Here is a detailed outline of the support you receive.
The sections follow the board guidelines. You can download a copy of these guidelines at the Codes and Guidelines page of the Chiropractic Board Web Site.
1. Responsibilities
This section discussed general professional and legal responsibilities for Chiropractors. It involves the need to record clinical records for each patient consultation and to keep information confidential and secure.
>> Instinctive Notes is designed to securely store all clinical and other records for your patients. Encryption is used across all components of the application and access to customer information is restricted. You can see full details of our approach to security in our security guide.
2. General principles to be applied
a. Clinical records can be kept in either paper or electronic format. Any electronic format should be the equivalent of any paper format and should be able to be printed.
>> Instinctive Notes stores all patient records electronically, either as SOAP notes, Medical alerts, Notes or as attachments you provide. All information can be viewed and downloaded by you and printed at any time.
b. Each patient should have an individual health record containing all the health information (radiographs excepted) held about them.
>> Every patient has a separate health record and all information is stored against this record. There are no limits to the number of items stored for each patient, you will never run into item or storage limits and every note and document you need to store can be stored.
c. A chiropractic clinical record should be made at the time of the consultation or as soon thereafter as practicable or as soon as information (such as test results) becomes available. It must be an accurate and contemporary reflection of all consultations or interactions. If the date the record is made is different to the date of the consultation, the date the record is made and the time and date of the consultation must be noted.
>> This is largely your responsibility to be timely and accurate in your note taking. Instinctive Notes records both an appointment time and the time the note is recorded automatically. Instinctive Notes provides a listing of appointments that are missing notes to help you keep on top of your note taking responsibilities and never miss a note.
d. Entries on a clinical record must be made in chronological order.
>> Notes are recorded with both the appointment time and the time recorded. All note listings are in order of appointment times, unless an appointment was not registered in Instinctive Notes in which case the note recorded time is used. Even if some notes are delayed, or taken out of order, they will be presented in chronological order of when each patient was seen.
e. Chiropractic clinical records must be legible and understandable and of such a quality that another chiropractor could read and reasonably understand the terminology and abbreviations used and, from the information provided, be equipped to manage the care of the patient. The Australian Dictionary of Clinical Abbreviations, Acronyms and Symbols is a useful resource for practitioners regarding abbreviations. It may be helpful for individual practitioners to maintain a readily accessible glossary of common abbreviations that they use to assist subsequent practitioners.
>> As an electronic record Instinctive Notes is always legible. Standard codes are used to describe many chiropractic techniques which makes them unambiguous. Custom codes are always standardised within a practice so an abbreviation is unambiguous and always means the same thing for all practitioners in the practice. Other lists, for muscles, cranials, limbs, organs, complaints, tests, exercises and home recommendations are standardised and unambiguous. The descriptions of all standard codes used in Instinctive Notes is available if required, just contact us for more details.
f. If documents are scanned to the record, such as external reports, the scanning needs to be undertaken in a way that retained the legibility of the original document.
>> Instinctive Notes allows attachments of reasonable size to be attached to the patient record. It is your responsibility to ensure legibility before an attachment is uploaded. Attachments taken directly as photos with the Instinctive Notes App will be legible.
g. Chiropractic clinical records must be able to be retrieved promptly when required.
>> Instinctive Notes provides a quickly searchable list of all clients, available at all times, with their complete treatment record, Notes, attachments and schedule history available.
h. Chiropractic clinical records must be stored securely and safeguarded against loss or damage, including a process for secure transmission and a backup of electronic records.
>> All information, including patient records, are stored in Australia and securely encrypted at all times. All access to data is by secure connection. Data is stored in multiple redundant databases at separate locations to guard against data loss. Data is backed up daily and restore operations are in place to rebuild lost data if necessary.
i. All comments in the clinical record should be clinically relevant, respectful of the patient and be couched in appropriate clinical, objective language.
>> This is your responsibility during note taking.
j. Chiropractors should be familiar with, and adhere to the requirements in the Board’s Code of Conduct for Chiropractors that relate to record keeping.
>> This is your responsibility during note taking.
k. Corrections can be made to a clinical record either at or after the time of original entry. The correction must be initialed, dated and tracked by the practitioner and the original entry must still be visible or digitally traceable.
