Improving Personal Injury Treatment Notes: A Guide for Chiropractors

Personal injury treatment notes play a critical role in chiropractic practices, affecting marketability with attorneys, reimbursement, and patient outcomes. However, poor documentation can have negative consequences. This post focuses on three simple steps to improve personal injury treatment notes, enhancing subjective sections, fortifying objective findings, and revitalizing assessments. By following these practical strategies, chiropractors can optimize their practice's efficiency, effectiveness, and overall care for patients with personal injuries.

The Importance of Good Notes

Accurate and detailed notes in personal injury cases are crucial for several reasons. They directly affect your marketability with attorneys, your ability to receive referrals, and your reimbursement, especially when dealing with PIP, MedPay, and third-party liability. Documentation supports treatment duration, type, and frequency, which is essential for insurance claims and legal proceedings. Poor notes can lead to reduced settlements and reimbursement denials, damaging your reputation and financial stability.

Real-Life Impact of Documentation

To emphasize the importance of good notes, let's consider some actual quotes from PI attorneys and insurance claims adjusters:

• "Attorneys need the information in the treatment records to use it in the demand package. If you don't have it in there, it makes it really hard."
• "If you have it in the records in a manner that's difficult to decipher, that's even worse."
• "Good documentation and case management plus communication and reports are crucial for more attorney referrals."

These quotes highlight that thorough, clear, and well-structured notes can make a significant difference in the success of personal injury cases.

Understanding Your Audience

When preparing your PI notes, remember that various parties, including claims adjusters, attorneys, and possibly even judges or juries, will scrutinize them. Poor notes can lead to reduced settlements and reimbursement denials. Therefore, it's vital to understand that your notes represent you and your practice. Good documentation showcases your professionalism and thoroughness.

Three Simple Steps to Improve Your PI Treatment Notes

Step 1: Enhance the Subjective Section

The subjective section often suffers from redundancy, with many providers copying and pasting symptoms from previous visits. This gives the impression of laziness and can negatively impact your credibility. To overcome this:

• Change Your Questioning Approach: Instead of asking, "How are you doing today?" ask, "What has changed since your last visit?" This focuses on changes in symptoms and their intensity, providing a more dynamic and accurate picture of the patient's condition.
• Document Specific Changes: Note any changes in symptom frequency, intensity, and duration. For example, "The patient experienced reduced neck pain for 3-4 hours post-treatment, but the pain gradually returned.
• Overcome Redundancy: Insurance carriers view redundancy as a sign of sloppiness and carelessness. By focusing on specific changes, you can demonstrate that you are actively monitoring and adjusting treatment based on the patient's progress.

Examples:

• Ineffective: "Same as last time."
• Effective: "Mr. Jones continues to report bilateral neck pain described as sharp and stabbing, which has worsened with driving and is relieved with treatments and home exercises. The patient experienced reduced neck pain for 3-4 hours post-treatment, but the pain gradually returned."

Step 2: Improve the Objective Section

The objective section, or the "meat and potatoes" of your notes, should provide clinical rationale and medical necessity for your treatments. This section should go beyond simple palpation and include:

• Detailed Descriptions: Use terms like "moderate palpatory muscle spasms noted in the cervical region" instead of vague descriptions like "tenderness."
• Objective Findings: Include findings from range of motion tests, ortho tests, and neuro tests. Documenting objective improvements or persistent issues supports the necessity of ongoing treatment.
• Clinical Rationale: This section should justify your treatments. If you find spasms, reduced range of motion, or positive ortho tests, these findings should guide your treatment plan.

Examples:

• Ineffective: "Tenderness in cervical spine."
• Effective: "Moderate palpatory muscle spasms noted in the right cervical region with associated trigger points. Range of motion decreased by 25% in right lateral flexion and rotation with endpoint pain."

Step 3: Refine the Assessment Section

The assessment section often appears redundant, with many providers repeating the same phrases. To enhance this section:

• Focus on Function: Use outcome assessments to track functional improvements. For example, "The patient's neck pain has decreased, allowing them to drive for longer periods."
• Use Descriptive Terms: Incorporate the word "because" to explain your assessments. For instance, "The patient's lower back pain persists because of prolonged sitting at their desk."
• Outcome Assessments: These tools are crucial for documenting functional improvements and guiding your treatment plan. They also help to avoid redundancy and provide concrete evidence of progress.

Examples:

• Ineffective: "Patient improving as expected."
• Effective: "The patient's neck and upper back are improving as expected because they have less pain when driving for long periods of time. The patient's lower back is improving slower than expected because they had to sit for long periods at their computer the last several days."

Additional Tips for Better PI Notes

Address Gaps in Care

Document any lapses in treatment immediately. Explain the reasons for the gap and note any home care the patient undertook during the absence. Being proactive about documenting gaps can help avoid issues with insurance carriers and attorneys questioning the continuity of care.

Customizing EMR Templates

• Spend Time Customizing: Before going live with any EMR system, spend time customizing the templates and macros to fit your practice's needs. This ensures that the system works for you and not the other way around.
• Regular Updates: Keep your EMR templates updated to reflect any changes in best practices or new information about personal injury documentation.

Handling New Symptoms

If a patient presents new symptoms during treatment:

• Evaluate Thoroughly: Conduct a history and examination of the new symptom.
• Document Clearly: Clearly document the onset, characteristics, and any changes in the new symptom.
• Link to Accident: Ensure you establish whether the new symptom is related to the original injury or if it might have a different cause.

Scheduling Tips for PI Patients

• Extra Time for PI Visits: Schedule extra time for PI patients to ensure you can thoroughly document their visits without feeling rushed. This can be built into your schedule by setting different appointment types.
• Multitasking During Visits: While performing treatments, ask the patient about their symptoms and improvements. This allows you to gather information without taking additional time.

Conclusion

Improving your personal injury treatment notes requires attention to detail and a proactive approach. By focusing on specific changes in the subjective section, providing detailed objective findings, and refining the assessment section with functional assessments, you can create notes that are both comprehensive and useful for all parties involved in a PI case. By following these steps, you can enhance your marketability, improve your reimbursement rates, and provide better support for your patients' legal cases.

Final Thoughts

Documentation in personal injury cases is not just about compliance; it's about building a strong case for your patients and ensuring they receive the care and compensation they deserve. With these detailed steps and tips, you can transform your PI notes into powerful tools that reflect your expertise and dedication to your patients' well-being.