Potential Board of Examiners Revisions to Rule
New Requirements on Chiropractic Documentation
As of the publishing of this blog, the Rules Committee of Texas Board of Chiropractic Examiners is considering very significant revisions to its Rule governing the content of chiropractic documentation. Specifically, it is my understanding that the Texas Board intends to overhaul its basic rule regarding chiropractic documentation.
As it currently exists, Texas Chiropractic Board Rules only generally require that a doctor must adequately document the services that he/she provides.
In this regard Texas Chiropractic Board Rule 75.2(a)(1)(A) requires that the doctor’s actions must conform to the minimal acceptable standards of chiropractic and that the doctor must “assess” and ”evaluate” his/her patient’s condition.
Board Rule 80.5(f) requires that doctor’s medical records must support all diagnoses, treatments and billing and that the doctor’s records must be signed by the doctor and the doctor’s staff that provided the service(s).
Thus, under current Board Rules doctors must only generally document their “analysis”, “diagnosis” and “course of treatment” and their documentation must comply with the minimum accepted standards of the profession. As they currently exist the Texas Board’s Rules governing documentation do not impose any specific identifiable criteria as to what a doctor must include vis a vis his/her analysis, diagnosis and treatment of a patient.
However, this “generic” approach to medical documentation is about to change. Proposals are now being considered and discussed by the Board’s Rule Committee that would require that every doctor include very specific, detailed, steps in his/her documentation with respect to the manner in which the doctor conducts his/her examination, arrives at his/her diagnosis and carries out his/her plan of treatment.
In this regard every Texas doctor will be required to generate significantly more identifiable information in support of the doctor’s proposed plan of treatment and in actual daily treatment notes and related medical records. These new requirements will significantly impact more than 90% of Texas doctors of chiropractic who simply incorporate generic record keeping and notes within their standard chiropractic patient records.
Most doctors are aware that the majority of chiropractic records are insufficiently detailed and lacking in clarity as to what the doctor’s medical conclusions are and what the doctor has done during the course of his patient care (maybe you’re not aware, but I am – and the Board is certainly aware)!
Accordingly, what the Board is proposing may not be all that bad. However, this Board almost certainly will impose a significantly greater burden/requirement on doctors to expand the degree of specificity and the amount of documentation of their medical services.
A number of state chiropractic boards currently require far greater detail in what a doctor of chiropractic must do and record in maintaining their patient medical records. Florida is a great example of a state that has a documentation rule that currently specifies what Texas may ultimately require with respect to the degree of detail required of a chiropractor’s care of their patient and how detailed the chiropractic records must be.
The State of Florida currently requires, at a minimum, that “[t]he medical record shall be legibly maintained and shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment and document the course and results of treatment accurately, by including, at a minimum, patient histories; examination results; test results; records of drugs dispensed or administered; reports of consultations and hospitalizations; and copies of records or other documentation obtained from other healthcare practitioners at the request of the physician and relied upon by the physician in determining the appropriate treatment of the patient. Initial and follow-up services (daily records) shall consist of documentation to justify care.”