10/24/2019

Disclaimer

• I wish I could guarantee that your work will “Bullet Proof” Documentation never be audited, reviewed, or denied after taking this course! Strategies (2019) • What I can promise is that you will leave here Steven G. Yeomans, DC, FACO with a better understanding of the methods of 404 Eureka St. documentation, the needed elements to Ripon, WI 54971-0263 920-748-3644 create a quality note, and various options [email protected] from which you can choose.

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The “Mission” of Documentation Bullet-Proof Documentation Strategies

• To “tell a story” about the patient presentation • Overview • To present in an efficient, concise, practical approach – Your documentation is a reflection of your quality the salient / important clinical features – SOAP Notes (Subjective/Objective/Assessment/Plan) • Utilize evidence based approaches when possible • Legibility • Utilize an outcomes based management system • “Tell a story” that is patient specific and concise • Efficient – short & sweet • To share with others when properly requested • Exam notes are longer / daily notes are short • SIGN YOUR NOTES!

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Documentation General Rules of Documentation • Why bother? Who benefits? • Use only blue or black ink – DC • Never use correction fluid or erase – Patient • Only use standard abbreviations – Insurer • Write legibly – Malpractice buffer • Patient’s name on all notes – Outcomes based research • Correct errors by putting one line through it & – Interdisciplinary communication & marketing initial/date it (discuss recent challenge) – Chiropractic (our reputation is at stake!) • Sign or electronic: provider name & date

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Error Correction Consideration Error Correction Consideration From Dr. Stephen Perle, DC, MS U. of Bridgeport (2-11-10) From Dr. Stephen Perle, DC, MS U. of Bridgeport (2-11-10) • The old “line through, date, sign” method may be • Word docs are not “encoded” and can be used against the Dr. altered = risk management issue – “Dr. I see that you have corrected errors in the chart. How – Encoded records includes a date stamp and many? How do we know the chart isn’t full of errors that haven’t been corrected yet?” includes the ability for an audit trail including – NEW Approach: put a single line through date/sign and appropriate changes to the record. notate the entry “void” and then write the correction – The attorney has a greater challenge with a void vs. the “old” error correction only method.

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Creating “Bullet-Proof” Notes So what do your notes look like???

• Evidence-based • Medical necessity • Chiropractic necessity • Quantitative versus Qualitative – Outcome-based • Tell the patient’s “story”

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Example 2 Example 1

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….or, this?

Example 3 SIGN YOUR NOTE!

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Documentation: Need For Change Insurance Audits

• Professionalism • Many insurers – not just Medicare – are • Public Image (our patients notice!) auditing our records – Cultural Authority • Penalties and / or refunds are being requested • Interdisciplinary Respect • DON’T IGNORE THESE FACTS! • 3rd Party Payer Demands • Malpractice Buffer IGNORANCE IS NOT BLISS!!!! • Medicare Audits****

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Historical Review of Chiropractic Documentation (2008-2016)

• Office of the Inspector General (OIG) report

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OIG Report Facts (2008)

• 94% were missing required elements – Treatment goals and treatment plan: 2 most common (Susan McClelland) • 83% had an insufficient treatment plan • 67% did not show medical necessity or were miscoded • 47% of the claims should not have been paid

2008 2008

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5/2009 OIG Report 10/2016 OIG Report

• Treatment Plan (TP) – one of the key elements Hundreds of Millions in Medicare Payments for to prove medical necessity to Medicare. Chiropractic Services Did Not Comply With – TP documentation was “insufficient” Medicare Requirements – TP is needed to track specific goal changes (to Source: OIG 10/18/2016 prove treatment was “active/corrective”) • Most Medicare payments for chiropractic services did not comply with – TP was found in 76%, BUT… Medicare requirements. • On the basis of our sample results, we estimated that $358.8 million, or • 43% lacked treatment goals approximately 82% of the $438.1 million paid by Medicare for • 17% lacked objective measures chiropractic services was unallowable. • 15% lacked the recommended level of care • These overpayments occurred because CMS's controls were not effective – Overall, only 11% of DC’s had “acceptable” TP’s in preventing payments for medically unnecessary chiropractic services. 2016 2009 https://oig.hhs.gov/oas/reports/region9/91402033.asp

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10/2016 OIG Report 10/2016 OIG Report Hundreds of Millions in Medicare Payments for Chiropractic Services Did Not Comply With Medicare Requirements Hundreds of Millions in Medicare Payments for (continued)… Chiropractic Services Did Not Comply With Source: OIG 10/18/2016 • We recommended that CMS do the following, which could have saved Medicare Medicare Requirements (continued)… an estimated $358.8 million for 2013: Source: OIG 10/18/2016 – (1) determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to • Strong controls to prevent improper payments for chiropractic services are identify services for review in excess of that number; important to program integrity. – (2) determine a reasonable limit for the number of chiropractic services that • For example, CMS could consider taking appropriate action to limit the Medicare will reimburse, take appropriate action to put that limit into effect, number of chiropractic services that Medicare will reimburse to a specified and implement a system edit to disallow services in excess of that limit; maximum (e.g., 30 per beneficiary per year). – (3) improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that • If such a limit had been in place during our audit period, it would have only medically necessary chiropractic services are billed to Medicare; and prevented chiropractors from billing a high number of medically unnecessary – (4) specifically identify significant obstacles to developing a more reliable services. control for identifying maintenance therapy and work to establish such a • Unless CMS implements strong controls, it is likely to continue to make control. improper payments to chiropractors.

https://oig.hhs.gov/oas/reports/region9/91402033.asp https://oig.hhs.gov/oas/reports/region9/91402033.asp

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10/2016 OIG Report 10/2016 OIG Report

OIG Auditor’s report: Summary of findings on DC payments (continued)… OIG Auditor’s report: Summary of findings on DC Source: Chiropractic Economics 10/24/2016 Specific problems identified by the Medicare administrative contractors (MACs), who process Part B claims for payments CMS, fell mostly into the following categories: • 1. Maintenance therapy. CMS guidelines state that acute subluxations of the spine may Source: Chiropractic Economics 10/24/2016 require up to three months of active treatment. Treatments beyond this time period are considered maintenance therapy, which is not a service covered by Medicare Part B. • Kathy Mills Chang, a certified medical compliance specialist and certified According to Chang, these are called “screens,” whereby Medicare sets internal professional chiropractic coder (MCS-P and CPCC), says, parameters for certain diagnosis codes to identify when most cases should be complete. “This alerts them that any care beyond that might be approaching – “The challenge is not the AT modifier or the updating of ‘box 14’ with the new maintenance care, and therefore, the provider may receive a request to justify initial treatment date of an episode. with additional documentation why this case requires more care than another,” Chang – The real problem is the DC understanding which care is ‘medically necessary’ says. • 2. Failure to document medical necessity. Even though patient records were submitted according to Medicare’s definition and which care would be defined as with the AT (acute treatment) modifier, upon investigation it was determined that the ‘maintenance care’ per Medicare’s definition. treatments provided did not warrant this coding. “This is truly the No. 1 problem with – The care is actually not ‘unnecessary’ but perhaps better defined as ‘not documentation and Medicare in our profession. It’s that the doctor may consider care ‘medically necessary’ and therefore coverable, so they bill Medicare with an AT medically necessary’ and therefore, doesn’t qualify for reimbursement from modifier indicating active treatment. However, the notes do not warrant active Medicare but rather is the patient’s financial responsibility.” treatment and fail to establish why the care meets Medicare’s definition.”

https://www.chiroeco.com/oig-report-summary-of-findings/ https://www.chiroeco.com/oig-report-summary-of-findings/

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10/2016 OIG Report 10/2016 OIG Report

OIG Auditor’s report: Summary of findings on DC OIG Auditor’s report: Summary of findings on DC payments (continued)… payments (continued)… Source: Chiropractic Economics 10/24/2016 Specific problems identified by the Medicare administrative contractors (MACs), who process Part B claims for Source: Chiropractic Economics 10/24/2016 CMS, fell mostly into the following categories: • Possible remediation of OIG report – The Office of Audit Services (OAS), which prepared the report, recommends • 3. Excessive treatments. A 2005 OIG report determined that a typical patient presenting for acute treatment requires approximately no more than 12 treatments. that “strong controls” be enacted to prevent payments for medically Although at this time CMS does not specify a maximum number of treatments, any unnecessary chiropractic treatments. number more than 12 is considered to be likely medically unnecessary, and after 24 – Specifically, the office suggests that a limit on the number of treatments treatments that likelihood is extremely probable, according to the report. would have sufficed to prevent the majority of the overpayments in question, • 4. Unnecessary services. Despite the education for chiropractors available on CMS and and mentions an annual number of 30 visits per patient as a target. MAC websites, chiropractors were found to be billing for services not covered by Medicare. According to Chang, the training on these websites is insufficient with – In the event a chiropractor exceeded that number of treatments with a given respect to chiropractic services, “and various consultants train these concepts patient per annum, CMS would need a system to identify such services for differently.” additional review. https://www.chiroeco.com/oig-report-summary-of-findings/ https://www.chiroeco.com/oig-report-summary-of-findings/

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10/2016 OIG Report 10/2016 OIG Report

OIG Auditor’s report: Summary of findings on DC OIG Auditor’s report: Summary of findings on DC payments (continued)… payments (continued)… Source: Chiropractic Economics 10/24/2016 Source: Chiropractic Economics 10/24/2016 • In response, CMS balked at this suggestion, citing unspecified obstacles that would prevent the implementation of such a system at this time. • In communication with the auditors, CMS concurred that setting a limit on the • The report stressed the need for additional training and education for chiropractors number of chiropractic services is desirable, but putting in place a system to so that the AT modifier is used correctly. identify cases that exceed that number is a step requiring a National Coverage Determination. • And finally, in the event a certain limit on the number of services CMS will allow per patient cannot be arrived upon, the report recommends a system for tracking – CMS also agreed that additional clarification on the proper use of the AT modifier will reduce the incidence of overpayments for chiropractic services and will work through “local the date a patient begins an episode of care, and flagging for review any educational activities” to realize that objective. treatments that exceed a reasonable timeframe (e.g., 90 days). • For doctors of chiropractic who would like to review the essentials of • “Certain MACs have listed 24 annual visit allowances that serve as a screen,” Chang notes. “At least these doctors know how to stay within the lines and when to compliant coding immediately, the American Chiropractic Association offers a make the patient financially responsible for the adjustments as maintenance.” training module titled “Medicare Documentation: Just Tell Me What to Do!” [MAC: Medicare Administrative Contractor: National Government Services, – This training is designed for practicing doctors, new practitioners, and students, and offered Jurisdiction 6: IL, MN, WI] SEE NOTES FOR PDF/NGS Tour for a small fee. For more in-depth training on Medicare compliance and billing, professional consultants are available in the chiropractic industry. SGY: I couldn’t access the URL 10-19-19 https://www.chiroeco.com/oig-report-summary-of-findings/ https://www.chiroeco.com/oig-report-summary-of-findings/

