Learning & Resource Center Articles
The Important Role of Documentation
By: Acufinder Editorial Staff
For practitioners of acupuncture and Oriental medicine, documentation plays a more important role than tracing a patient's progress and assessing the effectiveness of treatment--it helps practitioners guard against potential malpractice and liability disputes.
Practitioners of acupuncture and Oriental medicine are tasked with using their professional skills and training to treat clients who are often seeking holistic therapies to treat a range of health conditions. Failure by the practitioner to take proper notes, keep thorough and precise records, detail the reasoning behind a diagnosis, treatment or prescription of herbs can potentially be considered negligent during future audits of patient records. Typically the practice of acupuncture and Oriental medicine is not documented using the clinical terminology used in Western medicine, making it harder for others to interpret and classify. This makes it essential for the practitioner to document clearly and consistently.
Here are a few tools that can help minimize a practitioner's liability risks:
- Keep Quality Documentation: Treatment records and notes should be readable, accurate, up-to-date, thorough and complete. At times, patients may ask for copies of their treatment records so that they can be distributed to a subsequent service provider or an insurance company, lawyer or employer. Taking measures to ensure that documentation is in order guarantees that care is more coordinated between care professionals for the benefit of the patient. Additionally, if the records or notes are given to either an insurance company or lawyer, taking such steps can give the practitioner recourse if their professionalism or the treatment provided comes into question.
- Be Organized: Each page in a chart needs to be securely attached, have the patient's name and offer some identifier. Entries need to be signed or initialed and dated by the practitioner to be sure that they have assessed that particular document and are aware of and accountable for its contents.
- Ensure Health Background Forms are Completely Filled Out: When patients fill out forms about their health background, make sure that all of the spaces are completed. The practitioner should then review the material and sign or initial. It is also helpful to review the information with the patient to ensure that the patient's health status and health concerns are clearly understood. In instances where there are blanks, obtain a response from the patient and document why they failed to answer the question. Doing so safeguards practitioners if those "blank areas" turn out to be health problems either in future or while the patient is under their care. If the question does not pertain to the patient, then put N/A for not applicable.
- Use a Prescription Control Record: This particular record can be affixed to each chart and strategically placed on the inside of the front cover. It should include the list of what was prescribed to the patient over the course of their care. Don't forget to supply the date recommended and the dosage. Note any and all allergies. Having this information accessible is imperative, especially if circumstances arise where another practitioner has to take over care or the record is needed by the patient's primary care physician. Adverse reactions from taking different herbal or over-the-counter drugs can be serious, as can negative interactions with prescribed medications.
- Obtain Informed Consent: Some practitioners may perform a treatment that involves some risks. Any dangers, benefits or alternatives to the suggested treatment and prescriptions should be laid out verbally and in a consent form. When situations like this occur, it is crucial that the patient is fully aware of the risks and has formally consented to having the treatment conducted. Without this documentation, a practitioner can be sued if complications occur or if the patient claims not to have agreed to the treatment given.
- Make Both Subjective and Objective Notes: Have all your bases covered. Note the patient's complaints, and use their own words when feasible. Make thorough notes of symptoms, including onset and other treatments pursued. Observe and note mental, emotional and physical changes. These notes are useful if the practitioner needs to prove that problems existed prior to providing care. Record any Western medicine diagnosis or treatment received, including the name of the diagnosing/treating institution or medical professional. If self-diagnosed, put "per patient" to signal that the patient was the source of the information.
- Assess the Situation: A practitioner should write down their perception of the problem as well as their Oriental medicine diagnosis. The document ought to contain the justification for such conclusions and diagnoses. A separate sheet should include the results of all procedures. If there were any adverse reactions, state them and explain what was done to remedy the situation. Also note whether the patient was satisfied with the end solution to their problems. The more thorough and detailed a practitioner is the better.
- Outline a Blueprint for Treatment: There is nothing sounder than a well-crafted plan. Discuss - and note - what services and treatments you will provide during each visit including what points on the body will be needled, if any. Bring up concerns you may have and allow for the patient to do the same. Go over instructions on how frequently to take herbs and supplements and at what dosage. Make sure a copy of the directives is sent home with the client. Also record dietary suggestions and any recommendations such as tests or exercises. Explain why these suggestions were made. Clearly communicating and transcribing this information makes the client fully aware of what the services or proposals can and cannot do for them. Additionally, the patient is conscious of what they will need to do themselves in order for treatment to be as successful as possible.
- Include Telephone Conversations: If a client calls complaining of a new symptom or reaction to treatment or to further discuss their treatment plan, test results or lab reports, the conversations must be documented and dated. Also, note the time the patient called. It goes without saying that certain patient information should never be given over the phone and if information is rendered, the person at the office should ask questions to verify the caller is in fact the patient. Acupuncture and Oriental medicine practitioners must adhere to patient confidentiality regulations.
- Get Patient Feedback: A patient satisfactory survey gives practitioners insight as to how their clients perceive the care they've been given. If there are areas that need improvement, take the necessary steps to please the patients. They come first and are the foundation of any practice. Maintaining a high level of care and having those positives on record are a plus for the practice's reputation, as well as useful tools if a previously satisfied customer later makes false accusations regarding service.
- Properly Withdraw From Care: If a practitioner decides to cut professional ties with a patient, it should be done with the utmost care. Practitioner-patient relationships can be strained if the patient is non-compliant, uncooperative, consistently fails to make it to appointments or does not pay their bills. In these cases, a practitioner reserves the right to discontinue service, but might risk assertions of abandonment. To avoid this, the practitioner should write and mail the patient a letter stating the withdrawal. While giving a reason for the separation is elective, doing so offers greater protection. Following this, the practitioner should offer to send a copy of the patient's chart to the next practitioner they will be working with. If the patient does not have another practitioner already, referrals can be offered for other qualified practitioners.
In order to avoid legal ramifications, practitioners of Oriental medicine and acupuncture must place greater focus on keeping precise notes and documentation. Most importantly, the care a practitioner provides must make sense to the person receiving treatment and also to anyone who may review a patient record in future - particularly other medical professionals, insurance companies or lawyers. Excellent documentation defends the treatment given and plainly lays out the practitioner's role and responsibilities.
Medical Insurance Exchange of California. Claims prevention for acupuncturists: A guide to help you prevent patient injury, reduce liability risks, increase defensibility. 2001. Retrieved from: http://www.miec.com/Portals/0/pubs/AcuClaimsPrevention.pdf