>> Corrections can be made to any treatment or general note. Instinctive Notes records the change, who made it and the reason for the change. The original entry and every correction are stored in case the information is required in the future.
l. A treating chiropractor must not delegate responsibility for the accuracy of information in the chiropractic clinical record to another person.
>> This is generally your responsibility during note taking. Instinctive Notes allows independent accounts to be created for each practitioner so it is clear which practitioner recorded the notes for each patient consultation.
m. A treating chiropractor must recognise and facilitate a patient’s right to access information contained in their clinical records. If a patient disputes the information then it should be removed, unless the practitioner disagrees. In the latter situation, the record should be maintained with a note stating the patient’s beliefs about the accuracy of the record.
>> Corrections to information can be made. Explanatory notes can be added to the patient record, or to individual clinical notes, in the case where further detail regarding corrections and patient requests are needed.
n. The transfer of health information must be done promptly and securely when formally requested by the patient (preferably in writing), and patients advised of the location of records upon request. Practitioners should keep a record of any such requests.
>> This is largely your responsibility to be timely when responding to your patients. Please use a secure mechanism to send patient information (email is not secure unless the information is in an encrypted attachments). All Instinctive Notes data is held in Australian data centers located in Sydney.
3. Information to be recorded at an initial or new consultation
Instinctive Notes 2 provides a full SOAP note to record initial consultation and review consultations. Please note that Instinctive Notes 1 does not provide these features and initial consultations must be recorded on an alternate template and attached to Instinctive Notes to provide the necessary documentation for compliance. The below details refer to Instinctive Notes 2.
a. identifying details of the patient, including name, preferred name, contact details, date of birth and occupation
>> This information should be held in your practice management system. The patients name will be held in Instinctive Notes, and date of birth can be stored. You may attach patient intake forms to Instinctive Notes to keep all the detail in one place.
b. contact details of the person the patient wishes to be contacted in an emergency (not necessarily the next of kin)
>> This information should be held in your practice management system.
c. presenting complaint
>> Up to 12 presenting complaints can be recorded and tracked for a patient at any one time. Full details of each can be recoreded during the initial consultation and progress can be updated during each treatment. All changes to the complaint are recorded to provide a full history of the complaint over time.
d. examinations and investigations conducted and relevant clinical findings
>> The objective section of Instinctive Notes is available to record examinations and relevant clinical findings. A standardised test list provides clarity in recording tests performed and the relevant results. Diagrams with markup are provided for Range of Motion and Posture/Pain observations. Relevant documents may be attached to the consultation record.
e. relevant diagnosis(es)/clinical impressions/ working diagnosis(es), therapeutic trials or management/care plan(s)
>> Your working diagnosis of the underlying causes of an complaint can be added to the assessment section, with Notes added for trials and care plans. The scheduling of the forward plan of care is captured with the treatment details for your note.
f. current health history including a relevant medical history, systems review, work history, ‘red flags’, current medications/supplements, allergies, referrals
>> This information should be captured in your own patient intake forms and attached to the Instinctive Notes patient record.
g. any contraindications or health alerts
>> Medical/health alerts can be specifically added to Instinctive Notes and are prominantly displayed in the App prior to recording your notes so you may take relevant clinical actions. Contraindications can be added as alerts or into the assessment depending on the need to be alerted about them prior to each treament.
h. relevant family history
>> This information should be captured in your own patient intake forms and attached to the Instinctive Notes patient record.
i. relevant social and lifestyle history including cultural background (where clinically relevant)
>> This information should be captured in your own patient intake forms and attached to the Instinctive Notes patient record.
j. name of the consulting practitioner
>> The name of the practitioner is recorded with each note and is displayed in the note taking history for each patient. Each practitioner will have a log in to Instinctive Notes and the practitioner details are automatically recorded from who is logged in to the Instinctive Notes App at the time of recording the note. Only appointments attached to the specific practitioner in your Practice Management System are shown to the practitioner logged into Instinctive Notes to ensure the correct practitioner details are recorded.
