following abbreviations are commonly used to refer to segments of the spinal
column and pelvis:
C0, O: Occiput
OC: Occipital condyle
C1, A: Atlas
C2, AX: Axis
C3: Third cervical
C4: Fourth cervical
C5: Fifth cervical
C6: Sixth cervical
C7: Seventh lumbar
T1: First thoracic [or dorsal]
T2: Second thoracic
T3: Third thoracic
T4: Fourth thoracic
T5: Fifth thoracic
T6: Sixth thoracic
T7: Seventh thoracic
T8: Eighth thoracic
T9: Ninth thoracic
T10: Tenth thoracic
T11: Eleventh thoracic
T12: Twelfth thoracic
L1: First lumbar
L2: Second lumbar
L3: Third lumbar
L4: Fourth lumbar
L5: Fifth lumbar
S:
Sacrum
S1: First sacral segment
S2: Second sacral segment
S3: Third sacral segment
S4: Fourth sacral segment
S5: Fifth sacral segment
CO: Coccyx
IL: Ilium
Additionally, some of the prominent landmarks of spinal segments are abbreviated
below. These landmarks are often used as points of reference to define the orientation of
the vertebra within a three-dimensional space:
SP: spinous process
TP: transverse process
M: mamillary process
L: lamina
P: pedicle
B: body
Direction of Vertebral Misalignment:
A bone or spinal segment is usually “listed” in the direction it deviates from normal.
The following abbreviations are commonly used. The international coordinate system53,
which is often used in biomechanical research, is described in parenthesis:
Two-Dimensional Translational Motion:
A: Anterior (+Z)
P: Posterior (-Z)
R: Right (-X)
L: Left (+X)
S: Superior or cephalad (+Y)
I:
Inferior or caudal (-Y)
EX: External
IN: Internal
Three-Dimensional Motion:
Clockwise rotation: (+)
Counterclockwise rotation: (-)
F:
Flexion (+X)
E:
Extension (-X)
LLF: Left lateral flexion (-Z)
RLF: Right lateral flexion (+Z)
RR: Right spinous rotation (+Y)
LF: Left spinous rotation (-Y)
Examples of Combination Listings:
These two components of location and direction are often combined to describe a bone or
motor segment which has deviated from its normal position. For example,
L5 PL:
C6 PLI-BR:
T6 RP:
53
5th lumbar vertebra has deviated with spinous moved to the left.
6th cervical vertebra has deviated with its body moved to the right.
6th thoracic vertebra has deviated with the body posterior on the right.
White A, Panjabi M. Clinical biomechanics of the spine. Lippincott, Philadelphia, 1978
106752870
Chapter 5: Glossary
The following glossary is essentially limited to terms which involve the process of
documentation. In addition, definitions are suggested for some terms which are used in
so many different contexts, [such as acute and chronic] that they have become difficult to
define accurately.
AAROM: Active assisted range of motion. The patient is asked to perform voluntary
movement of the joint throughout its arc of movement, and the examiner applies a mild
force in the same direction as the patient’s movement. The purpose is to ensure that full
range of motion has been measured, and to assess the quality of the joint movement upon
reaching the endpoint of movement.
Acute: having symptomatology for a relatively short length of time. A common
definition is symptoms which are noticed for less than 6 weeks upon presentation.54
AROM: Active range of motion, performed with the patient voluntarily moving the
joint. The examiner is looking for differences in range of motion and the patient’s
willingness to perform the movement.55
Assessment: The portion of the patient clinical record which details the doctor’s
impression, diagnosis or opinions of the case.
Chief complaint: The patient’s primary health concern which results in seeking
treatment from the doctor.
Chronic: having symptomatology for an extended length of time. A commonly
accepted criteria for a chronic complaint is symptomatology which are apparent for more
than 16 weeks upon initial presentation.56
Disability: The alteration of an individual’s capacity to meet personal, social or
occupational demands, or statutory or regulatory requirements because of an impairment.
Disability refers to an activity or task the individual cannot accomplish.57 Disability is
the inability to perform specific work-related activities. Disability is a functional deficit.
Impairment: The loss, loss of use or derangement of any body part, system, or function.