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10/2016 OIG Report State of WI

OIG Auditor’s report: Summary of findings on DC OIG Auditor’s report: Summary of findings on DC payments (continued)… payments (continued)… Source: Chiropractic Economics 10/24/2016 Source: Chiropractic Economics 10/24/2016 • It should be noted that the OAS only audited a total of 105 billings to CMS totaling $2,447, and extrapolated this out to the $359 million figure cited in the report. – Brad Cost, CEO of Infinedi Electronic Data Interchange, notes that the statistical relevance of even a small data set is important in today’s world as it defines the government’s perception of chiropractic, and correct coding is essential now more than ever before. – And Chang sums up the issue in two points: 1) incorrect documentation and 2) lack of understanding of the definition of medical necessity versus maintenance care. • Ultimately, while CMS may have found the contested claims to have not established medical necessity, this may have been largely due to documentation inadequacies, and not evidence of intentional misconduct. https://www.chiroeco.com/oig-report-summary-of-findings/ https://www.dhs.wisconsin.gov/oig/index.htm

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State of WI State of WI

Office of the Inspector General (OIG) (continued)… • The Office of the Inspector General (OIG) protects Wisconsin taxpayers by Office of the Inspector General (OIG) (continued)… tracking and preventing fraud, waste, and abuse in public assistance programs administered by DHS, like Medicaid, FoodShare, and Family Care. – At the same time, OIG's internal audits protect the accountability of DHS programs and operations. • Established in October 2011, OIG consolidates all program integrity, audit, and fraud investigation activities into one office. – Since its beginning, it has saved taxpayers millions of dollars. – Staff works closely with other state and local partners to identify misuses of NEXT SLIDE CLOSE UP public assistance funds, and where appropriate, forwards fraud cases to federal, state, and local officials for prosecution. • Misuse of public funds affects each person who lives in Wisconsin. – We encourage everyone to report suspected fraud, waste, or abuse. – Call the fraud hotline at 877-865-3432 or use the fraud reporting website(link is external). You may remain anonymous, if you wish.

https://www.dhs.wisconsin.gov/oig/index.htm https://www.dhs.wisconsin.gov/oig/index.htm

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State of WI State of WI

Office of the Inspector General (OIG) (SAME AS LAST SLIDE)… Office of the Inspector General (OIG) (continued)…

• Fraud is any intentional act or omission designed to deceive others in order to get undeserved money or other items of value. Examples of fraud include: ➢ Accepting kickbacks for referring Medicaid patients to a particular provider ➢ Billing a long-term care program for services that were not provided ➢ Billing for services for a recipient or provider who is incarcerated or deceased ➢ Billing inflated hours to an agency providing home healthcare ➢ Failing to accurately report on applications who and how many people make up a household ➢ Forging or altering documentation ➢ Making purchases for personal items that are charged to government programs ➢ Overstating needs on the Personal Care Screening Tool or Long Term Care NEXT SLIDE CLOSE UP Functional Screen ➢ Receiving benefits in more than one state at a time ➢ Underreporting income to receive BadgerCare, FoodShare or other benefits

https://www.dhs.wisconsin.gov/oig/index.htm https://www.dhs.wisconsin.gov/oig/index.htm

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State of WI Medicare Documentation Office of the Inspector General (OIG) (SAME AS LAST SLIDE)

Abuse is behaving improperly or unreasonably, or misusing your position or authority. Examples of abuse include: • Medicare has specific requirements, but nothing extraordinary • Using government computers and software for personal use • Earning personal awards or incentives while spending government funds • ACA Clinical Documentation Manual • Intentionally using the wrong billing code resulting in a higher payment • Performing and billing for medically unnecessary services – Recommendations, not guidelines • Using work time to conduct personal business – General formats for good documentation (e.g., SOAP, SNOCAMP, SOAAP) – Any format acceptable, if contains the required information

https://www.dhs.wisconsin.gov/oig/index.htm

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ACA Website ACA Website (10/19/19)

Medicare Audit Record Request Tips Medicare https://www.acatoday.org/Practice-Resources/Medicare/Medicare-Audit-Record- Medicare News Request-Tips MACRA Medicare Audit Record Request Tips...acing Medicare audits and/or record requests. Advance Beneficiary Notice of Noncoverage ...Medicare, doctors of chiropractic, chiropractors, audits, record requests, Documentation Requirements CMS Medicare Audit Record Request Tips ... Medicare Specific Coding Requirements Updated: 3/20/2018 Physician Medicare Fee Schedule FAQ Source: Pages Medicare Modifiers Medicare Fee Schedules Documentation Guidelines Medicare Records Request https://www.acatoday.org/Practice-Resources/Coding-Documentation- Medicare Audit Record Request Tips Reimbursement/Documentation/Documentation-Guidelines Targeted Probe and Education (TPE) ation Guidelines...ation Guidelines ... Medicare Training Updated: 5/3/2017 Source: Pages SGY: THESE WORK! SGY: New Slide! See Handout #10 for info from these 2 links

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Documentation Methods Chart – How Do You Organize It?

Method Advantages Disadvantages • Intake forms Detailed Labor intensive – Dictation Legible Costly* History / Consultation notes / Past Hx / ROS Unrestricted Need special equipment • Examination Forms • Special Tests – reports Initial set up time Automated Documentation software Training • X-ray Reports Fast Cost • Treatment plan • Legibility Daily notes Low cost Hand written Labor intensive Unrestricted • Re-evaluation notes Slow • Claims forms

Low cost Legibility • Outcomes questionnaires Travel cards Fast Increase likelihood of denial • Outside records Customizable To hard to review • Return to Work forms • PT log * Depending on transcription service vs. voice activation

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Chart “Anatomy” Chart “Anatomy”

LEFT SIDE RIGHT SIDE

Top sheet: Outcomes Assessment Record Hand written SOAP note (all hand written notes including outcome tools, history. Past Hx & exam forms, - anything handwritten)

Second sheet (if applicable): Patient sign in form Tab 1 (white) Rehab /exercise forms & notes

Tab 1 PT Log Tab 2 (yellow): Transcribed/dictated notes

Tab 2 Vitamin, medication, brace log Tab 3 (blue) X-ray report (both mine & outside) For EHR, set up “folders” for each tab & scan in your “old” paperwork Tab 3 Insurance information Tab 4 (green) Outside records (if not too bulky)

Last page: Photocopy log Tab 5 (red) Return to work forms

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EHR Example (ChiroTouch) EHR Example (ChiroTouch)

Folders = tabs

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Documentation: Need For Change Susan McClelland info (2009):

From: Susan McClelland [[email protected]] Sent: Thursday, February 19, 2009 10:02 AM • Professionalism To: 'Steve Yeomans' • Public Image (our patients notice!) Subject: RE: Medicare Missing Elements – Cultural Authority Q: What is the most common missing elements found in Medicare Audits? 1. A: “#1, by far, is the treatment plan. Must have a) frequency and duration, b) specific • Interdisciplinary Respect goals, and c) objective measures of effectiveness (b and c is where your book comes in). rd 2. Second most common missing element is aggravating and relieving factors. Also • 3 Party Payer Demands frequently missing are vitals and notation of presence/absence of contraindications.”

• Malpractice Buffer Susan McClelland, BS, CCA, FICC (h.c.) McClelland Consulting LLC • Medicare Audits**** Blacksburg, VA

Ref: ACA Coding Solutions and ACA Clinical Documentation manuals.

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Susan McClelland info (update 2015): Susan McClelland info (update 2019): Susan McClelland 4:35 PM (11 minutes ago) to me 1. Yes, all three of these things are still an issue. Yes, “cloning” notes is still an issue. There really isn’t anything new—same old mistakes. :(

2. The main thing about Medicare documentation is differentiating between “active” care and maintenance care… and the differentiation is showing there is a “reasonable expectation of improvement.” If there is, it’s active care; if there isn’t, it’s maintenance care. Now, how do you show that? By setting FUNCTIONAL goals in the treatment plan and then tracking progress toward those goals. If you can show clinically significant functional improvement, you’re 90% of the way home. 1. 3. The other things are, of course, having an acceptable history (S), physical examination (O), and documentation of services rendered (P) on each visit as well as authenticating the notes (signature).

4. Also, a common error, is not actually documenting that a service was rendered… many docs will note the subluxations found but do not actually document they were adjusted. You can’t just list the subluxations and levels… you have to specifically state which levels were adjusted (e.g., “manual manipulation to L3-4 and L4-5”).

Let me know if you have further questions!

Take care, 2. Susan Susan McClelland, FICC MCCLELLAND CONSULTING LLC 153 Walters Drive Christiansburg VA 24073-1041 49 50

Susan McClelland info (update 2019): 4. (continued): Susan McClelland Slides Susan McClelland Sat, Oct 19, 5:36 PM (19 hours ago) • NOTE: Permission was granted to utilize the That’s fine [SGY: re: HVLA or LVLA CMT]. You just need SOMETHING to show you not only FOUND the “subluxations” (Obj), but also ADJUSTED (Plan) them. following slides

CMS lists these terms as “acceptable,” but most contractors allow a few more:

“A number of different terms composed of the following words may be used to describe manual manipulation as defined above: • Spine or spinal adjustment by manual means; • Spine or spinal manipulation; • Manual adjustment; and • Vertebral manipulation or adjustment.

