Dr. Noah Volz has volunteered the content he produced from his DC2Be Podcast. He did great work while he endeavored to discover all he could about chiropractic as a student. Although most likely an exercise entered upon for his own benefit/learning, the content he produced was also quite valuable, so we will be sharing it here. Enjoy!
Saving You from Documentation Disasters, An Interview with Dr. Gregg Friedman
By Noah Volz
https://www.youtube.com/watch?v=7ZkqQNqqJ3k
Welcome to DC2Be Revolution. Helping chiropractic students think big in order to live large. I'm your host Noah Volz and today I'm here with Dr. Gregg Friedman. He's a second generation chiropractor and has been in practice for more than 30 years. In addition to practicing part time Gregg performs independent medical examinations, reviews records, testifies as an expert witness and teaches documentation seminars to chiropractors all over the country.
Dr. Friedman, thanks so much for being here. I wanted to talk a little bit about documentation because that's where I initially came into contact with you. I'm a student and I'm starting to go into clinic. We have these SOAP forms that I fill out, which includes: subjective; objective; assessment; plan. I'm just wondering what your feeling is on the way that students are currently doing documentation and the way that schools are currently teaching documentation?
Dr. Friedman: I don't know that I can really answer it because I'm not sure how students are actually documenting. I'm not even sure how the schools are teaching it all. I'll tell you that I've had a few students at my seminars recently and a few very new graduates from different schools and they say that some of the stuff that I've talked about sounds somewhat familiar with some of the other things they’ve heard. The problem is that when I was in school 30-plus years ago we learned how to do soap notes. Back in those days no one really cared about how we documented. No one asked for our records. We would make notes of their subjective report of whether the patient is better or not better and objective findings of whether they have some subluxation somewhere and assessment of doing okay and a plan I did this or did whatever else.
That was it until we started getting asked for records on a regular basis which started, happening somewhere around 20 years ago. I remember the first time I got this request on a personal injury patient I called the adjuster and I said what do you want?
She said we want your records.
I said okay but I don't know that I could read my own writing. How are you supposed to do that?
That's okay, send them anyway.
What are you looking for in these records of mine that you probably won't be able to read?
We're looking to see if you established medical necessity.
This was 20 something years ago and the whole profession was confused. We had no idea. We’d never even heard of the term medical necessity. We didn't know what it meant so I asked her.
I said well, what is that exactly?
She said, “well I don't know, but I'll know it when I see it.
I thought I better figure this out because if this keeps happening we're in a big pickle so I had to start figuring out what to do. I don't know how students are learning how to document, all I can tell you is that 99.9% of all chiropractic records that I review are grossly lacking. If anybody were to look at their records for a Medicare audit or personal injury review they'll lose.
I need to get into schools and say this is what we have to do. What they are teaching in school is a great start, but we need to go into a few other things. For example: problem oriented medical records, ODG guidelines, CCGPP guidelines, HCFA, Medicare and all these different things. We've got to figure out a way to document this stuff but not just for insurance patients; not just for Medicare patients; not just for personal injury. We've got to find one way to document for all our patients. Regardless of who's paying. It's the right thing to do and that way it doesn’t matter who looks at our documentation. This is the most effective way that we can communicate to the public what chiropractic is. We are doing a horrible job of communicating to our peers. If we can improve this one thing, I think we could really make a difference.
Noah: As a student where can I get more information, where can I figure out how to start to integrate some of this documentation language into my current documentation?
Dr. Friedman: Some good sources for you would be CCGPP. That's the Council for Chiropractic Guidelines and Practice Parameters, now known as Clinical Compass. They're excellent and it is a great start for us. There is the ODG or Official Disability Guidelines. Those are not really chiropractic, those are evidence-based guidelines for all providers, like chiropractors, medical doctors, physical therapists, massage therapists, acupuncture, all of it. They've got a whole bunch of research and most payers are using these official disability guidelines. The problem with them is that it's a subscription-based thing which costs a few hundred dollars a year to subscribe. I've got a few one-hour webinars through Chirocredit.com where I've taken both the ODG and the CCGPP and I put together a program called clinical justification of the chiropractic treatment, which covers headaches, neck pain, lower back pain, shoulder pain and so on. This gives you an idea about CCGPP.
Medicare has requirements for chiropractors. Now, it only really applies, to Medicare patients but once you see these requirements, it's really pretty good and it's quite easy to do and it's something that we can do as chiropractors very quickly. That's one of the big problems that chiropractors have. They say if we have to do all this documentation there's no way that I can see more than four patients in an hour.
