Commentary - Added
Since the determination of the necessity for past, present and future care can only be made when all relevant information is contained in the patient records, the issue of record keeping is an important one.
Many chiropractors provide care solely directed at addressing vertebral subluxation and its related components. The record-keeping practices of these chiropractors will normally contain descriptions of the care that is unique to his/her particular method or technique system. These methods for recording subluxation and their correction can be highly idiosyncratic. These recordings should be considered acceptable as long as they adequately describe the care being provided to reduce, correct or stabilize the subluxation.
Attending chiropractors should not need to provide anything more than a simple legend that describes any non-standard abbreviations or descriptions regarding their note taking. Notes indicating the level(s), type, positions, listing, coordinates of subluxation(s) should be considered adequate. Notes may also contain information regarding the methods used to correct the subluxation(s). If a particular method is to be used on each visit it should not be considered necessary that the attending chiropractor describe this each and every visit as this would be redundant. Brief notations as to any deviation from the plan should be considered adequate.
The S.O.A.P. format is one of several acceptable approaches to recording notes and it may be used with patients who have a symptomatic presentation. However, if a patient is undergoing "wellness" type care, does not present with symptoms, and is purely undergoing subluxation analysis and resultant reduction it may not be always be necessary to provide subjective reports (S) from the patient and/or a detailed assessment (A). The notes in such a case may only indicate the information pertaining to the objective, subluxation oriented chiropractic findings and the resultant plan to correct them during that visit. The assessment (A) might be considered redundant in such a case since this information (listings, coordinates, segments adjusted etc) may exist in the objective (O) section. Further, if the practice objective of the chiropractor is narrowly focused on subluxation then the practitioner may not have a listing of diagnoses other than subluxation and these might be listed in the objective section already. More detailed assessments as to long term response to care may be handled during re-examinations. Chiropractic spinal evaluation, evaluation for subluxation and other similar terms should be considered an appropriate subjective (O) notation when applicable.
Beyond the plans (P) for that particular visit additional notations regarding future plans may or may not be necessary depending on the type of care or method being rendered.
_________________________________________________________ Council on Chiropractic Practice Clinical Practice Guideline Number 1 Vertebral Subluxation in Chiropractic Practice – 2003 Update & Revision