Impairments are defined as conditions that interfere with an individual’s “activities of
daily living”, or the inability to perform certain physical tasks, which may or may not be
associated with work activities58. An impairment is an anatomic deficit.
Maintenance care: 1. Treatment given in the absence of significant symptomatology;
2. well-person care; 3. preventative or prophylactic care
54
Fromeyer J. Back Pain and Sciatica. N Engl J Med., 318:291-300, 1988
Magee D. Orthopedic Physical Assessment. WB Saunders, Philadelphia, 1992.
56
Mayer T, Gatchel R. Functional restoration for spinal disorders: a sports medicine approach. Leee &
Febiger, Philadelphia, 1988.
57
American Medical Association. Guides to the evaluation of permanent impairment, 4 th ed. AMA,
Chicago, 1993.
58
American Medical Association. Guides to the evaluation of permanent impairment, 4 th ed. AMA,
Chicago, 1993.
55
27
Objective: Items in the patient record which can be accurately and repeatedly measured.
OPQRST: A mnemonic device for the essential elements of the history of the present
illness. The initials represent: onset, palliative and provocative factors, quality of pain,
radiation, severity, and timing (frequency).
Plan: Treatment plan; a written outline of the proposed care for the patient
PROM: Passive range of motion. The patient is asked to relax as much as possible, and
the examiner supplies all the force necessary to move the joint throughout its arc of
movement. Passive testing is usually performed if deficits in active range of motion are
noted.
SOAP: A mnemonic for subjective, objective, assessment, plan.
Sub-acute: symptoms which are present for a period greater than an acute presentation,
and less than a chronic presentation. A commonly accepted definition of sub acute would
be the presence of symptomatology for 6-16 weeks upon initial presentation.
Subjective: Items in the patient record which are derived from the patient’s verbal or
written communications with the doctor.
Supportive care: 1. Treatment provided after the patient has reached maximum
medical/chiropractic improvement and has not reached a full recovery; 2. treatment
given to diminish permanent or chronic symptomatology when a full recovery is not
possible; 3. treatment provided to alleviate the symptomatology of a known anatomic
deficit.
28
Chapter 6:
Commonly used abbreviations
The abbreviations listed below do not represent a comprehensive listing, or an attempt to
replace a medical dictionary. These abbreviations are often used by chiropractors , and
originate in the following areas:
1. Commonly encountered diagnoses
2. Commonly used abbreviations describing patient symptomatology in daily or
progress notes.
3. Commonly used anatomic abbreviations.
Note that some of the abbreviations can take on different meanings, depending upon the
context. For example, the abbreviation “P” can mean either “pulse” or “treatment plan”,
depending upon its usage.
>: greater than
<: less than
: arc
: frequency
: change
: decreased
: increased
: none, no
: right
L : left
B : bilateral
~: approximately
1: primary
2: secondary
3: tertiary
a.: before
A: assessment
a.c.: before meals
AAROM: active assisted range of
motion
ab: abdominal
AC: acromioclavicular
ad feb.: fever present
ad int.: in the interim
ad lib.: as wanted
adj.: adjustment
adl: activities of daily living
agg: aggravate
ant.: anterior
AP: anteroposterior
AROM: active range of motion
AS: ankylosing spondylitis
b.i.d.: twice per day
B: bilateral
B/B: Bowel/bladder
BCP: birth control pills
BM: bowel movement
BP: blood pressure
BX: biopsy
c: with
c/o: complains of
C: cervical
CA: carcinoma
CB: contrast bath
CBC: complete blood count
CBR: complete bed rest
cerv: cervical
cmt: chiropractic manipulative therapy
29
COPD: chronic obstructive pulmonary
disease
CP: cold packs
CP: cerebral palsy
cp: cervical pain
c-s: cervical spine
