Effective Date of Rule: Thirty-one days after filing.

     Purpose: The adopted rules clarify and define that documentation of care must be legible and completed in a timely manner. Chiropractors, ancillary staff, patients, and other stakeholders should better understand the expectations of adequate documentation of care. This will further enhance public protection.

     Citation of Existing Rules Affected by this Order: Amending WAC 246-808-560.

     Statutory Authority for Adoption: RCW 18.25.0171.

     Other Authority: Chapter 18.25 RCW.

      Adopted under notice filed as WSR 10-02-079 on January 5, 2010.

     Changes Other than Editing from Proposed to Adopted Version: Subsection (1) added "whether or not symptoms are present" for clarity: Subjective health status updates, whether or not symptoms are present, must be documented for every patient encounter. Subsection (4) moved "if applicable" to read: The region(s) of all treatment and, if applicable, the specific level(s) of chiropractic adjustments must be recorded in the patient encounter documentation.

     A final cost-benefit analysis is available by contacting Leann Yount, Program Manager, Department of Health, Chiropractic Program, P.O. Box 47852, Olympia, WA 98504-7852, phone (360) 236-4856, fax (360) 236-2901, e-mail leann.yount@doh.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: April 15, 2010.

Ronald G. Rogers, DC

Chair

OTS-2104.10

AMENDATORY SECTION(Amending WSR 96-16-074, filed 8/6/96, effective 9/6/96)

WAC 246-808-560   Documentation of care.   (((1) The recordkeeping procedures of a chiropractor shall be adequate to provide documentation of the necessity and rationale for examination, diagnostic/analytical procedures, and chiropractic services. The required documentation shall include, but not necessarily be limited to, the patient's history and/or subjective complaints; examination findings and/or objective findings; and a record of all chiropractic services performed.

     (2) Chiropractic examinations shall be documented by specifying subjective complaints, objective findings, an assessment or appraisal of the patient's condition and the plan for care. Daily chart notes may be brief notations recorded in the patient's chart file between examinations. These notations shall indicate any changes in the care or progress of the patient and the chiropractic, diagnostic, or analytical services performed or ordered. Detailed entries need not be documented on every visit as long as examinations are performed at reasonable intervals and those examinations are documented as specified in this section.

     (3) If a code is utilized by the doctor in connection with recordkeeping, a code legend shall be included in the records.)) A doctor of chiropractic must keep complete and accurate documentation on all patients and patient encounters. This documentation is necessary to protect the health, well-being and safety of the patient.

     (1) The patient record must detail the patient's clinical history, the rationale for the examination, diagnostic or analytical procedures, and treatment services provided. The diagnosis or clinical impression must be contained in the patient record, not merely recorded on billing forms or statements. Subjective health status updates, whether or not symptoms are present, must be documented for every patient encounter.

     (2) Documentation for the initial record must include at a minimum:

     (a) The patient's history;

     (b) Subjective presentation;

     (c) Examination findings or objective findings relating to the patient's presenting condition;

     (d) Any diagnostic testing performed;

     (e) A diagnosis or impression;

     (f) Any treatment or care provided; and

     (g) Plan of care.

     (3) Reexaminations, being necessary to monitor the progress or update the current status of a patient, must be documented at reasonable intervals sufficient to reflect the effectiveness of the treatment. Reexaminations must also be documented whenever there is an unexpected change in the subjective or objective status of the patient. Reexamination documentation must include the subjective presentation and objective findings. This documentation shall also reflect changes in the patient's care and progress and in the treatment plan.

     (4) Documentation between examinations must be recorded for every patient encounter. Documentation must sufficiently record all the services provided, as well as any changes in the patient's presentation or condition. The region(s) of all treatment and, if applicable, the specific level(s) of chiropractic adjustments must be recorded in the patient encounter documentation.

     (5) Patient records must be legible, permanent, and recorded in a timely manner. Documentation that is not recorded on the date of service must designate both the date of service and the date of the chart note entry. Corrections or additions to the patient's records must be corrected by a single line drawn through the text and initialed so the original entry remains legible. In the case of computer-organized documentation, unintended entries may be identified and corrected, but must not be deleted from the record. Errors in spelling and grammar may be corrected and deleted.

     (6) Correspondence relating to any referrals concerning the diagnosis or treatment of the patient must be retained in the patient record.

     (7) Patient records should clearly identify the provider of services by name, initials, or signature. If the chiropractor uses a code in the documentation, a code legend must be made available upon request.

[Statutory Authority: Chapter 18.25 RCW. 96-16-074, § 246-808-560, filed 8/6/96, effective 9/6/96.]

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