(This journal article originally appeared in The Annual Journal from Acupuncture NZ 2017)
It is probably fair to say that health practitioners are not drawn to their profession because they want to write clinical records, and TCM practitioners are no exception.
Writing up notes is time consuming and often feels like it is getting in the way of doing the ‘real work’ of treating patients. The reality is that good record keeping is as much a part of an effective TCM practitioner’s role as inserting needles.
Why take comprehensive clinical notes?
Comprehensive clinical notes are important for clinical reasoning, to meet professional and funder expectations, and to inform communication with other health professionals.
Clinical reasoning
There are a number of ways that disciplined note taking can affect clinical reasoning.
Writing detailed notes demands thorough questioning, which in turn can lead to the discovery of important information that may not otherwise have come to light, including possible red flags.
When undertaking follow-up treatments, access to the correct information makes it much easier to know what questions to ask and maintains continuity of goals and treatment.
Many TCM practitioners work with other clinicians. If, from a patient’s notes, other clinicians can easily comprehend the background to the patient’s condition, and the previous practitioner’s diagnosis, treatment rationale and strategy, then there is less likely to be confusion and more likely to be better collaboration within the team.
Professional and funder expectations
Registered acupuncturists are expected to meet the same requirements as other medical professionals.
In 2005, Health and Disability Commissioner Ron Paterson wrote an editorial in NZ Doctor, stating:
There is probably no single issue that comes to my attention during investigations as frequently, or gives rise to as much adverse comment from expert advisors, as the quality of records. Yet good clinical records are integral to providing care. They demonstrate the rationale for establishing a diagnosis, set out the key information that underpins decisions about ongoing care, and can help safeguard practitioners when faced with allegations of inadequate or negligent practice.1
In the same piece he goes on to emphasise that clinical notes are often the only credible evidence that can protect the doctor, and that even where there was a poor outcome, if the notes show adherence to best practice, the practitioner may still not be found to have breached duty of care.1
While the piece was written for general practitioners, the principles apply equally to TCM practitioners. It is important to note that, in regard to clinical records, often what is not written is just as important as what is.
ACC is a major funder of TCM acupuncturists, having paid $34 million (including GST) to this group in the last financial year. In addition to adhering to professional standards, it’s important to remember that they are also obliged to meet ACC’s record-keeping criteria.2
Whilst not every claim is case managed, ACC can and does audit clinical records to ensure that their funding expectations are being met. If clinical notes are not up to their requirements, they may put in place processes to improve provider performance. In some cases, where significant concerns have been identified or where improvements aren’t made, this may result in reversal of payments and referral to professional associations. 2
Some common issues ACC find with clinical records are the absence of clinical notes; notes that are illegible or not in English; conditions being treated that are clearly not related to an injury; treatment of family members or work colleagues; and notes being copy-pasted from treatment to treatment, without any changes to show the patient’s progress (or lack of).2
Communication with other health professionals
Clinical notes inform communication with other health professionals. Whether writing a progress letter to a patient’s GP, or a referral letter to another practitioner, if the patient’s records are lacking, it is hard to provide the appropriate information.
What should clinical notes contain?
General clinical notes need to record relevant clinical information, options discussed, decisions made, the treatment, treatment plan and advice given.3
ACC requirements are more extensive:
- Accident, how it occurred and any mechanisms of injury
- Injury symptoms and clinical significance
- Reason for the presentation, or the main reason if the consultation/visit involves more than one condition
- History and examination findings, including important negatives
- Relevant past history, including medications
- Initial working diagnosis
- Pain and effect on sleep, work and other activities of daily life
- Employment history – current employment, the physical, perceptual and mental demands of work as it relates to the patient’s functional limitations, and the willingness of the employer to make workplace accommodations
- Initial advice you’ve given the patient, e.g. about work fitness or injury-related restrictions
- Treatment undertaken and tests and investigations required
- Management and follow-up plan.4
Follow-up consultations need to include:
- The patient’s progress
- Your evaluation of the effectiveness of previous treatment
- New aspects of history and examination, and the results of any new tests or investigations
- Any restated or revised diagnosis
- Any subsequent advice given to the patient
- Any treatment provided
- The reason for any change to an earlier treatment plan
- Work capacity and return-to-work barriers.4
It is important to track employment-related information, functional outcomes, and treatment planning. Notes should demonstrate that the practitioner has considered what the best treatment pathway is, including estimations of the number of treatments required and options if these are not met.2
Note taking systems
SOAP
A common approach to organising clinical notes is SOAP notes. SOAP stands for Subjective Objective Assessment Plan.
Subjective is the patient’s story. This includes their complaint, history, and symptoms.
Objective is the practitioner’s story. This section includes measureable elements, such as range of motion; objective instruments, such as the PHQ-9 depression test; and general observations made by the practitioner, ranging from the demeanor of the patient to the results of palpation.