In any case in which the term(s) used to describe the service performed suggests that it may not have been treatment by means of manual manipulation, the A/B MAC (B) analyst refers the claim for professional review and interpretation.”

(Claims Processing Manual; Chapter 15) – SEE NOTES! 51 52

“Requirements” Required Documentation • Medicare documentation requirements • Identification of – Unique to Medicare documentation subluxation • When you sign and file a claim with Medicare, – X-ray understand that you are testifying that you have the required documentation on file. – P.A.R.T. • Initial visit • If you do NOT have the required documentation, • Subsequent visits then you have, in fact, filed a “false claim,” which would normally be considered fraud. • “Medical” necessity

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Medicare Audits Medicare Audits

• 3 “TOP” reasons for “failing” an audit (based • 3 “TOP” reasons for “failing” an audit: on conversations with Susan McClelland): – 1) NO Signature – 1) NO Signature – 2) NO Treatment plan (change as needed)

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Medicare Audits Medicare Audits

• 3 “TOP” reasons for “failing” an audit: • 3 “TOP” reasons for “failing” an audit: – 1) NO Signature – 1) NO Signature – 2) NO Treatment plan (change as needed) – 3) NO “Patient Specific” treatment goals – 2) NO Treatment plan (change as needed) • USE: Quadruple Visual Analogue Scale (QVAS) – • USE: Patient Specific Functional Scale (see PDF) – for “SPINE SPECIFIC 3) NO “Patient Specific” treatment goals COMPLAINTS” • These 2 tools satisfy the PQRS Medicare requirement • Place a statement in your “GOALS” that make reference to the use of these forms as “…for a specific list of patient-specific goals.” NOTE: WHEN you add the use of these 2 tools, you are satisfying the 2 PQRS Measures!

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Medicare: Patient Quality Reporting Pain Assessment Options (NOT limited to): System (PQRS)

• Measure #131: Pain Assessment and Follow-Up • Measure #182: Functional Outcome Assessment

SGY recommendations

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Functional Outcome Assessment Options (NOT limited to): #131 Pain Assessment & F.U. (1 of several options; consider verbal assessment) #131 Pain Assessment SGY recommendations & F.U. (1 of several options; consider verbal assessment)

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Patient Specific Functional Scale

1. Pick 3 ADLs most important

2. Grade each 0 – 10

3. Pt score / 30 x 100 = ___%

4. Repeat q 2-4 weeks

5. Compare scores

6. Modify care or D/C

#182 Functional OA

Ref: Susan McClelland (permission granted to include slides) 63 64

HCPCS Codes

Ref: Susan McClelland (permission granted to include the following slides) Ref: Susan McClelland (permission granted to include the following slides) 65 66

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Ref: Dr. Ron Short, DC PQRS 2014

• SUMMARY – Reporting the PQRS measures is essential for 2 reasons • To ensure that you are paid the maximum amount available from Medicare • To build as accurate of a performance database as possible for chiropractic procedures and for yourself.

SEE PDFs / handouts REF: http://www.chiromedicare.net/wp-content/uploads/2012/06/Physician-Quality-Reporting-System-Update-2014.pdf

Ref: Susan McClelland (permission granted to include the slides) 67 68

Medicare Documentation Required Documentation

• Medicare has specific requirements, • Identification of but nothing extraordinary subluxation • ACA Clinical Documentation Manual – X-ray – Recommendations, not guidelines – PART – General formats for good documentation • Initial visit (e.g., SOAP, SNOCAMP, SOAAP) – Any format acceptable, if contains the • Subsequent visits required information • “Medical” necessity

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Identify Subluxation: X-ray Identify Subluxation: PART

• Reasonably proximate • Pain/tenderness – 12 months prior • Asymmetry/misalignment • Range of motion abnormality – 3 months following • Tissue/tone changes • Exception if chronic/permanent To demonstrate a subluxation based on physical examination, two of the four criteria mentioned • CT/MRI may be under “physical examination” are required, one accepted of which must be asymmetry/misalignment or range of motion abnormality.

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Pain/Tenderness Asymmetry/Misalignment

• Evaluated in terms of location, quality, and • Identified on a sectional or segmental intensity level • Clinical note • Clinical note – Pain and tenderness findings may be – Asymmetry and misalignment findings may be identified through: observation, percussion, identified through: observation (posture and palpation, provocation, pain scales, gait analysis), static palpation for algometers, pain questionnaires, etc. misalignment of vertebral segments, diagnostic imaging, etc.

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Range of Motion Tissue/Tone

• Changes in active, passive, and accessory joint movements resulting in an increase • Changes in the characteristics of or decrease of sectional or segmental contiguous and associated soft tissues mobility including skin, fascia, muscle, and • Clinical note ligament – ROM abnormalities may be identified through: • Clinical note motion palpation, observation, stress – Tissue/tone changes may be identified diagnostic imaging, ROM measurements, etc. through: observation, palpation, use of instrumentation, tests for length and strength, etc.

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Initial Visit Initial Visit (cont.)

• History – Description of the present illness – Statement of general health • Symptoms causing patient to seek treatment • Mechanism of trauma – Family history, if relevant • Quality and character of symptoms/problem – Past health history • Onset, duration, intensity, frequency, location, – Description of the present illness and radiation of symptoms – Secondary complaints • Aggravating and relieving factors • Prior interventions, treatments, and medications

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Initial Visit (cont.) Initial Visit (cont.)

• Evaluation of musculoskeletal/nervous – Secondary Diagnosis system through physical examination • Neuromusculoskeletal • Diagnosis condition – The primary diagnosis must be subluxation, • Directly/causally including the level of subluxation, either so related to noted stated or identified by a term descriptive of subluxation subluxation. Such terms may refer either to the • On approved list in condition of the spinal joint involved or to the Local Coverage direction of position assumed by the particular Determination (LCD) bone named.

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Initial Visit (cont.) Sample Treatment Plan CMT and adjunctive modalities daily for 1 wk and • Treatment plan 3x/wk for the following 2 wks. Re-eval at that time; L MRI may be indicated. Off work 2 wks. – Recommended level of care (duration and Home care: Cryo q 2 hrs x 15 mins; avoid frequency of visits) strenuous activities; LS support to be worn when up. Short-term goals: Decrease pain (≤ 4) and – Specific treatment goals spasm; increase pain-free LS flexion (≥ 45 – Objective measures to evaluate treatment degrees). Long-term goals: Restore ability to tie effectiveness shoes w/o pain, sit/stand for prolonged periods (≥ 2 hrs.), and get in/out vehicles w/o difficulty; • Date of initial treatment return normal sleep patterns. BJP

SGY: Use Patient Specific Functional Scale (SPINE ONLY ADL COMPLAINTS)

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Subsequent Visits Subsequent Visits (cont.)

• History • Physical exam – Review of – Exam of area of spine involved in chief complaint diagnosis – Changes since – Assessment of change in patient last visit condition since last visit – System review, – Evaluation of treatment effectiveness if relevant • Documentation of treatment given on day of visit

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Sample Subsequent Visit Note Sample Subsequent Visit Note

05-15-06: Patient notes diminished 05-15-06: intensity/frequency of headache. VAS S/ ↓ intensity/freq HA. VAS ↓ 4/10. decreased to 4/10. Overall cervical O/ ↓ BIL C PVMS/TDP; jt fix Oc-C1, C5- muscle spasm/tenderness bilaterally, but 6. decreased. Joint fixation Oc-C1 and A/ ↑ C5-6. Condition resolving. Atlas and C5 P/ CMT: Oc-C1, C5-6. Return Tues. adjusted. Continue treatment plan as BJP prescribed. Return Tuesday. BJP Or, …

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Sample Subsequent Visit Note Sample Subsequent Visit Note

06-29-06: Patient reports continued pain 03-24-07: (5/10 VAS) in lower back with some ROM S/ Pt states LBP ↓ by 1/3 and easier to get improvement. Lumbar paraspinal muscle in/out car. Sleep improved. VAS ↓ 5/10. rigidity and tenderness unchanged. O/ Flex +LS 60º; Rt SLR +Rt LS 50º; myo Hypomobile/subluxation L5, L3, T12; tension LB genl; jt fix L4-5, Rt SI CMT rendered same. Patient is mildly A/ Resolving improved and will continue with active P/ CMT: LPL4-5, RPIN-LAIN protocols. To be seen in three days. T/ 8 min US-EMS combo bi L/SI/SN BJP Return Friday. BJP Or, …

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SUBJECTIVE (of SOAP) Subjective

sub·jec·tive • Many approaches (sŭb-jek'tiv),

1. Perceived only by the patient only and not evident to the examiner; said –SORE of certain symptoms, such as pain. 2. Colored by one's personal beliefs and attitudes. Compare: objective (2). –SNOCAMP [L. subjectivus, fr. subjicio, to throw under] –SOAAP –SOAP

https://medical-dictionary.thefreedictionary.com/subjective

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Patient Presentation History of the Present Illness (HPI)

• Acute • Acronyms – Major Medical – May include Pre-authorizations • CMS (Centers for Medicare and Medicaid Services) – Personal Injury – Special intake (Accident Q’s) – Location – Worker’s Compensation – Special intake (WC Q’s) – Quality – Medicare – Unique features (PART and PQRS) – Severity • Exacerbation vs. Aggravation – Duration • Recurrence – Timing • Chronic – Context – • Wellness Modifying factors – Associated signs & symptoms

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History of the Present Illness (HPI) Comparison of Options

• Different options: – (LMN)OPQRST”U” – OPQRST or PQRST – CLEARAST – LIQOR AAA – SCHOLAR – COLDER AS

REF: http://en.wikipedia.org/wiki/History_of_the_present_illness

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History of the Present Illness (HPI) History of the Present Illness (HPI)

• History • L: LOCATION – Use for each complaint – “(LMN)OPQRST(U)” • M: Mechanism of Injury vs. Medical History • N: New

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History of the Present Illness (HPI)

• “OPQRST(U)” – Examination History (use for each complaint) – O – Onset – P – Pain ↑ & ↓ (Provocative and Palliative) – Q – Quality (sharp, dull, pins/needles, tingly, burn) – R – Radiation/Location (AE/AK vs. BE/BK; A=above; B=below E=elbow; K=knee) – S – Severity (Pain: right now: 3/10, on ave. 4/10, at best 2/10, at worst 7/10) – T – Timing (AM>PM; Fri.>Mon., menstruation, etc.) Worse in the AM for 30 min. – U – “U” ever have this before???