c-t: cervicothroacic
csa: chiropractic spinal adjustment
CT: computed tomography
ctd: cumulative trauma disorder
cts: carpal tunnel syndrome
CVA: cerebrovascular accident
CVP: central venous pressure
D: dorsal [syn. thoracic]
D/C: discontinue
DD: differential diagnosis
DDD: degenerative disc disease
DIP: distal interphalangeal joint
dimin: diminished
DJD: degenerative joint disease
DRG: dorsal root ganglion
DSLR: double straight leg raise
DTR: deep tendon reflex
Dx: diagnosis
ECG or EKG: electrocardiogram
EEG: electroencephalogram
EMG: electromyography
ems: electrical muscle stimulation
EPP: end point pain
ES: erector spinae muscles
ESI: epidural steroid injection
ESR: erythrocyte sedimentation rate
exacer: exacerbation
ext: extension
FBG/FBS: fasting blood glucose/sugar
FH: family history
fix: fixation
flex: flexion
FUO: fever of unknown origin
Fx: fracture
G-H: Gleno-humeral
GI: gastrointestinal
GU: genitourinary
HA: headache
Hb or Hgb: hemoglobin
Hct: hematocrit
HEENT or EENT:
head/eyes,ears,nose,throat
hmp: hot moist packs
HNP: herniated nucleus pulposis
hpi: history of present illness
HR: heart rate
HTN: hypertension
hv: high volt
HVG: high volt galvanism
Hx: history
ice mass: ice massage
IF, IFC: interferential current
im: intermittent
imp: improved
inf.: inferior
iso: isometric
IT, IST: intersegmental traction
ITB: iliotibial band
IUD: intrauterine device
ivd: intervertebral disc
ivf: intervertebral foramen
JVP: jugular venous pressure
KJ: knee jerk
L or lum: lumbar
L or Lt: left
lat: lateral
LATX: long axis traction
LBP: lower back pain
lbp: lower back pain
LC: lower cervical
LD: lower dorsal
LE: lower extremity
llf: left lateral flexion
LLI: leg length inequality
LLQ: left lower quadrant
lm: lateral meniscus
LMN: lower motor neuron
lr: left rotation
lum or L: lumbar
L/S: lumbosacral
30
l-s: lumbar spine
LT: light touch [sensation]
LUQ: left upper quadrant
lv: low volt
m: muscle
mass: massage
mbp: midback pain
MCP: metacarpophalangeal joint
MCRC: maximum cervical rotatory
compression
MCV: mean cell volume
med: medial
MI: myocardial infarction
MLR: maximum lifting restriction
mm.: muscles
mm: medial meniscus
mp: motion palpation
MTP: midthoracic pain or
metatarsalphalangeal joint
MVA: motor vehicle accident
myo: muscle
n: nerve
nad: no abnormalities detected
NBM or NPO: nothing by mouth
NCV: nerve conduction velocity
NKC: no know cause
NKI: no known injury
n/l: normal limits
nn.: nerves
nr: nerve root
NSR: normal sinus rhythm
O: objective
OA: osteoarthritis
OB/GYN: obstetrics and gynecology
OC: oral contraceptive
oc: office call
occ.: occipital
occ.: occasional
OTC: over the counter
p: after
P: Plan
P: pulse
p.c.: after meals
p.r.n.: as needed
pap.: papanicolaou smear
PE: physical examination
PERRLA: pupils equal, round, reactive
to light and accommodation
PFA: patellofemoral arthralgia
PH: past history
phono: phonophoresis
PIP: proximal interphalangeal joint
PMI: point of maximum intensity
pn, px.: pain
PND: postnasal drainage
PNF: proprioceptive neuromuscular
facilitation
PPD: permanent partial disability
prn: whenever necessary; as needed
PROM: passive range of motion
PT: physical therapy
Pt. ed.: patient education
Pt., pt.: patient
PT: physical therapist
PVC: premature ventricular contraction
px, pn: pain
q.a.m.: every morning
q.d.: every day
q.h.: every hour
q.i.d.: four times per day
q.o.d.: every other day
q.p.m.: every afternoon/evening
QL: quadratus lumborum
R: respiration
RA: rheumatoid arthritis
rad: radiate, radiation
rlf: right lateral flexion
RLQ: right lower quadrant
RTW: return to work
RO, R/O: rule out
ROM: range of motion
rr: right rotation
RUQ: right upper quadrant
Rx: therapy or prescription
Rx: medication
s: without
31
S: subjective
S: sacral
SA: sacral apex
sa: spinal adjustment
SB: sacral base
SC: sternoclavicular joint
SCM: sternocleidomastoidious muscle
sho: shoulder
