From: webinfo@chiroviewpresents.com .. 8-28-00


Thomas Freedland, DC - 
ChiroView Presents Department Head - Utilization Review
TFreedland@aol.com


First, a File Review is not an examination or a substitute for an 
examination.  A File Review occurs when a peer is asked to look at 
the available clinical records to determine if the documentation 
supports the submitted charges and procedure codes.  It also looks to 
see if the frequency of care is supported and appears reasonable in 
light of the mechanism of injury.  Again, file review is based solely 
on the documentation available as submitted by the treating 
provider.  Some may ask, how can anyone make such a determination 
without examination of the patient?  The insurance company's 
contract with the patient generally outlines that they will pay for 
treatment which is reasonable and necessary and related to the 
covered condition.  It is your job as the treating provider to supply 
adequate documentation to establish clinical necessity.  Anything 
less is a disservice to your patient.  

We all went into healthcare with a desire to help people.  Part of the 
obligation of a good doctor is providing adequate documentation of 
services performed.  Your skill as a practitioner encompasses many 
aspects, ranging from examination, diagnosis, analysis, and 
determination of appropriate care.  But, of equal value is how well 
you are able to document and convey the information about the 
patient to a third party, whether that be another chiropractor, 
medical doctor, or another interested third party.

Let's pause a minute and reflect back on the reasons that we 
document patient care and record chart findings:

1. Chart documentation is kept so that you, as the provider, can 
recall from visit to visit what has happened and what your 
anticipated course of care or modification in course of care should 
be.  

2. The chart record can also be used to forward information to 
another provider who might be taking over care or whose opinion you 
have asked to evaluate the patient's status.  

3. Most State Boards establish rules or regulations that make 
charting an obligatory responsibility.

4. As the issue here, the chart record provides clinical explanations 
to a third party to determine medical necessity.  

5. The chart note also has a protective mean purpose.  Should a 
complaint be filed or charge of malpractice lodged, the chart record 
would then serve to establish what procedure was performed and the 
clinical circumstances surrounding it.  

As a general rule, your chart record (inclusive of intake, 
examination, and subsequent chart notes) should provide information 
about the presenting complaint, past medical history, as 
appropriate, whether it's related to the incident in question or not, 
modifying factors, as well as the effects the problem has on the 
patient's activities.  Your examination should address the areas of 
complaint or injury, associated and related components, and should 
help to guide you to the appropriate diagnosis and the development 
of a treatment plan.  The chart record should provide a story 
explaining the patient's response to care over the course of time, 
expectations met, the necessity for any diagnostic tests or 
referrals, and an expected date of release or determination of 
disability.  The record should be in a form that would allow a peer to 
assume treatment of the patient by primarily reviewing the records.  
Your patients deserve documentation to this level as a protection 
should somet!
hing disastrous befall you such as an accident, injury, or death.

Take a moment and look at your chart records.  Do they provide an 
accurate level of documentation as described above?  Could someone 
else review the notes and assume treatment of your patient based 
solely on documentation and without inferring or speculating on 
anything in the course of care.  Ask a fellow practitioner to look at 
your notes and records and see if they can make such a 
determination.  If they can assume treatment based on your 
documentation, then more than likely it is adequate to meet the 
medical necessity aspect of the insurance contract.  If it does not, 
perhaps it's time to revise your method of clinical documentation.  

In a file review your patient's records are evaluated by a peer to 
determine whether there is sufficient information to support the 
care as billed.  If your documentation does not meet this standard, 
you are not providing adequate care to your patients.  Care 
encompasses more than just treatment.  Without documentation you 
are leaving your patient vulnerable.  If treatment is not supported 
during a file review because of inadequate documentation, who is 
the ultimate responsible party?