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Patient History Form Patient History Form (EHR)

99 100

Past Medical and Family History Form Past Medical and Family History (EHR)

Continued next slide

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Past Medical and Family History (EHR) Review of Systems

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Review of Systems (EHR) Daily SOAP

• Short but concise • Important information: – What’s changed since the last appointment? • Better, No Change, or Worse? What do you attribute it to?

– Category options: • One liner vs. headings • EHR: General, Location, Quality, Progress, Pain scale, Frequency, Timing, Provocative, Palliative, Home care, Response after last therapy, Improvements noted since starting care

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Daily SOAP Note Daily SOAP Note

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ALL Guidelines include: CASE MANAGEMENT STEPS: Daily SOAP Note 1. Diagnostic Triage (rule out red flags)* EHR 2. Identify yellow flags & attend those that are manageable* 3. Provide Reassurance/Advice 4. Provide Symptomatic Relief 5. Utilize Outcomes Management * 6. Promote Functional Restoration* 7. Determine End Points of Care * * 5 of the 7 are included in the documentation process

SGY: Proper documentation is an integral part of the case management process!!!

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Ruling Out “Red Flags” Diagnostic Triage (Chapter 19 text)

•Diagnostic Triage »Red Flags »Mechanical »Nerve Root Use: 1) Red Flag Q. 2) Mechanical Diagnosis & Treatment (MDT)/McKenzie approach (“Directional Preference”)

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Diagnostic Triage Red Flags (Chap 19 text) 1) Cauda Equina Syndrome 2) Cancer / Tumor 1. > 50 y.o. 2. + past history of CA: 98% specificity (Deyo, 1992) 3. Unexplained weight loss 4. Pain > 1 month 5. No improvement with conservative Tx Red Flags 3) Infection (AHCPR and others) 4) Fracture (See Red Flag Questionnaire p638)

Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992 Aug 12;268(6):760-5.

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Red Flag Questionnaire • Cancer • Infection • Fracture • Cauda Equina See Forms CD

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Identify “yellow” flags Yellow Flags Questionnaire (See chap 21, Appendix pg 654 & Forms CD) (see FORMS CD)

• SF/HSQ-12 or 36 • Depression screener questions • SF/HSQ-12 or 36 • Mental Health Scale, Emotional Scale • Exaggerated Pain Drawing • SCL-90-R (Beck’s, Severity Index) • depression and anxiety subscales •STarT Back Screening Tool •Orebro 12-item Screening tool •Bournemouth Questionnaire (3 of 7 questions) •Yellow Flags Questionnaire

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BACK TO BASICS II. Outcomes Assessment • What are the primary categories for OATs? (SUBJECTIVE: Patient Driven information) • When should I use / administer the tools? • How often should repeat their use? Overview: Which tool(S) to utilize? • How do I score the questionnaires? • How do I keep track of the scores and changes? • What tools should I use? • How much of a change in score is “clinically significant?” (vs. MDC: Minimal Detectable Change)

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What OATs should I use? Overview: Which tool(S) to utilize? (Table 1) (Important Domains for NMSK conditions) ASSESSMENT GOALS INSTRUMENT(S)

1. GENERAL HEALTH COOP health charts, HSQ, SF-36, SF-12 ⚫ Pain (1. QVAS & 2. Pain Drawing) 2. PAIN PERCEPTION NPS / VAS, Pain Drawing – Right Now – Average 3. CONDITION-SPECIFIC a. Oswestry, Roland-Morris, FRI, many others a. LBP b. NDI, Headache Q. , Bournemouth Q (C & LB) – At Best b. NECK c. CTS, UE, Shoulder, Ankle, Knee, Hip c. Extremities – At Worst 4. PSYCHOMETRICS SF-36* , SF-12*, Waddell's signs**, SARS**, Mod. Zung, ⚫ (3. Bournemouth & 4. PSFS) Mod. Somatic Perception, MMPI, Beck’s Depression Disability/Function Scale, BQ (3 Q’s) , & others ⚫ Global Impression of Change (5. re-examinations only) 5. PATIENT SATISFACTION Chiropractic satisfaction Q., Visit specific Q. 6. JOB DISSATISFACTION Work APGAR (Total of 4-5 tools is sufficient) 7. DISABILITY Vermont DP Questionnaire, Yellow Flags Q 8. Hybrid Questionnaires Bournemouth Q. (BQ) (for LBP or Neck)

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Two Additional Categories When should I use the tools?

9. Clinical Global Impression of Change Change (several versions) 10. Work Spinal Function Sort Assessment

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WHEN SHOULD THE TOOLS BE USED? (Table 2) Two Additional Categories TEST 1ST DAILY RTW RE- EXACER- DIS- 6-MONTH VISITS &/or BATIONS CHARGE Follow VISIT 2 weeks EXAM 2- Up 1ST DAILY RTW RE- EXACER- DIS- 6-Mo. CHARGE Follow 4/weeks TEST VISIT VISITS &/or EXAM BATIONS X Possibly X Up 1. GEN.HEALTH 2 2-

X X X X X X X weeks 4/week 2. PAIN Q.'s s 3. Pain Drawing X X X X X

4. CONDITION- X X X X X X X X X SPECIFIC/ HYBRID 9. Assess. of Clinical Ch 5. PSYCHOMETRIC Possibly Possibly Possibly

6. Pt. SATISFACTION X X X 10. Work Possibly Possibly X Possibly Assessment 7. JOB Possibly Possibly Possibly DISSATISFACTION 8. DISABILITY Possibly Possibly Possibly PREDICTION TOTALS 2-4 1 3 4+ 4 5+ 2

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PRACTICE BASED RESEARCH How Do I Score OATs?

• Prove the long-term benefits of chiropractic • FORMULA: care by sending the patient the same OATs – Pt Score/Max. Possible x 100 = ______% forms at a 6- and/or 12 month point post- discharge. • Software: www.caretrak-outcomes.com – This will also serve as an excellent patient – Scores and graphs the results recall/reminder if their condition is – Includes the objective outcomes (QFCE) Info unstable/failing/recurrent (see Table 2). • OPTION: – Research opportunities: prove long-term chiro benefits (outcomes based research) – 99211 – E/M service that does not require the doctors presence, review of data with patient.

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Where to put the scores? Outcomes Assessment Record!

• Score Card for OATS PAIN Domain • Place on left side of chart

• Repeat q 2-4 wks

• Compare scores / ∆ Tx plan

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Pain Scales Assessment of Pain Intensity

• Visual Analog Scale Verbal Pain Intensity Scale Visual Analog Scale

• Numerical Pain Scale No Mild Moderate Severe Very Worst No Worst pain pain pain pain severe possible pain possible • Pain Drawing/Diagram pain pain pain Faces Scale • Others 0–10 Numeric Pain Intensity Scale – McGill / Melzak Questionnaire

– Pain Disability Questionnaire 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 No Moderate Worst – Dallas Pain Questionnaire pain pain possible pain McCaffery M, Pasero C. Pain: Clinical Manual. Mosby, Inc. 1999:16. Portenoy RK, Kanner RM, eds. Pain Management: Theory and Practice. 1996:8-10. Wong DL. Waley and Wong’s Essentials of Pediatric Nursing 5th ed. 1997:1215-1216.

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QVAS • Complete for each separate complaint Pain Diagrams • Photocopy on back of Pain Diagram Outcome Assessment Tools – Pain Surveys

Scoring Method – Pain Diagram – scoring (optional – not 1. Add up #1, 2, 4 recommended, SGY) 2. Divide by 3 3. Multiply x 100 4. Scores < 50 = “Low Intensity” “Patients who report that more than 30% of the total body surface 5. Scores >50 = areas are affected by pain, have a higher degree of psychological “High Intensty” distress.” Pp 44-45 “Sample Forms” Ellis, JS. Non Somatic Pain Physical Medicine and Rehabilitation, Volume 5, No. 1, Feb. 1991, p103-132

Von Korff M, Deyo RA, Cherkin D, Barlow SF. Back pain in primary care: outcomes at 1 year. Spine 1993; 18:855-62.

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Pain Drawing with QVAS (pp 44-45 “Sample Forms…”) Name: ______Date: ______Pain Diagrams Please be sure to fill this out extremely accurately. Mark the area on your body where you feel the described sensation(s). Use the appropriate symbol(s), mark areas of radiating pain, and include all affected areas. You may draw in the face as well.

Numbness ------Pins & ooooooo Burning xxxxxxxxx Stabbing /////////// Aching ((((((((( ------Needles ooooooo Pain xxxxxxxx Pain /////////// Pain (((((((( Outcome Assessment Tools • Pain Surveys – Pain Diagram

VISUAL ANALOGUE SCALE

Please mark on the line the pain level that most accurately represents your pain: NO PAIN: 0 1 2 3 4 5 6 7 8 9 10 UNBEARABLE PAIN

a) Right Now:---- 0 1 2 3 4 5 6 7 8 9 10 ______b) Average Pain 0 1 2 3 4 5 6 7 8 9 10 ______c) At Best ------0 1 2 3 4 5 6 7 8 9 10 ______d) At Worst------0 1 2 3 4 5 6 7 8 9 10 ______

135 136

Pain Diagrams

Outcome Assessment Tools • Pain Surveys – Pain Diagram

1. total leg pain – 2 pts 2. bilateral whole leg pain – 2 pts 3. added explanatory notes – 1 pt “I took a lot of care with this pain diagram. I thought it might be my last chance to tell someone what I have to put up with.”