Assessment is the patient’s differential diagnosis.
Plan includes the treatment strategy and the treatment itself.
In theory it is perfectly possible to include all of the information in a SOAP note in a single block of text. In practice it can be useful to separate the sections, as this makes it easier to find specific data, and can help prompt the clinician to enter the relevant information.
Structured notes
A SOAP note is a simple example of structured notes. Notes are recorded in a form, with key information held in discrete fields. Structured notes can have distinct advantages, including reduced writing; headings that prompt you to record important information and organise your thinking; ease in finding key points from the consultation record; and the ability to undertake more useful data analysis.
The main disadvantages of structured notes are the lack of flexibility and dependence on the design of the form. A poorly designed form can leave the practitioner searching for the right box to fill out, or writing information in the wrong place. Another problem is fitting everything onto a form, as fields that may not be used still take up space. One way to circumvent this is to use a computerised system.
Electronic medical record systems
A computerised form can be much larger than a paper one because it doesn’t have to fit on a page. Electronic notes have other advantages too – notes don’t take up space in the clinic and sheets of paper don’t fall out of folders and get lost. Depending on the system, notes can also be much easier to search and they can be integrated with other systems, such as HealthLink and ACC billing.
Some practitioners don’t like EMR systems because they feel that typing on a computer detracts from the quality of interaction with their patient. Many also find that systems available do not meet the needs of their profession, as they are designed for a particular modality. A few are more general and allow significant customisation by the clinician, but this can present other challenges, as few clinicians have the time or inclination to create the necessary content.
Time saving tools in some EMR systems can also make it very easy to take inaccurate notes. The most obvious examples are systems that automatically pre-populate follow-up records with previously entered data, or provide for the insertion of large bodies of text with a keystroke, using macros.
In both cases, the practitioner should be editing the preloaded text to make it accurate. It is very easy to leave in inaccuracies if this isn’t done.
Many older EMR systems run on locally installed software. Limitations of this include the necessity of managing backups and that the practitioner needs to be in the clinic to access their notes. More modern systems are typically cloud-based, meaning the data is stored centrally. This adds flexibility, as notes can be accessed from anywhere with an internet connection, and potentially from mobile devices. Backups are managed by the provider. Cloud-based systems do need to be chosen carefully though.
Ideally a cloud-based EMR system should be compliant with the relevant Ministry of Health (MOH), Health Information Standards Organisation (HISO) standards.5 Newly released MOH rules allow health providers to choose where they will store their data, according to their appetite for risk. The old sovereignty rule, where health data had to remain within NZ borders, has been removed, with sovereignty now expanded to include other developed countries, such as Australia and the US.6
Conclusion
In conclusion, taking comprehensive clinical notes is an important part of clinical practice. They influence clincal reasoning, demonstrate compliance, and inform communication with other health providers.
Structured note taking has significant advantages, though form design is important and form content needs to be tailored to the profession of the practitioner to be useful.
Similarly, electronic medical record systems can offer big advantages over paper records, but they only come into their own when the system is designed for the profession of the clinician using it. Care also needs to be taken with EMR to ensure that inaccurate information isn’t entered by mistake through pre-population of forms or macros.
Cloud-based EMR systems offer greater flexibility but care needs to be taken to check that the system is compliant with MOH security requirements.
About the author
Scott Pearson
BHSc Acupuncture, Dip Tuina
Scott Pearson is currently CEO and Founder of the cloud-based EMR provider, Noted Limited.
Before Noted, Scott was a founder of the Newtown Acupuncture Centre in Wellington and registered acupuncturist. He remains passionate about TCM and takes every opportunity to promote the profession.
Prior to his clinical career, Scott was co-founder and CEO of a character animation software company. Scott successfully sold this company to a US acquirer in 2006. He was nominated for an Emmy in 2003 – one of the many highlights of a 16 year career in computer animation and broadcast graphics.
REFERENCES
- Ron Paterson. NZ Doctor. 2005 May 4. [Internet]. 2005 May 4 [cited 2017 May 3].
Available from: PDF - Kim Eland, Clinical Lead Allied Health, ACC – interview, 2017 April 28
- Medical Council of New Good Medical Practice. 2016 December [cited 2017 May 3].
Available from: PDF - Accident Compensation Corporation. ACC Guidelines – Treatment Provider Handbook. [Internet]. 2016 [cited 2017 May 3].
Available from: PDF - Ministry of Health. HISO 10029:2015 Health Information Security Framework. 2015 December 9 [cited 2017 May 3].
Available from: https://www.health.govt.nz/publication/hiso-100292015-health-information-security-framework - Ministry of Health. Ministry Updates Cloud Computing Policy. 2017 April 28 [cited 2017 May 3].
Available from: https://www.health.govt.nz/news-media/news-items/ministry-updates-cloud-computing-policy
