Ongoing treatment notes: What to write down when there’s nothing to say

You know who they are – they’re your “regulars.” 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 patients love you, and you love them right back, maybe because 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 complaints?  

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: Adjustments), then your record keeping for these beloved patients 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 reflects the quality of notes found in your patient files. Fortunately, there are some tricks of the trade that can 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 specific things.
• Use abbreviations and the key to your abbreviations more effectively

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, special 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
• 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 always 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, referrals)?

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-assessment 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 annually 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 comparison. 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/Palpations/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, referrals and self-care recommendations.

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.