Score > 5 pts (>2 points = abnormal)

Ransford, Dians & Mooney. The Pain Drawing as an Aid to the Psychological Evaluation of Patients with Low Back Pain. Spine 1976; 1(2); June 76

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Condition-Specific Questionnaires

• Bournemouth Questionnaires (Neck & Back) • Oswestry LBP Disability Questionnaire • Roland Morris Disability Questionnaire • Neck Disability Index • Headache Disability Index • Extremity Questionnaires (Many)

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Lumbar– Bournemouth Q. (pp 57 “Sample Forms…”) Neck – Bournemouth Q. (pp 58 “Sample Forms…”)

Scale: 0 – 10 (best to worst) Scale: 0 – 10 (best to worst)

1. Pain on Average 1. Pain on Average 2. ADL Tolerance 2. ADL Tolerance 3. Recreation, Social, Family 3. Recreation, Social, Family 4. Anxiety * 4. Anxiety * 5. Depression * 5. Depression * 6. Work Tolerance 6. Work Tolerance 7. Coping / Control * 7. Coping / Control *

Scoring: Pt score (add up ea. Item) / Scoring: Pt score (add up ea. Item) / Max. possible (70) X 100 = ____% Max. possible (70) X 100 = ____%

Example: 42/70 x 100 = 60% Example: 42/70 x 100 = 60%

* Yellow Flag Questions * Yellow Flag Questions

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Pp 53 “Sample Forms” Pp 54 “Sample Forms” Scoring Method Scoring Method Formula: Pt Score/Total Formula: Pt Score/Total x 100 = __% x 100 = __% Eg. 23/50 x 100 = 46% Eg. 23/50 x 100 = 46% NOTE: NOTE: 1) If all 10 sections are 1) If all 10 sections are completed, simply completed, simply double the raw double the raw patient score patient score 2) The denominator 2) The denominator reduces by 5 for each reduces by 5 for each section NOT section NOT completed completed 3) At least 6 sections 3) At least 6 sections must be completed must be completed to be valid. to be valid.

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Scoring & Interpretation Scoring Method Methods for the ODI & NDI 1. Add up all the checked items 2. Total = Score

SEE BOTTOM OF THE FORM FOR RM-18 OPTION

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pg 52 “Sample Forms…”

SCORING Yes=4 Patient Specific Sometimes=2 Functional Scale No=0 1. Add up all the “Yes” X 4=___ pp 59 “Sample Forms…” 2. Add up all the “Sometimes” 1. Pick 3 ADLs most important X 2 = _____ 3. TOTAL = the final 2. Grade each 0 – 10 score (the max. possible is 100 so no 3. Pt score / 30 x 100 = ___% formula needed) 4. OPTIONAL: score the E & F questions separately 4. Repeat q 2-4 weeks (not recommended). If desired divide the 5. Compare scores total of the E & F questions & divide by 6. Modify care or D/C the total score (not total possible)

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Scoring Method

0 = BAD PGIC 4 = No Problem Hence, Pt score/Max X 100 = • Use at re-exams & X% where 100% = GOOD and discharge 0% = BAD (The opposite of what we’re used to. • Compare to scores of other OATs Feel free to flip flop the 0-4 so 0% = Good and 100% = • Score of 1 or 2 = 50% & Bad (like most OATs) 30% improvement, respectively

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Scoring Method Upper & Lower Extremity Functional 0 = BAD 4 = No Problem Index / Scale

Hence, Pt score/Max X 100 = X% where 100% = GOOD and • Scoring Method 0% = BAD (The opposite of what we’re used to. – FORMULA: PT Score / TOTAL possible (80) TIMES (X) 100 = ______% Feel free to flip flop the 0-4 so 0% = Good and 100% = – EXAMPLE: 43 / 80 = .56 x 100 = 56% Bad (like most OATs)

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Outcomes Assessment Record Outcomes

Assessment • Score Card for OATS

Record • Place on left side of chart

• Repeat q 2-4 wks

(From the “Forms/New Forms CD” & pp 65-66 “Sample Forms…”)

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EHR Example (ChiroTouch)

SGY: We also include a paragraph “Outcomes Assessment Tools” after the OPQRST’s daily SOAPs

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Outcomes Assessments (10/7/19): Bournemouth Questionnaire: Raquel completed a Bournemouth questionnaire and scored 97%. This So how much of a score change is questionnaire includes seven domains (pain intensity, effect of work on pain, effect of pain on social activity, anxiety, depression, ability to carry out normal activities and ability to control the pain) regarding the low back. needed? Pain Drawing: Raquel completed a pain drawing which is physiologically consistent with her complaint(s). Patient Specific Functional Pain Scales: A patient specific functional and pain scales (PSFS) questionnaire was filled out by Raquel which requests the patient to list up to 3 activities that she is unable to perform or • MCIC – Minimal Clinically Important Change is having difficulty with as a result of their chief complaint. She listed the following activities: bending forward, sitting to standing and sitting longer than 30 minutes. Each activity is rated on a 0-10 scale with 10 being unable and 0 being able to perform. Raquel scored 30% on this questionnaire.

Problem list [SGY: Summary of pertinent PFSH & ROF]: Past Hospitalizations: (2009) Childbirth X2 Surgical History: (2009) Cesarean section Supplements/Vitamins: None Social Habits: Caffeine: Yes. Drinks 2 cups of coffee and tea per day Tobacco: No. Former smoker Alcohol: Yes. Drinks 1 glass of wine occasionally Exercise: No. Sleep Interrupted: Yes. 1X per night for 2 months Average Hours of Sleep: 9 hours Review of Systems: Musculoskeletal: Back pain 157 158

Minimal Clinically Important Change (MCIC) Minimal Clinically Important Change How is the in an outcome determined? • A PGIC may ask if the patient is “very much improved, • A key dimension of responsiveness is the minimal much improved, slightly improved, unchanged, or clinically important change in an outcome in a specific worse” with care [47, 59]. patient population [47, 79]. • This is the smallest change in the OA score which the • The PGIC for improvement has been defined by patient perceives as beneficial. A patient’s own global subtracting the mean OA score of “unchanged” from impression of change (PGIC) “much improved” or “very much improved” [47, 59]. (improvement/deterioration) is the most commonly • The PGIC for deterioration has been defined by the used external criterion to compare the outcome subtracting the mean OA score of “unchanged” from against [47, 59]. “worse” [59] • PGIC scores are calculated on the basis of the patients 47. Farra JT, Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity own perception of change with care. measured on an 11-point numerical pain rating scale. Pain 2001;94:149-158. 59. Hagg O. Fritzell P:, Nordwall A. The clinical importance of changes in outcome scores after treatment for chronic low back pain. Eur Spine J 2003;12:12-20.

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What is the minimum amount of change in Patients' Global Impression of Change (PGIC) pain severity / intensity that is clinically significant? scale.

Since the start of the treatment, my overall • Farra and colleagues demonstrated in patients status is: (circle one response) with scores of at least 4/10 that an improvement of 2 points or 30% was shown be a clinically 1 Very Much Improved 2 Much Improved meaningful improvement [47]. 3 Minimally Improved • This equates to the patient’s own global 4 No Change 5 Minimally Worse impression of change (PGIC) of “much improved”. 6 Much Worse • A 50% improvement was shown to correspond to 7 Very Much Worse a PGIC of “very much improved”. Farra JT, Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149-158.

- 30% improvement = PGIC of “much improved” - 50% improvement = PGIC of “very much improved”

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MCIC for Pain Intensity Average Pain Intensity Hagg and colleagues found a nearly identical change of 18-19/100 in the VAS of chronic low back pain The report of average pain intensity has been found to patients to be clinically significant [59] correlate with a 3 month daily pain diary in a number of studies [80, 82, 136]. These validity studies support using measures of average or usual pain intensity for up to a 3-month recall period with acceptable discrimination. 47. Farra JT, Young JP, LaMoureauz L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001;94:149-158. 80. Jensen MP, Karoly P, O’Riordan EF, et al. The subjective experience of acute pain: an 59. Hagg O. Fritzell P:, Nordwall A. The clinical importance of changes in assessment of the utility of 10 indices. Clin J Pain 1989:153-9. outcome scores after treatment for chronic low back pain. Eur Spine J 82. Jensen MP, Turner JA, Romano JM. What is the maximum number of levels needed in 2003;12:12-20. pain intensity measurement? Pain 1994;58:387-92. 136. Stewart WF, Lipton RB, Simon D, et al. Validity of an illness severity measure for headache in a population sample of migraine sufferers. Pain 1999;79:291-301

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OBJECTIVE (of SOAP) Objective Information

objective Examination [ob-jek´tiv] • Vitals 1. perceptible by the external senses. 2. a clear, concise declarative statement that directs action toward a specific goal. • Observation 3. the lens or system of lenses of a microscope nearest the object that is being examined. • Palpation • Range of motion • Orthopedic tests • Neurological tests • Diagnostic tests

https://medical-dictionary.thefreedictionary.com/objective (See “Sample Forms for Documentation”)

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(See “Sample Forms for Documentation”) (See “Sample Forms for Documentation” 167 168

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VITAL SIGNS

• Blood Pressure • Pulse • Respiration • Height UPDATE: Add BMI, pO2 • Weight • Temperature • Age • BMI (“the new vital sign”) • pO2

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Quantitative vs. Qualitative “Hard” vs. “Soft” Tests Documentation Methods

Clinical Attribute Qualitative Chart Note Quantitative Chart Note • Many orthopedic and neurological tests have a

Palpatory The has pain in the Palpation of the piriformis = tight/tender w/ radiation to lateral calf subjective nature to them – they rely on the patient to Examination upper right thigh. graded at +2-3/4.* provide feed back or for the doctor to interpret them Orthopedic Straight leg raise was Rt SLR + at 45 degrees = Rt LBP & Rt leg pain to mid/lateral calf • Ideally tests that are completely objective have more tests positive on the right weight but there are very few – blood tests, SSEP, EEG, Neurological Muscle weakness was Rt biceps is graded at 3/5 (movement against gravity only) EMG/NCV, bone scan tests found in the right bicep. – These STILL require interpretation

The patient has swelling The patient presents with inflammation and edema over the right iliac Visualization • Sciatica: SLR (n. root tension) + motor/sensory over the right hip. crest. The swelling is localized and well demarcated with visible redness. (Include circumferential mensuration) dermatomal loss + centralization = neural compromise BP – 120/80, HR 72, R The patient is a 32 year old female with an athletic build. She is 68 (>90% sensitive & specific, Donaldson, 1995) Vital signs 16, HT 68”, WT 205, inches tall and weighs 115 with a standing heart rate of 72 beats per 98.6°F, BMI 33 minute and a resting blood pressure of 120/80. BMI 28. – Use an inclinometer and measure the supine SLR & document progress! *American College of Rheumatology (1990): Palpation scale 0-4 scale (next slide)

