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Record Keeping: Why It’s Important


January 2, 2008
By Dr. J. Bruce Walton DC

Topics

The ‘Why’ and ‘How’ of patient information in chiropractic practice

26Chiropractic records are essential to the quality of a patient’s care and not just a standard of practice to which all doctors must adhere. The College of Chiropractors of Ontario (CCO) is mandated and committed to proactively governing the chiropractic profession in Ontario in the public interest. As part of its ongoing quality assurance initiatives, CCO officially launched its record-keeping workshops in May of 2005.

The Record Keeping Workshops were the CCO’s first foray into mandatory continuing education on a specific topic. Given the success of this program and the feedback from members, the CCO may develop other topics to help members maximize patient care.

The goals of the workshops are:
• to demonstrate the importance of high quality records;
• to improve understanding of standards of practice related to record keeping;
• to make record keeping easy by showing what works and what does not work; and
• to have some collegial fun!
To date, the CCO has hosted more than 20 workshops in a variety of venues around the province. From Windsor to Ottawa, in St. Catharines and Timmins, Toronto and Thunder Bay – as well as several other cities in Ontario – more than 2,900 active members have attended.

Why workshops?
The workshops’ focus is to present a variety of record-keeping styles that would work in various practice settings. While the CCO does not mandate the use of any particular form, the message given to participants is clear; spend the time to create a style of record keeping that meets regulations and standards, as well as your individual needs. The workshops always serve to remind participants the “golden rule” of record keeping: another registered chiropractor should be able to step into your office and pick up where you left off – using only your records – and continue to provide the patient with the necessary quality of care. If a chiropractor’s records are not kept in this manner, patient care will surely suffer.

What happens in a workshop?
During the workshop, participants are treated to a multimedia presentation covering various CCO regulations, standards of practice, policies and guidelines on topics such as consent, recording the daily visit, how to handle fees, radiology records, re-evaluations and privacy. The CCO Council have chosen four presenters – all practising chiropractors – with a wealth of experience and knowledge about regulations and standards governing the profession. The presenters include Drs. Frazer Smith, Keith Thomson, Dennis Mizel and myself, Bruce Walton, as well as the CCO’s registrar and general counsel, Ms. Jo-Ann Willson. These individuals take what could be a dry and boring topic and make it real and entertaining for the attendees.

During the five-hour workshop, doctors are shown an assortment of “sterilized” files pulled from the CCO archives. These examples – the good, the bad and the ugly of record keeping – serve as reminders of their responsibilities in a practice setting. Presenters walk participants through a new-patient experience in a typical chiropractic office. Topics, such as how to record the intake and consultation information, the initial exam, and the re-evaluation are discussed. All of these elements must be accurately recorded in order to maintain CCO standards and assure that patients are receiving the highest quality of care.

The case for high quality record keeping
A patient file should read like a storybook with the patient’s experience in the chiropractor’s office as its topic. Think of the consultation and initial exam, diagnosis and plan of care as the opening chapter. Daily visits comprise the chapters of the story, with re-evaluations providing a climax at the end of each chapter.

Maintaining high quality patient records is not only essential for ensuring optimal patient care; patient records are also an essential aspect of  “defensive practices” strategy. Thorough and accurate records are the only defence a doctor has when asked to defend or validate the billing of care to any third party. As Dr. Greg Dunn, of the Canadian Chiropractic Protective Association, has stated, “Saying that you did something is not very helpful if you didn’t document it. If you chronicle your care at the time of treatment it is almost irrefutable.”

The voice of the people: attendees evaluate the workshops
The CCO has received overwhelmingly positive feedback from members who have attended the workshops. (Many wondered why the workshops were not offered sooner!). Some doctors attended the workshop a second time, bringing along their staff to ensure that they, too, were adhering to the necessary requirements for record keeping. Many work-shops were filled to capacity as word of the quality of the event spread and more members rushed to register. Some workshops even had waiting lists!

The success of these workshops has generated interest from other Canadian jurisdictions. In March 2006, Dr. Frazer Smith and I travelled to St. John’s, Newfoundland, to present segments of the CCO workshop to delegates from the Canadian Federation of Chiropractic Regulatory Boards – now  known as “The Federation”. Since then, the Manitoba Chiropractor’s Association has adopted, and presented, the program and the Chiropractor’s Association of Saskat-chewan is in the process of doing so. At the last “Federation” meeting in May 2007, in Vancouver, the “Federation” members reached an agreement, in principle, to begin drafting a national policy regarding patient record keeping.

Starting ‘em early: Record-keeping workshops for students
CCO has also made great efforts to reach the student population. All students are exposed to good record-keeping practices in school and teaching clinics. However, when students graduate and go into practice, they must adhere to their regulator’s standards of practice, including how they keep their patient records.

Since 2006, the CCO has held a record-keeping workshop at the Canadian Memorial Chiropractic College in the fall. Workshops are also held following the Legislation and Ethics examination in June, in an effort to reach doctors early in their careers.

Credits and upcoming workshops
It has become apparent that the CCO patient record-keeping workshops are an invaluable outreach program.  Attendees have greatly appreciated the efforts made by the CCO to explain regulations and standards coupled with the many examples shown of how to adhere to them. Participants leave the workshop with a much greater understanding of the CCO, why it exists, how it functions, and how each registered member is an active participant in the process of self-regulation.

The CCO thanks all members and staff who have participated in the workshops to date and looks forward to your ongoing enthusiasm and commitment to all the CCO quality assurance initiatives.

The CCO will be holding four workshops before the end of 2007 – one in Sudbury, one in Thunder Bay and two in Toronto. To ensure that all future chiropractors are current with patient record-keeping standards, the CCO plans to provide one or two workshops per year in the future.

For up-to-date information on these and other CCO programs, please visit the CCO’s website at www.cco.on.ca.•