SI: sacroiliac joint
SLR: straight leg raise test
sm: spinal manipulation
smt: spinal manipulative therapy
SOB: shortness of breath
SP: spinous process
spondy: spondylolisthesis
SSLR: sitting straight leg raise test
ST: sharp touch [sensation]
Stat.: immediately, at once
STM: soft tissue massage
sup.: superior
SWD: short-wave diathermy
Sx: symptoms
T: temperature
T: thoracic
Telecon: telephone conversation
t.i.d.: three times per day
thor: thoracic
TIA: transient ischemic attack
T/L: thoracolumbar
TMJ: temporomandibular joint
tos: thoracic outlet syndrome
TP: trigger point
TPD: temporary partial disability
TPR: temperature, pulse and respiration
TPT: trigger point therapy
trap: trapezius
t-s: thoracic spine
tt: taut and tender
TTD: total temporary disability
ttt: tender to touch
tx, txrn: traction
Tx: treatment
Tx: telephone call
UA, U/A: urine analysis
UE: upper extremity
UMN: upper motor neuron
URI: upper respiratory infection
US: ultrasound
UTI: urinary tract infection
UV: ultraviolet
VSC: vertebral subluxation complex
WLR: well leg raise test
WNL: within normal limits
w/o: without
WP: whirlpool
x: number of times performed [x2 =
twice; x3 =three times, etc.]
XR: x-ray
yo: years old
z-joint: zygapophyseal joint
32
Appendix A
The Health Care Financing Administration has recently produced guidelines which
address the level of history recommended for each particular evaluation/management
code. The HCFA guidelines specify which factors must be included to qualify for a
particular history, as well as the documenting factors which must be included. The
history is one factor which determines proper evaluation/management code selection.
The factors and their use are summarized in the chart below:
Possible
choices for
E/M code
Type of
History [used
to determine
proper E/M
code]
History of Present
Illness [HPI]
 the location of the
problem
 the quality
 the severity of the
problem
 the duration of the
problem
 the timing of the
problem
 the context
 modifying factors
 associated signs
and symptoms
99201
99212
99202
99213
Problemfocused
Expanded
problemfocused
Detailed
Brief
(1-3 of the
above factors)
Brief
(1-3 of the above
factors)
Extended
(4 or more of the
above factors)
Extended
(4 or more of the
above factors)
99203
99214
99204
99205
99215
Comprehensiv
e
Review of Systems
[ROS]
 eyes
 ears, nose, throat
and mouth
 cardiovascular
 respiratory
 gastrointestinal
 genitourinary
 musculoskeletal
 integumentary
 neurologic
 psychiatric
 endocrine
 hematologic or
lymphatic
 allergic or
immunologic
N/A
Past Family
and/or
Social
History
[PFSH]
 Past history
 Family
history
 Social
history
Problem-pertinent
(1 of the above
systems reviewed )
Extended
(2-9 of the above
systems reviewed)
Complete
(10 or more of the
above systems
reviewed)
N/A
N/A
Pertinent (1)
Complete
(2 or 3)
33
Appendix B:
Selected bibliography and reading list
1. Arnoff GM, ed. Evaluation and treatment of chronic pain. Williams and Wilkins,
Baltimore, 1992.
2. Baird, R. Health record documentation: charting guidelines. Digest Chiropractic
Econ 1981; 52: 32-3.
3. Bates, B. A guide to physical examination and history taking, 5th ed. Lippincott,
Philadelphia. 1991.
4. Boone W, et al. Practice Guidelines for Straight Chiropractic. World Chiropractic
Alliance, Chandler, AZ. 1993.
5. Braddom RL, ed. Physical Medicine and Rehabilitation. WB Saunders, London,
1996.
6. Camins M, O’Leary P. Disorders of the cervical spine. Williams and Wilkins,
Baltimore, 1992.
7. Curl, DD. Chiropractic approach to head pain. Williams and Wilkins, Baltimore,
1994.
8. Croft AC. Chief complaints in narrative reports. In: Dynamic Chiropractic, May 6,
1994. Motion Palpation Institute, Huntington Beach, CA.
9. Evans RC. Illustrated essentials in orthopedic physical assessment. Mosby, St.
Louis, 1994.
10. Ferezy, JS. The chiropractic neurological examination. Aspen, Gaithersburg, MD
1992.