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PHYSICAL EXAMINATION

• ELEMENTS – Vital Signs – Observation

Pattern your EHR using this as an outline

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OBSERVATION Objective Information • General Appearance / affect (include scars, birth marks, skin lesions, etc.) • State of Consciousness: • Examination – “…was pleasant, alert, well-groomed, answered questions relevantly, and well oriented • Vitals to time and station/place.” • Observation • Posture/reactions to ROM (bias/preference), tests, procedures: – “…rises from sitting w/ (mild/mod/severe) hesitation, lists to the right upon flexion/extension, antalgic 15° flexion/RLF; elevated LT ilium, LT shoulder, LT occiput, w/ • Palpation ant. Based occip. & shoulder protraction; bilateral pes planus / ankle pronation exaggerated in mid-stance gait.” – “…pain behavior was significant w/ positive Jump Sign & verbal expressions of pain during ART applied to the RT piriformis, iliopsoas, and hamstring muscles. – “…patient is flexion biased/preferred with sharp pain limiting lumbar extension to 10% of the expected range of motion.” – “…agitation was noted with …a) sitting >2-3 minutes; b) when rising from the prone position; c) attempting double SLR; d)…changing positions during the examination, “ etc. – “…poor form was noted during exercise training performing a supine bridge with improved significantly after modifications were made.”

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PALPATION

• Pulses & Capillary filling • Muscle: Tissue/tone, trigger points, pain (by name or location) • Bone/Joint: List spinal segments, SIJ, etc. – Static & Motion Palpation • Some include listings here & in the “PLAN” of the SOAP note • Temperature, moist vs. dry • Abdominal, rectal, chest/breast • Other: masses, thyroid, lymph nodes, trophic changes

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Identify Subluxation: PART Palpatory Pain Scale SOFT TISSUE TENDERNESS GRADING SCHEME (Hubbard, et al.; Wolfe, et al.) • Pain/tenderness (PALPATION) Grade I mild tenderness to moderate palpation . • Asymmetry/misalignment (OBSERV & PALP) Grade II moderate tenderness with grimace &/or flinch to moderate palpation. Grade III severe tenderness with withdrawal (+"Jump Sign") • Range of motion abnormality (ROM) Grade IV severe tenderness with withdrawal (+jump sign) to non-noxious • Tissue/tone changes (PALPATION) stimuli (i.e. superficial palpation, pin prick, gentle percussion)* * In non-injured tissue, this is a sign of neuropathic pain. To demonstrate a subluxation based on physical (4kg pressure = enough to blanch the palpating finger nail bed) examination, two of the four criteria Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous needle EMG activity. Spine 1993; mentioned under “physical examination” 18:1803-1807. are required, one of which must be Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the asymmetry/misalignment or range of classification of fibromyalgia. Arthritis Rheum. 1990; 33: 160-172. motion abnormality.

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Objective Information

• Examination • Vitals • Observation • Palpation • Range of motion

CERVICAL SPINE

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Range of Motion

• Errors with landmarks • Bad to eyeball – Round numbers (~40% accurate) • Goniometer – old method (less reliable) (~60% accurate) • Inclinometers are best “low tech” method (~80% accurate) – Single versus dual (for spinal ROM, dual is best) – 3 consecutive measures calculate the mean (AMA Guides) • If the average is less than 50 degrees then the measurements must all fall within 5 degrees of the mean • If the average is greater than 50 degrees then the measurements must fall within 10% of the mean LUMBAR • The test can be done up to 6 times to obtain 3 consecutive measurements • 95851 – ROM with report (usually included w/ exam E&M code such as 99213) SPINE – Only use if measured on a different date of service (but have a reason to measure ROM to support an extra billing)

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Objective Information

• Examination • Vitals • Observation • Palpation • Range of motion

• Orthopedic tests Pattern your EHR using this as an outline CERVICAL SPINE

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Orthopedic Tests • GOAL: Provocative tests to determine Dx – PROS: Great initially • Can sometimes guide treatment – When pain is reduced: » Cervical distraction if reduces pain = Cervical Traction – When pain is increased: » It teaches us to guide the patient to AVOID that position – CONS: When pain is controlled 4-6wks after the acute initial presentation, these are either: Pattern your EHR using LUMBAR SPINE this as an outline • Positive: Interpreted as treatment is not helping • Negative: Interpreted as treatment is no longer needed • Only measure pain provocation, NOT FUNCTIONAL LOSS

(See “sample Forms for Documentation” 187 188

Great Website for Orthopedic Test information

Reprinted with permission from Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline. http://www.pthaven.com/page/show/161711-apley-scratch-test Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and research, 1994

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http://www.pthaven.com/page/show/161711- apley-scratch-test

http://www.pthaven.com/page/show/161711-apley-scratch-test http://www.pthaven.com/page/show/161711-apley-scratch-test 191 192

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Objective Information

• Examination • Vitals • Observation • Palpation • Range of motion • Orthopedic tests • Neurological tests • Diagnostic tests

(See “sample Forms for Documentation”) http://www.pthaven.com/page/show/161711-apley-scratch-test

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Neurological Examination

• Motor • Sensory • Balance (optional) • Cerebrum (“SOMA”) Pattern your EHR using • Cerebellum (the “Dys-’s”) this as an outline CERVICAL • Cranial nerves SPINE

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Neurological Examination

• Motor – Muscle Tests: MEMORIZE by nerve root!!! – DTR’s (Deep Tendon Reflexes): Reflex Hammer • Wexler Scale: 0 (Absent), +1 (Hyporeflexia), +2 NORMAL (slug/brisk), +3 Hyper-, +4 w/ hyper- w/transient clonus, +5 w/ sustained clonus Pattern your EHR using – Superficial Reflexes: (physiological vs. pathological) this as an outline LUMBAR SPINE – Grip Strength – Jamar Hand Dynamometer (Swanson) – Circumferential Mensuration (tape measure) • Atrophy – Palpation: Paralysis: flaccid vs. spastic

(See “sample Forms for Documentation” 197 198

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Neurological Examination Neurological Examination

• Sensory • Balance – Organs of proprioception – MEMORIZE and correlate w/ the history • Mechanoreceptors – Dermatome LT vs. RT Upper & Lower Extremities • Sensory peripheral nerves • Repeat several times (consistency) • Dorsal columns – Options: • Sensory cortex • Inner ear – Vestibular division of Cranial VIII • Sharp (Whartonberg Pin Wheel vs. pin) – Rhomberg • Dull (end of an eraser) • Short Physical Performance Battery (Geriatrics) • Light touch (hand, cotton swab, opposite end of the pinwheel) – One leg Balance Test • Vibration (C-128) • Eyes Open vs. closed (see next slide – PREVIEW of next • Hot/Cold block)

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QFCE: One Leg Standing

EXAMPLE: 55 yo Eyes Closed 5 sec. / 25 sec. (normal) X 100 = 20% of normal

9A&B. One leg Stand-Eyes open & closed (Bohanon, 1984; Bly, 1991)

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Neurological Examination Neurological Examination

• Cerebrum (“SOMA”) • Cerebellum – S = State of Consciousness (recall Glasgow Scale) – Gait: unsteady & clumsy motion of limbs and torso – O = Object recognition • Wide ataxic gait • Eyes open or closed w/o dizziness – M = Memory (short vs. long term) – Rapid alternating movements: uncoordinated – A = Ability to use numbers (subtract from 100 by • Finger to nose test (“Dysmetria”) 3’s or 7’s if they had the prior knowledge) • Dyssynergia: rapid flipping of the hands up/down • Dysdiadochokinesia: rapid clapping (1 hand into the other) – Involuntary occular movements • Nystagmus – lateral (L / R eye movements)

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Neurological Examination Objective Information

• Cranial nerves • Examination • Vitals – II-XII typically tested (omitting the olfactory/smell) • Observation • Palpation – Memorize w/ mnemonic devices • Range of motion – NAMES • Orthopedic tests • Neurological tests • “On Old Olympus Tower Tops A Fin And German Viewed Some Hops” • Diagnostic tests – Motor vs. Sensory • “Some Say Marry Mary But My Brother Says Be Brave Marry Mary” (S=Sensory, M=Motor, B=Both)

(See “Sample Forms for Documentation”)

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Diagnostic Tests

• Most Common Stage of Care Definition Reexamination Frequency – X-ray: Spinal (with vs. w/o stressing), Extremity Symptoms are present less 30 days or 12 visits or as Acute • Less Common than 6 weeks clinically indicated – MRI, CT Scan, Bone Scan, Blood tests/UA, Fluoroscopic Symptoms have been present 3 months or 18 visits or as studies Chronic more than 18 weeks clinically indicated – EMG/NCV • New Symptoms are due to a 6 months to 1 year or as Supportive known, permanent deficit, a – Tensor Diffuse Imaging (TDI); fMRI, PET clinically indicated full recovery is not expected • REFER vs. Co-manage ???