There is a way to do this, you just got to be able to know all the different nuances here. For example, I was on somebody else's webinar recently he was teaching about Medicare documentation and this doctor knows a lot of stuff about medical documentation, but when I was looking to see what he was recommending I thought to myself well that's okay but that's really not required because if you do this that isn't required so why don't we save ourselves a long time and just do the required part. We could even do more than what's required and in very little time. Also, there's tricks about one of the big weaknesses I see is in the patient history. When the patient comes in you document the chief complaint. That’s easy if they come in with lower back pain or neck pain or headaches, that's their chief complaint.
Real world patients, most patients come in to us with headaches, neck pain, and lower back pain. So you're like okay, we were told in school 30-plus years ago, of those three symptoms which would you consider the chief complaint and the patient would say the low back pain is worse and we would say okay and that's it. We treat the rest of it, but we'd only document the lower back pain and it wasn't until I learned about this problem that it occurred to me, could you imagine treating the person for these other problems and not documenting that and some bad outcome happens and you've got to defend yourself now or someone like me has to defend you and it wasn't documented. Can you imagine that?
So here's the first little gem for you. When your patient has multiple symptoms for which they want treatment you consider all of them. You document the chief complaint and each one of the complaints. You're going to do a full on history for each of them.
The acronym you use is OPQRST, you're going to find out OPQRST and I mean all those letters, do not drop any of those letters. All those letters for each complaint, but there are faster easier ways to do this than to sit there for 20 minutes.
I feel like a lot of that could be done in the written history. They're writing it in, then you're looking over it, you're making any notes if they forgot to fill anything in.
Noah: I know in our clinic we are required to do each complaint and we're required to do much more than LMNOP QRS P for each complaint. Which means that most of our initial visits, if it's more than one complaint, takes at least three hours. If you're new you have to do all the orthos. What would you recommend for somebody like me?
Dr. Friedman: I found the same thing and I find I just don't have time to sit there if it takes me 20 minutes to get through that with a patient for one condition, that's an hour for three different conditions there's no way I want to do that. So I designed my intake forms just like that so I made sure I had all the requirements from the OPQRST for all the problems. Then I would send the patient the paperwork ahead of time. When they would call into the office to make their appointment we would get their email address or we would send them to a website and we would tell them make sure they finish it ahead of time. We tell them, “at your first appointment bring the completed forms with you to your first visit it will save you a lot of time.” In actuality it doesn't really save them any time. It's saving us time. We tell them “if you can't do it, if something happens, your printer breaks or runs out of ink, that's okay just show up 45 minutes earlier than your appointment to fill out the paperwork.”
This is a gentle way of telling them this is going to take them some time in the office. Most patients, once you explain that to them they will do it ahead and I'll do it, at least most of it, thoroughly. They'll skip some spots and that's okay. We anticipate that, I'll have my staff greet the new patient and they will just ask them, “Did you fill out the paperwork?” They will look through every page and if they skipped anything, which they usually will, she thanks them for doing what they did and gives it back to them to finish up.
It takes maybe five minutes and then the patient is taken into my room and I do the consultation. Now we know that this has all been completed, I'm going to read all of back to them. That will drive me to ask other questions, so the patient has done 99% of the work for me. I'm going to pick up the other 1%. For example they might say they have headaches. I'm going to ask them, “show me what part of your head it is?” At the front, the back? Then I write in that specific thing. They may say neck pain and I'm going to ask them. “Is it your whole neck, is it one side of the neck?” I'm going to write it down and then there might be other things through the history that they're going to say and I'm going to think well that's interesting, “tell me more about that?”
That is the gravy. The basic meat and potatoes, they could do that for us ahead of time on paper. It saves a ton of time.
Noah: I know we're talking about paper forms here, but what about electronic forms and the standardization of forms?
Dr. Friedman: The standardization of terminology has been very frustrating for a long time. Some chiropractors live and die by the word subluxation. You have other chiropractors who say that we should get rid of that word altogether. Which is it? We've got to come up with some kind of a plan on being consistent. When I document the word subluxation in my notes I always use the word hypo mobile in front of that because if you ever use the word subluxation with a medical doctor they don't recognize our subluxation. They only recognize the medical definition of the subluxation so they look at us like we're nuts, why would you manipulate a hypermobile, partially dislocated segment? That's the opposite of what we're doing but it's just terminology so I if I'm going to use the word subluxation I'll always use the word hypomobile in front.
Some doctors don't even like to use the word and that's because Medicare actually tells us other words that are that are okay to use: fixation, restriction, or aberrant motion. Whatever, it doesn't matter. It’s inefficient. Medicare says that they only pay chiropractors for the adjustment and we're adjusting subluxation. However they won't let us use the word subluxation in our diagnosis. For diagnosis we say segmental somatic dysfunction, because the subluxation diagnoses means a medical subluxation. It's a problem, the use of language.