4. Information to be recorded at a subsequent consultation or any consultation where care or advice is provided
Instinctive Notes treatment notes can capture all the requirements in this section with the exception of details of informed consent, see below for details.
a. date of the consultation
>> The consultation date is automtically recorded from the appointment details in your practice management system.
b. any change in consulting practitioner
>> The name of the practitioner is recorded with each note and is displayed in the note taking history for each patient. Changes in the consulting practitioner are therefore clearly displayed in the history for each patient. To vary the consulting practitioner for a patient simply book that patient with the alternate practitioner in your practice management system and the details will be automatically updated in Instinctive Notes.
c. name of the person providing information if not the patient, e.g. parent, guardian
>> This information should be added to the "Notes" field in the plan treatment area.
d. reason for care/consultation
>> Indicated by the presenting complaint recorded during the initial consultation or updated during a review. If there is an alternate reason or a new complaint it can be recorded at any time. Instinctive Notes prompts for an update on the status of all presenting complaints so an ongoing record of the patient response to treatment is recorded and available.
e. relevant subjective information including response to any treatment, including that provided by other practitioners
>> Additional information on wellbeing and progress of a patient complaint can be added quickly to every treatment note, and a prompt will be made to ensure this detail is captured. If there are additional subjective details provided by a patient they can be added to the complaint details currently under management or added as a new complaint. Any updates to current complaints will be recorded as new detail so the ongoing changes to the complaint are easy to review over time. Information provided by other practitioners as a document can be attached to the subjective area if received during a specific consultation.
f. relevant objective information about any examination or investigation conducted and relevant clinical findings
>> Any additional testing or ROM/Posture/Pain analysis undertaken can be recorded in the Subjective area of the note during any treatment.
g. the documentation of any offer of a chaperone to patients or when any such request is made by a patient
>> This information should be added to the "Notes" field in the plan treatment area.
h. details of any informed consent (see Code of Conduct for Chiropractors section 3.5)
>> Specific informed consent should be captured on your own informed consent forms and attached to the patient record in Instinctive Notes. Updates to informed consent discussions should be added to the "Notes" field in the plan treatment area.
i. when there are changes to any previous consent i.e. withdrawn, extended, modified, along with notes on the parameters of the change
>> This information should be added to the "Notes" field in the plan treatment note. If the change is substantial an addiitonal informed consent form should be completed and attached to the patient record.
j. changes to a documented working diagnosis or therapeutic trial
>> Changes should be added to the assessment area of the note.
k. changes to a documented management/care plan
>> Instinctive Notes allows easy updating of the plan for each patient. Schedules and wellness plans can be set and changed as required. Original plan elements are stored and available for review if necessary.
l. procedures conducted, techniques used and advice/instructions given
>> Instinctive Notes adjustment codes, along with the adjustment method, and the muscle, organ, limbs and cranial lists allow quick selection of the procedures conducted and techniques used. Custom codes can be set up for each practitioner to capture details not covered by the standard templates. Add any additional advice to the "Notes" field in the treatment note. Specific home care recommendations can be recorded in the plan area general home recommendations and exercises.
m. items prescribed, administered or supplied for the patient
>> Specific products prescribed can be added in the plan home care area of the note.
n. any referrals, letters, correspondence, clinical records, reports, or any relevant communications regarding the patient
>> This information should be attached to the patient record, which can then be viewed in alongside patient treatment notes.
o. any unusual sequelae of treatment or changes in contra-indications or health alerts
>> Medical alerts and notes can be recorded against the patient record. Medical alerts are prominantly displayed during note taking to ensure treatment can be adjusted as required. Contra-indication changes can be added to the assessment area of the note if they are not previously recorded as a medical alert.
p. any relevant diagnostic data, including accompanying reports
>> This information should be attached to the patient record, which can then be viewed in alongside patient treatment notes.
q. setting and context (e.g. after hours, home visit or at a sporting event)
>> Instinctive Notes can configure appointment types, either transferred from your practice management system, or directly. Appointment types should be set to allow easy understanding of the setting and context of an appointment. An appointment type description is stored with the treatment note when it is recorded.
r. details of anyone contributing to the chiropractic care and record
>> This information should be added to the "Notes" field in the treatment note.
5. Summary
Instinctive Notes provides an easy method of capturing all the information required to meet the Chiropractic Board guidelines on clinical record keeping.
Many of the most time consuming elements of record keeping are quickly or automatically recorded by Instinctive Notes. Much of the less common and ancillary information can be added to the free text notes available on every treatment note.
Instinctive Notes will continue to develop more effective recording and automation for as many different record keeping requirements as possible to ensure that your record keeping responsibilities are met with the minimum of effort.