– Specialty Consultation (DC specialist, Family Practitioner, Maintenance or preventative No active symptoms As clinically indicated Ortho, Neuro, Internal Medicine, Vascular surgeon)

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ASSESSMENT (of SOAP)

Assessment [ uh-ses-muh nt ] • Diagnostic impression noun • Complicating factors the act of assessing; appraisal; evaluation. • Pertinent risk factors • Short term and long term goals • Stage of treatment

https://www.dictionary.com/browse/assessment?s=t

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• All codes must be specific and valid • Smoker • Obese • Supported by documentation (S,O & P entries) • Diabetic • Level(s) of subluxation may be identified • Work stress • Neuromusculoskeletal problem may be listed as • Previous surgeries a secondary diagnosis • Degenerative conditions • Boney anomalies – spondylolisthesis, Schmorals node • Pregnancy • Poor compliance

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Stage of Care Definition Reexamination frequency: • Baseline • Making progress • Plateau – short of reaching pre-injury Symptoms are present less 30 days or 12 visits or as Acute – Refer for more tests or services than 6 weeks clinically indicated – Wean care or justify supportive care – Discharge Symptoms have been present 3 months or 18 visits or as Chronic • Plateau – frequent exacerbations/remissions more than 18 weeks clinically indicated – Consider additional forms of care • Home based exercise Symptoms are due to a • In office rehab 6 months to 1 year or as Supportive known, permanent deficit, a • Co-treatment with another provider clinically indicated full recovery is not expected • Patient worsening – Review patient history Maintenance or – Discuss outsides stresses contributing to problem ergonomics / work station No active symptoms As clinically indicated preventative – Poor patient compliance – Inappropriate care – Mis-diagnosis

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• Excellent – patient is at MMI • Therapeutic goals • Good – may have permanent residuals but • ADL goals that is not expected or, not ADL limiting • Time frames • Amount of improvement expected • Poor – Permanent residuals are expected • USE YOUR OATs FORMS FOR PATIENT SPECIFIC • Fair – patient may live or die GOAL SETTING • Guarded – they may die – “…please refer to the outcomes assessment forms in the file for a list of quantitative patient specific goals. The goal is to reduce each ADL score 1-2 points per week.”

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PLAN (of SOAP)

• Monitor milestones in reaching treatment Plan [ plan ]

goals – “pain level has decreased 50%” noun a scheme or method of acting, doing, proceeding, making, etc., developed in • Patient ADL’s improving – “Patient is now advance: battle plans. a design or scheme of arrangement: an elaborate plan for seating guests. able to walk a mile “; “sit for 30 min.” a specific project or definite purpose: plans for the future.

• Change since last appointment – Improving, verb (used with object), planned, plan·ning. to arrange a method or scheme beforehand for (any work, enterprise, or loss or modifications of employment (list proceeding):to plan a new recreation center. to make plans for: to plan one's vacation. duties under duress) .

https://www.dictionary.com/browse/plan?s=t

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• Informed consent to treat • Adjustments • Therapeutic treatment plan • Modalities – treatment times, settings, • Educational treatment plan • Area, response • Diagnostic test plan • Visit frequency • Coordination of care with other professionals • Traction • Discharge vs. Maintenance Care • Exercises • Prescriptions – pillow, orthotics, supplements

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• What was done? • Why was it done? • Location? • Amount of service done in units and time performed.

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• What tests will be run and when • Home Exercises • Always follow a time line • Activities of Daily living • Work hardening • Lifestyle discussion

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• Final Re-examination: MTB reached? • SOAP Format • Non-compliant patient • Track changes in symptoms – intensity and frequency and lifestyle changes • Graduation to wellness / elective care or PRN • Any significant modifications in the treatment plan • Track continuation of care following the treatment plan • Because of the frequency of care the daily notes can be brief

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• Assess progress • New complaint • Exacerbation • Change treatment plan

Q: Is this “P” enough?

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• Billing for more than 3 or 4 modalities or procedures per visit creating a high daily bill • Have patient fill out a pain diagram or • Billing for evaluation and management (E/M) on each patient encounter in addition to a therapy outcomes assessment questionnaire • Total charges for treatment are not reasonable in the area • Treatment for soft tissue injury exceed 3 months • New exam • The records do not support the diagnosis or treatment plan • Multiple providers in a single office with multiple evaluations • Change treatment plan • 4-5 treatments per week for more than a two week period • Repeated diagnostic testing • Change visit frequency • Excessive use of passive modalities after 4-8 weeks of treatment • Property damage to your automobile are not proportional to your injuries • Consider diagnostic tests or referral • Unclear documentation • Provider bills submitted all at one time • Multiple accidents with a previous history of long treatment periods • Lapse of more than 2 weeks between an accident and the first doctor visit

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• Complaint of symptoms with no corresponding diagnosis • Continued treatment without documented improvement Self-Audits • Use of an experimental or unusual treatments or diagnostic procedures • Post accident diagnosis of TMJ or Fibromyalgia • Extended rental or purchase of a TENS unit • Care does not decrease over time • Passive care for more than 2 weeks without adding a home exercise program • Canned medical reports and notes • Errors of an obvious nature such as the patients gender, race or age • Diagnosis and treatment don’t match • Clinic using several names or a PO box • Medical billing on weekends or holidays • Improper use of modifiers • When billing a attorney on a lien basis always bill the patient. Don’t just send the bill to the attorney • Always use one fee schedule that you discuss with your patients prior to care • Avoid using the term “whiplash” in your diagnosis • Avoid adjusting and using a manual therapy in the same region on the same visit

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Personal Injury (PI)

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PI Documentation OVERVIEW OF PI MANAGEMENT

• Slip & Falls • Mechanism of injury – BE VERY SPECIFIC • Get outside records • Domestic violence • Review outside x-rays, MRI, CT, special tests • Motor Vehicle Collisions • Schedule re-exams on a regular basis (use OATs) • Start home exercise training in the 1st few visits • Integrate active care by the 4th week • Any time litigation is involved – QFCE specific (max. 3 months) – Supervised exercise training 3x/wk; re-QFCE q 4wks – Modify program using ADL/sport specific movements • Discharge at MMI / MTB & manage PRN – Determines future anticipated care needs – Do an impairment rating – ONLY WHEN REQUESTED (litigation)

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Documentation unique to PI Auto Accident Questionnaire (See “Sample Forms • PI History Form for Documentation”) – Review the MVC Police Report • Assignment, Lien & Authorization to release medical records & information – Letter of protection • Transcribe SOAP notes • Utilize Outcomes Assessment Tools (q2-4 weeks)

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Auto Accident Auto Accident Questionnaire Questionnaire

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Auto Accident See Questionnaire NCMIC Forms PDF

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See See NCMIC NCMIC Forms Forms PDF PDF

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Expanded History Form – Attorney Lien USE THIS ESPECIALLY ON THE FINAL EXAMINATION (Impairment Rating) • BACKGROUND – We expect to be paid for services rendered – At times, we may forego immediate payment based on reasonable assurances that we’ll be paid after settlement of a PI case or receive some other form of third party payment.

https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf

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Attorney Lien Attorney Lien

• ADVANTAGES • DISADVANTAGES – A Lien protects the doctor in many ways – Not all states recognize the validity of this form for all • By instructing the insurance company making payments or of the purposes mentioned above. A Dr. should the attorney who receives it to pay the doctor directly provide a copy of theis form to local counsel for review to determine if it meets the requirements of • By assigning to the Dr. all rights that the patient might have that state’s lien statute to the payment from third parties, including the right to file suit to secure that payment – The provisions of this form may be extremely difficult • By granting a lien to the Dr. against all 3rd parties for the to enforce in those states that do not grant such proceeds statutory protection to the provider. Many states have held that the insurance company or attorney is not • By permitting the Dr. to release the patient’s records TO bound by the form’s terms since it was not signed by ANYONE if necessary to obtain payments. the 3rd party. • The agreement is irrevocable according to its terms

https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf

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Attorney Lien Attorney Lien

• DISADVANTAGES • Other options – The document is also extremely harsh. • Eg., It grants the Dr. the right to release records to the insurance – Other payment services that are less onerous company defending the person responsible for the accident. • Letter of protection (see sample) Certainly no attorney representing a patient would allow his/her client to sign such a release. It is also “irrevocable;” a term which a • Use the following Lien ONLY AFTER consulting court may find “against public policy” if a Dr. tried to enforce its terms against a patient who later sought to revoke the agreement. with your local council/attorney st – Even though a patient may have signed it (usually at the 1 – Use the form with discretion visit), some patients may take offense to the blunt terms. • Even if they sign it without comment, the form may “strain” the Dr.-Patient relationship from the outset, and the Dr. may be puzzled by the patient’s “negative attitude.”

https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf

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(continued)

See pp 212 & 213 from NCMIC PDF; BLANK form is Included in the notes for this course

See pp 212 & 213 from NCMIC PDF

https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf

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Letter of Protection (PG 377 NCMIC PDF) See pp 212 & 213 from NCMIC PDF; BLANK form is Included in the • BACKGROUND notes for this – Assignments, liens, and irrevocable instructions to course an attorney may all fail to get the Dr. paid after a PI claim or suit has been settled or tried. – Different state laws rules (check w/ your attorney) – OPTION: Use this vs. a lien • This is a simple letter from the attorney that states he/she will pay the Dr.’s bill from the proceeds of the settlement or judgment before giving any money to the client.

https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf

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Letter of Protection (PG 377 NCMIC PDF) Letter of Protection (PG 377 NCMIC PDF)

• OBJECTIVES • POTENTIAL DISADVANTAGES – Use this form and cover letter – less threatening vs. a lien – The use of liens, assignment forms and Letters of – Less likely to be rejected by the attorney Protection can be criticized by defense lawyers in – This seeks the same protection without being so PI cases to make the doctor’s opinion appear less confrontational credible because it permits an argument that he – Consider waiving formal protection when dealing with has a financial “interest” in the outcome of the a lawyer with whom you’ve worked well with previously case. • Draft a simple letter stating that it is your understanding that your bill will be protected unless the attorney advises otherwise.POTENTIAL DISADVANTAGES

https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf https://www.uws.edu/wp-content/uploads/2013/10/NCMIC-Chiropractic-Forms.pdf

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Letter requesting the “Letter of Protection” Letter requesting the “Letter of Protection” From NCMIC PDF; BLANK form is From NCMIC Included in the PDF; notes for this BLANK form is course Included in the notes for this course

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Irrevocable instructions to “Letter of attorney from the Protection” patient to pay to the Dr. doctor from the attorney

From NCMIC PDF; BLANK form is Included in the notes for this course

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Worker’s Compensation

Letter to attorney who failed to honor lien

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Worker’s Compensation Overview Worker’s Compensation Overview

• KNOW your State statutes as it pertains to WC (each jurisdiction is unique) • KNOW your State statutes as it pertains to WC (each jurisdiction is unique) • Establish dialogue with the employers on Day 1! • Establish dialogue with the employers on Day 1! • Mechanism of Injury: a) Direct injury; b) Repetitive Motion; c) Aggravation • Mechanism of Injury: a) Direct injury; b) Repetitive Motion; c) Aggravation of a pre-existing condition? of a pre-existing condition? • Use Return to Work Form and be specific • Use Return to Work Form and be specific – Use Job Demands Questionnaire – Use Job Demands Questionnaire – Use Spinal and/or Hand Function Sort – Use Spinal and/or Hand Function Sort • Static Position Tolerance Tests • Static Position Tolerance Tests – Use the Work APGAR form (Work Satisfaction tool) – Use the Work APGAR form (Work Satisfaction tool) – Try to get the patient back to work ASAP – Try to get the patient back to work ASAP • Dictate notes, Schedule re-exams and use OATs on a regular basis • Dictate notes, Schedule re-exams and use OATs on a regular basis • Consider a Work Station Evaluation if RTW fails repeatedly (use video • Consider a Work Station Evaluation if RTW fails repeatedly (use video tape/digital movie Consent Form (SEE NCMIC Forms PDF) tape/digital movie Consent Form (SEE NCMIC Forms PDF) – Have both the worker and the employer sign it – Have both the worker and the employer sign it – Be prepared to make suggestions about ergonomics (some suggestions will – Be prepared to make suggestions about ergonomics (some suggestions will not be possible d/t OSHA limitations, patient refusal, cost, etc. not be possible d/t OSHA limitations, patient refusal, cost, etc.