In school we learned anatomical language. They also learn it in medical school, they learn it in nursing school, they learn it in all the different healthcare schools. It's a language so that regardless of our specialty we can communicate with other providers and other specialties and we all know what each other's talking about. The problem is most chiropractors will document this, they will say patient has lower back pain that radiates to the right leg. Because I review records I recognize that in the language of anatomical position the lower extremity is divided in half by the knee and we refer to the extremity above the knee as the thigh and below the knee is leg.
Chiropractors are notorious for saying lower back pain radiates to the right leg. Which means it skips the thigh altogether and goes below the knee, and encompasses the entire extremity below the knee. We should be documenting so that we all know what we're talking about. Saying lower back pain that radiates to the right posterolateral thigh and to the right posterolateral leg and to the fifth digit of the right foot. That’s how professionals know exactly what I'm talking about. With that information you've already started thinking about your differential diagnosis. You start thinking about what orthopedic tests you are going to do. Or X-rays, maybe an MRI.
That's how we've got to document so that anybody looking at these SOAP notes knows what we're doing. Another pet peeve of mine are muscle tests. We learn how to do muscle testing and grading muscle strength five, four, three, two, one, and zero. I reviewed a case one time and a person was a passenger in the car, they didn't hit anything, there's no real accident, they simply went over a curb in the car. The patient felt neck pain. There was no documentation anywhere of any radicular symptoms. The chiropractor examining this patient did a bunch of muscle tests and noted grade two muscle weakness in five or six different muscle groups and I'm looking at that and I'm thinking that patient is sitting in a hospital room in a halo-brace waiting for the neurosurgeon to come in. There's no way, that that makes us look like idiots, that makes that doctor look like an idiot and it's a stain on the entire profession. It's just because we're not thinking about this stuff. We learn this.
We've got to be legitimate about this, when we document the right terminology that helps go a long way.
You asked about the electronic medical records and electronic health records. There's two different things and a lot of people are mixing these up and it's frustrating. There's electronic health records, that's one thing and there's electronic medical record that's another thing. They're totally different and I maintain that an electronic health record is an utter waste of time for most chiropractors. If you are working in a multidisciplinary clinic it might make sense, but for a chiropractic office don't spend any money on it.
An electronic medical record is a digital version of your soap notes, the chart notes. That is more accessible and it may make more sense but here's the other problem. I review a lot of chiropractic records and I would say when I review records now, which are mainly personal injury records, some Workers comp, and some malpractice stuff. These days they are computerized so you would think that helps, right? Because they've got all the templates in there. It used to be that reviewers would say that your records are illegible and I couldn't read them and we suspected that they were crap. Now that I could actually read them I could prove it and that's what's happening. What we're seeing is the same crappy documentation that they used to do on paper or a travel card. Now it is the same junk in a nice legible format that does nothing.
If you have an EMR or EHR, whatever you use, you've got to make sure that it's documenting the right things, at the right time, in the right way. What would I recommend for an EMR program? I recommend, learn how to document properly first before you go out buying stuff. Learn how to document so you could evaluate these various programs and determine if it's going to do we need. One of the biggest issues now is function, You've got to be able to assess the function and a lot of chiropractors, we were taught it was all on your orthopedic and neurologic tests and that is just not the case unless you're doing a lot of disk stuff.
That exam isn't going to show you a whole lot and a lot of the programs out there are fully based on that. Which is not going to help you out, you've got to have the ability to document function. Which takes too long. These doctors they try various programs. I could do this faster by hand, yeah maybe, but you're still documenting the wrong stuff. It’s got to be three things:
It's got to be legible
It's got to be the right stuff that you're documenting
You've got to document things at the right time and for example, when you do a reexamination.
Noah: So you don't recommend any EMR software? You recommend getting the documentation training, is that correct?
I do recommend one, it's one that I made but I'm not going to talk about it here. I'm not here to sell anything, so if somebody wants that they can find me and ask me, but the biggest thing is if you don't know how to document properly then the profession can never move forward. I've heard this from doctors. They say I think I document pretty well. Just by you saying that, I know you don't because I would say. “I know exactly how to document properly.” If you're not sure about it you've got to learn this stuff because then you could look at these things and say, “that that's not going to work or that's not going to make sense.” It's so much easier that way. What happens now is a doctor that maybe doesn't know how to document very well goes to a website for some product that's being sold and they sign up for a demo. The salesperson is demonstrating all these different things and there's pretty colors and there's little noises every now and then. Then there's all these things that the doctor, who means well, is thinking. What they don't realize is that when I'm looking at these programs I'm thinking: “that's not true or that's completely irrelevant or that's ridiculous, nobody needs to do that or that's a complete waste of time.” You need to understand what's happening so that you can evaluate these things the same way I do. Otherwise you are vulnerable to any sales pitch that's out there and then buy it and then you're miserable with it and then do you end up getting rid of it and you just wasted thousands of dollars.