11. Foreman S, Stahl M. Medical-legal issues in chiropractic. Williams and Wilkins,
Baltimore, 1990.
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CHART AUDIT CHECKLIST
1. Billed services are documented (X-ray, PT, rehab)
2. Special studies performed include explanation of why the test is necessary and a
description of the impact the test(s) had on treatment &/or diagnostic decisions
3. Diagnosis made is supported by the findings of the case
4. Legibility
5. List risk factors of a prolonged recovery (See appendix A)
 Conditions – diabetes, cardiovascular disease, CNS disorders, medication
interactions, etc.
 Yellow flags (depression, anxiety, poor coping strategies, fear avoidant behavior,
job dissatisfaction, etc.)
6. Treatment Plan - included? Followed?
7. Periodic recheck and updated treatment plan. Followed?
8. Exacerbations affect recovery? Home vs. work?
9. Were work restrictions/modifications issued? Followed?
10. Outcomes oriented documentation
11. Goal oriented management
12. Use of the Appeal process
13. Reasons for care denial
a. Insurance letter/opinion
b. Based on consultant file review (MD vs. DC vs. "anonymous"; qualifications
included?)
c. Based on IME
d. Guidelines cited
e. Records reviewed listed?
14. MMI reached? If so, when? If not, any predictions or special tests needed before
MMI is reached?
15. Treatment effectiveness
16. Pertinent past history findings (list & describe impact to the current case)
17. Rehabilitation (progression from passive to active care)
a. Anything more than "exercises given" listed? How frequently? Any followup? Any objective physical testing pre-/post-rehab to document outcomes?
b. If multiple units (each 15 minutes) - is this clearly documented (what was
performed, SOAP approach for rehab service, "scorecard" of performance,
etc.)
18. Was each page signed & dated?
36
APPENDIX A
Risk factors of chronicity & Yellow Flags
A. Risk factors (Documentation):
1. Abnormal illness behavior (Waddell's, SF-6)
2. Job dissatisfaction
3. Past Hx of >4 episodes
4. Symptoms > 1 wk w/o health provision
5. Severe pain intensity (Triple VAS) (>69%)
6. New condition / injury related to pre-existing
structural pathology or skeletal anomaly
7. Weak back extensor musculature
(Static back endurance test)
8. Smokes 1 pack or greater / day
9. Poor self-rated health (SF/HSQ-36 or -12)
10. Heavy Job Classification
B. Yellow Flags
Yellow Flags
Symptoms
Yellow Flag
Reference
Number of pain sites
Duration of symptoms
Linton, 1998; Linton, 1997
Cherkin, 1996; Von Korff, 1993; Linton 1998;
Linton 1997
Duration of symptoms before the 1st visit
Van den Hoogen, 1997
Past history of numerous episodes
Frank, 1996; Cherkin, 1996; Hazard, 1996;
Burton, 1995
Past hospitalization or surgery for similar
Van den Hoogen, 1997; Hazard, 1996; Lancourt,
complaint
1992
Severe pain intensity
Frank, 1996; Cherkin, 1996; Von Korff, 1993;
Linton, 1998; Hazard, 1996
Frequency of painful episodes over the last Linton, 1998; Linton, 1997
3 months
Sciatica
Frank, 1996; Cherkin, 1996; Burton, 1995; Salim,
1998; Lancourt, 1992
Psycho-social
Anxiety
Locus of control
Depression
Cherkin, 1996
Burton, 1995
Cherkin, 1996; Linton, 1998; Linton, 1997;
Klennerman, 1995
37
Catastrophizing
Self-rated health as poor
Heavy smoker
Belief that you shouldn’t work with your
current pain
Job dissatisfaction
Anticipation of trouble sitting or standing
at work 6 weeks into the future
Anticipation of disability 6 months into the
future
Function
Does physical activity make your pain
worse?
Tolerance for light work
Is sleep affected by your pain?