SGY 5/14/19, Strangely, this slide preceded Q2 but is repeated here (ERROR!)

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From NCMIC PDF; BLANK form is Included in the notes for this course

From NCMIC PDF; BLANK form is Included in the notes for this course

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From NCMIC From NCMIC PDF; PDF; BLANK form is BLANK form is Included in the Included in the notes for this notes for this course From courseNCMIC PDF; BLANK form is Included in the notes for this course

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From NCMIC From NCMIC PDF; PDF; BLANK form is BLANK form is Included in the Included in the notes for this notes for this course course

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From NCMIC PDF; BLANK form is Included in the notes for this course

From NCMIC PDF; BLANK form is Included in the notes for this course

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From NCMIC PDF; BLANK form is From NCMIC Included in the PDF; notes for this BLANK form is course Included in the notes for this course

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Work-Readiness Assessment: Spinal & Hand Function Sort

Documentation for Return To Work (RTW):

1) JDQ From NCMIC 2) Spinal FS / Hand FS PDF; 3) Static Pos. Tolerance T BLANK form is Included in the 4) RTW Form notes for this course

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Documentation for Return Documentation for Return To Work (RTW): To Work (RTW): 1) JDQ 1) JDQ 2) Spinal FS / Hand FS 2) Spinal FS / Hand FS 3) Static Pos. Tolerance T 3) Static Pos. Tolerance T 4) RTW Form 4) RTW Form

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Documentation for RTW Documentation for RTW 1) JDQ • PACT: Performance Assessment & Capacity Testing 1) JDQ 2) SFS / HFS • Leonard Matheson, PhD 2) Spinal FS / Hand FS 3) SPTT • Mary Matheson, MS 3) SPTT 4) RTW Form 4) RTW Form

PACT Spinal Function Sort • The purpose of the EPIC Spinal Function Sort (SFS) is to quantify ability to perform work tasks that involve the spine and lower • PACT: Performance Assessment & extremities. Capacity Testing • Leonard Matheson, PhD • The SFS quantifies and documents reported • Mary Matheson, MS functional capacity with very little effort or expense.

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Documentation for RTW Documentation for RTW • PACT: Performance Assessment & Capacity Testing 1) JDQ • PACT: Performance Assessment & Capacity Testing 1) JDQ • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Mary Matheson, MS 3) SPTT • Mary Matheson, MS 3) SPTT 4) RTW Form 4) RTW Form

• In treatment programs, the patient’s progress can • In employment screening programs in be documented easily. industrial settings, the SFS compares the job • The SFS provides a baseline measure of function applicant’s current abilities to job demands, in everyday tasks, to compare to progress in and sets a baseline of abilities. subsequent treatment, extending the benefits beyond the clinic’s walls, into the patient’s life at home, at work, and in the community. • In comparison with functional tests, magnification of dysfunction can be identified.

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Documentation for RTW Documentation for RTW • PACT: Performance Assessment & Capacity Testing 1) JDQ • PACT: Performance Assessment & Capacity Testing 1) JDQ • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Mary Matheson, MS 3) SPTT • Mary Matheson, MS 3) SPTT 4) RTW Form 4) RTW Form • Procedures • Content – The SFS is an untimed paper and pencil test. – In the SFS, drawings of spine and lower extremity tasks are supplemented by drawings that depict • The evaluee is instructed to “Look at each drawing and read common activities of daily living and work tasks. the description. On a separate answer sheet, indicate your current level of ability to perform the task.” – The drawings have been selected by experts in rehabilitation from hundreds of tasks that persons – The answer sheet provides a 5-point rating from with upper extremity impairments report present “Able” to “Restricted” to “Unable.” significant challenges. • Operational definitions of these adjectives are provided in – Each of the 50 drawings in the test booklet is the standardized instructions. There is also a sixth rating accompanied by a simple task description. which is depicted as “?” and indicates, “I don’t know.”

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Documentation for RTW Documentation for RTW • PACT: Performance Assessment & Capacity Testing 1) JDQ • PACT: Performance Assessment & Capacity Testing 1) JDQ • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Mary Matheson, MS 3) SPTT • Mary Matheson, MS 3) SPTT 4) RTW Form 4) RTW Form • Hand Scoring • Procedures – The SFS is easily scored by hand and yields a single – The SFS can be administered by a technician “Rating of Perceived Capacity” which ranges from following standardized instructions. 0 to 200. Two internal validity check” drawings are • Although administration is not timed, the SFS usually included that are similar to drawings presented requires 8 minutes to complete. earlier. These are used to screen for inconsistent • Items can be read to the evaluee who is illiterate, responding, along with a graded scoring strategy although the combination of text and pictures allows that evaluates intra-test consistency evaluees with low literacy levels to complete the test independently.

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Documentation for RTW Documentation for RTW • PACT: Performance Assessment & Capacity Testing 1) JDQ • PACT: Performance Assessment & Capacity Testing 1) JDQ • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Leonard Matheson, PhD 2) Spinal FS / Hand FS • Mary Matheson, MS 3) SPTT • Mary Matheson, MS 3) SPTT 4) RTW Form 4) RTW Form

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SCALE: 1 = ABLE 5 = UNABLE 2, 3, & 4 = Restricted “?” – Unknown (try to help the patient circle “the best answer”)

Documentation for RTW 1) JDQ 2) Spinal FS / Hand FS 3) SPTT 4) RTW Form

See the “score card” (next slide)

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Normative Data of the SFS

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Documentation for RTW Documentation for RTW 1) JDQ 1) JDQ 2) SFS / HFS 2) SFS / HFS 3) Static Posi Tolerance T 3) Static Posi Tolerance T 4) RTW Form 4) RTW Form

NOTE: This is “Objective” NOTE: This is “Objective” and correlates to #2 and correlates to #2 SFS/HFS which is SFS/HFS which is “Subjective” “Subjective”

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Documentation for RTW Documentation for RTW 1) JDQ • EPIC: Hand Function Sort 1) JDQ 2) SFS / HFS • Leonard Matheson, PhD 2) SFS / Hand Function Sort 3) Static Posi Tolerance T • Mary Matheson, MS 3) SPTT 4) RTW Form 4) RTW Form

NOTE: This is “Objective” and correlates to #2 SFS/HFS which is “Subjective”

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Documentation for RTW Documentation for RTW 1) JDQ 1) JDQ 2) SFS / Hand Function Sort 2) SFS / Hand Function Sort 3) SPTT 3) SPTT 4) RTW Form 4) RTW Form

• EPIC: Hand Function Sort • EPIC: Hand Function Sort • Leonard Matheson, PhD • Leonard Matheson, PhD • Mary Matheson, MS • Mary Matheson, MS

HFS: HFS: • 62 Pictures • 62 Pictures • Scoring 0-248 RPC range; • Scoring 0-248 RPC range; • 3 internal reliability checks (1 & • 3 internal reliability checks (1 & 14; 18 & 33, 55 & 60) 14; 18 & 33, 55 & 60)

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RTW FORM Documentation for RTW 1) JDQ 2) SFS / HFS Documentation for RTW 3) SPTT 1) JDQ 4) Return To Work Form 2) SFS / HFS (See pg 38 “Sample Forms”) 3) SPTT 4) Return To Work Form (See pg 38 “Sample Forms”)

See Next Slide: Close up

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Documentation Documentation for Return for RTW RTW Conclusion To Work (RTW): 1) JDQ 1) Job Demands Q 2) SFS / HFS 2) Spinal FS / Hand FS 3) SPTT 3) Static Pos. Tolerance T 4) Return To 4) RTW Form Work Form (See pg 38 “Sample • SFS is a GREAT tool for helping determine a patient’s work restrictions Forms”) • SFS + QFCE + JDQ + SPTT / (Standing ROM tests) = Ideal for WCE/FCE • (optional): Add lift / carry capacity (weights in crate; eg. EPIC & PILE Tests) – Floor-waist – Waist-shoulder – Shoulder-over head ______SFS=spinal function sort; QFCE=Quantitative Functional Capacity Evaluation; JDQ=Job Demands Questionnaire; SPTT=Static Position Tolerance Tests; WCE=Work Capacity Evaluation; FCE=Functional Capacity Evaluation; PILE: Progressive Isoinertial Lifting Eval.; EPIC: Matheson’s Lift Capacity Eval. (https://www.epicrehab.com/)

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(SEE NEXT SLIDE FOR SCORING METHOD)

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vs.

NEW PDF OPTION!!!

The Text is now offer on a PDF format where each Chapter is an individual PDF file – this allows one to print individual pages, highlight, insert text boxes, etc., AND, no need to lug around the heavy, bulky text!

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Either the paper text OR the PDF text comes with a CD of Forms that I add to annually (since 2000) –

See “Seminar Special”

Read any chapter, print any page, add post-it notes (if your software allows that feature – new Adobe + (free download!) Download the folder into your documents and access anytime!

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