Noah: Thanks for giving students a lens into documentation so that they don't make that huge mistake. Having been a chiropractor for so long you've seen a lot of changes. If you were to map out the trajectory of where we're going what do you see as the future of chiropractic and what can students do today to be prepared for that eventual future?
Dr. Friedman: There's been a debate, a schism for decades in our profession. The straights against the mixer's kind of a thing. Which is just the stupidest thing I've ever heard. Here's a quick story for you. I was at a very fancy dinner in Seattle, Washington years ago and we're all in our suits and we're sitting at a table with wine and I'm sitting next to a guy who's an MD and PhD at the University of Washington School of Medicine. This guy's big-time, very proper, very serious and as we're drinking some wine. He says, can I ask you an awkward question? ‘Sure,” I say. “Okay, so my question is: “Is there really an organized faction of homosexual chiropractors? “
I said not that I know of. Why would you ask that?
He says, “because I've only heard about the straights and the mixers.”
I looked at him as I spit out wine through my nose and I asked, “ are you telling me that for all this time you've thought that a straight chiropractor was heterosexual and a mixer is homosexual?”
That we continue to do this is just idiotic. Look, the reality is that straight versus mixer is so stupid because a straight chiropractor say’s they only adjust. A mixer might use modalities. I don't care what you do. The bottom line is this. Are you getting good outcomes with your patients? That's all I can review. That's all I'm looking for, all I care about.
As long as what you're doing is within our scope, you're not hurting a patient, and it's legal, I'm only looking at - are you showing positive outcomes? Are you treating properly? Forget all this other stuff - all about the tors and the tic and the progressives.
I've been a chiropractor so long and with my family history you know I understand. I've seen patients over the years who come into me with non-musculoskeletal stuff. They want to know if I could help and I tell them up front. Look, I don't have any research on that and in over 30 years of practice I've worked on those a few times and there is a pretty decent success rate. Not every time, but you know, sometimes. I'm not going to hook you into a 58 visit program for $3,000. Those kind of treatment plans, which I still see out there in our profession, kills us.
That makes the entire profession look bad and that's a big problem with that but I remember when it happened. It started with practice management consultants, because chiropractors have notoriously been weak at getting new patients. So these consultants said, “If you're not good at getting new patients we need to find a way for you to hold on to the ones that you have.” It made sense at the time and a lot of doctors did these long-term treatment plans. I did it.
I stopped doing it, those patients don't refer. I found that most patients don’t mind coming in for two weeks to start. I was going to get 80% of my referrals the first two weeks. It all depends on what happens in the first two weeks of care. Hopefully the person starts getting better and gets improved outcomes. The symptoms get better first, typically the function takes longer than the symptoms.
It’s all about having a two week treatment plan to begin care. Students were telling me that they didn't learn how to do treatment plans. In clinic they told them to do a one or two visit treatment plan. That kind of miracle cure does happen sometimes, but we can't predict that. That's not a treatment plan. Alternatively a treatment plan is also not 58 visits or $8,000. There are much defined things that we've got to look for, that are based on both symptoms and function. We're going to do an initial baseline assessment then we're going to treat you for a trial period and then we will reassess to see if we're on the right track. If it works then we go for another trial of care and if it's still showing improvement keep going. If they’re not showing improvement, then change something. A technique, modality or exercise protocol. Document a change, go for another trial of that period of time and reassess. So even for those chiropractors who love to see wellness patients, they need to be careful with them. I tell them; “that could take some time and I don't know if it's going to happen or not for you”, but I'm not going to hook them into a long treatment plan, but instead, we're going to go a few weeks at a time I'm going to teach them about chiropractic as much as I can.
A lot of people will say. “I feel great with this, I can just come in like every week or two.” I've got one patient right now, she's 74 years old, and she’s a Medicare patient. I've already told her what Medicare will not do with her. Another patient of mine is 83 and she comes in every two weeks, she's been coming every two weeks for four years. I don't bill Medicare, she's a maintenance patient. She pays cash for this and she feels better with that. I educated her and then if she wants to do that for the rest of her life that is her prerogative, but I'm not going to make her do something and come up with some crazy treatment plan that make sense.
Noah: Our place in the medical umbrella is working with the neuro-muscular skeletal system and having very clear goals of the outcomes that we want to achieve in terms of symptoms and function and working towards those goals with the treatment program and then seeing if we achieve those goals or not and if we didn't change the treatment plan or referring to somebody else. Taking a lot of accountability. I know people are going to want to learn more about you, they're going to want to follow what you're doing. How can people get in touch with you and learn more?
Dr. Gregg: I have a website they can go through which is www.gotdocumentation.com. The name of my seminars is Got Documentation.