Disability
Heavy job demand
Past disability for the same/similar
complaint in prior 12 months
Disabled at present
Burton, 1995
Cherkin, 1996; Waddell, 1996
Waddell, 1996; Cats-Baril, 1991; Hazard, 1996
Linton, 1998; Linton, 1997
Cherkin, 1996; Cats-Baril, 1991
Hazard, 1996
Hazard, 1996
Linton, 1998; Linton, 1997
Linton, 1998; Linton, 1997
Linton, 1998; Linton, 1997
Waddell, 1996
Hazard, 1996
Hazard, 1996
38
APPENDIX B: Physical Medicine and Rehabilitation Services
Supervised Modalities
Code
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
Description
Hot or cold packs
Traction, mechanical
Electrical stimulation (unattended)
Vasopneumatic devices
Paraffin bath
Microwave
Whirlpool
Diathermy
Infrared
Ultraviolet
RVU*
.29
.46
.40
.45
.33
.28
.38
.29
.27
.28
Constant Attendance
Code
Description
RVU*
97032 Electrical stimulation (manual), each 15 minutes
.40
97033 Iontophoresis, each 15 minutes
.42
97034 Contrast baths, each 15 minutes
.32
97035 Ultrasound, each 15 minutes
.33
97036 Hubbard tank, each 15 minutes
.51
97039 Unlisted attended modality (specify type and time)
.47
Table 1. The use of modalities in a musculoskeletal practice is common. Various attended
and non-attended or supervised modalities are described. The Relative Value Units are
located in the right hand column.
Table 2. Treatment Services
97110 Therapeutic procedure, one or more areas, each 15 minutes; OR,
Therapeutic exercises to develop strength and endurance, range of
motion and flexibility
97112 Neuromuscular reeducation of movement, balance, coordination,
kinesthetic sense, posture, and proprioception, ea. 15 min.
97113 Aquatic therapy with therapeutic exercises, ea. 15 min.
97116 Gait Training (includes stair climbing), ea. 15 min.
97124 Massage, including effleurage, petrissage and/or tapotement
(stroking, compression, percussion)
97139 Unlisted therapeutic procedure (specify) ea. 15 min.
97140 Mobilization, manipulation, manual traction, lymphatic drainage, ea.
15 minutes
97150 Therapeutic procedure(s), group (2 or more individuals)
97504 Orthotics fitting and training upper and/or lower extremities; each
15 minutes
97520 Prosthetic fitting and training upper and/or lower extremities; each
15 minutes
.60
.59
.66
.52
.47
.49
.61
.62
39
97530
Therapeutic activities, direct (one on one) patient contact by the
provider (use of dynamic activities to improve functional
performance), each 15 minutes
97535 Self care/home management training (e.g., activities of daily living
and compensatory training, meal preparation, safety procedures, and
instructions in use of adaptive equipment) direct one on one contact
by provider, each 15 minutes.
97537 Community /work reintegration training (e.g., shopping,
transportation, money management, avocational activities and/or
work environment/modification analysis), work task analysis, direct
one on one contact by provider, each 15 minutes. [for wheelchair
management/propulsion training, use 97542, each 15 minutes]
97542 Wheelchair management/propulsion training, each 15 minutes
97545 Work hardening/conditioning; initial 2 hours
97546 each additional hour
Table 2. A listing of treatment services is found in this table with the associated CPT
code number. NE stands for Not Established.
.63
.64
.64
.44
NE
NE
Table 3 Tests and Measurements
(For muscle testing, manual or electrical, joint range of motion, electromyography or
nerve velocity determination, see 95831-95904)
97703 Checkout for orthotic/prosthetic use, established patient, each 15
.46
minutes
97750 Physical performance test or measurement (e.g., musculoskeletal,
.72
functional; capacity), with written report, each 15 minutes
Other Procedures
97770 Development of cognitive skills to improve attention,
.75
memory, problem solving., includes compensatory training
and/or sensory integrative activities, direct (one-on-one)
patient contact by the provider, each 15 minutes
97780 Acupuncture, on or more needles; without electrical
NE
stimulation
97781 With electrical stimulation
NE
97799 Unlisted physical medicine service or procedure
NE
th
* Taken from: 6 Annual edition 1998 ChiroCode DeskBook, Leavitt Crandall Institute,
Inc. Mesa, AR, 1997
Table 3. When tests or measures are performed, specific CPT codes can be assigned to
the service. When other services such as acupuncture is performed, CPT codes specific to
those services are also available.
40
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