Components of Case Management
1. DatabaseHistory = Subjective (S) part of SOAP
- Outcomes instruments = Objective (O) part of SOAP
- Specialist consults
2. Clinical impression
Problem list = Assessment (A) part of SOAP
3. Written plan
- Diagnostic plan (DxP)
- Treatment plan (RxP) = Plan (P) part of SOAP
- Patient education plan (EdP)
4. Case progress
- Routine treatment encounters (mini-SOAP)
- Periodic reevaluation (midi-SOAP)
Initially, the clinician attempts to gather information about the patient and his or her problems. Usually, this starts with taking a history of the present complaint, followed by a review of systems and past history.
[ 10 ], [ 11 ]
After the doctor has an adequate picture of the patient's subjective perception of the condition, objective information is obtained by direct examination of the area of complaint and related systems. Initially, and, depending on presenting factors, an appropriate level of physical and/or regional examination may be in order. Examples of comprehensive and efficient chiropractic consultation, history, and examination forms are provided at the end of this chapter.
History and examination findings should narrow the list of possible causes of the patient's complaints. Frequently, one or more different factors or conditions may be contributing to the problem. Special studies, such as laboratory tests and imaging studies (radiograph, computed tomography/magnetic resonance imaging scan, scintography, etc.), may be useful to rule in or out various possibilities.
In the past, traditional medical beliefs sometimes placed greater value on the doctor's "objective" perspective but, in fact, patient reports and outcomes tracking can be reliable and valid. [ 7 ]Although all patient reports and examination findings may be subject to deliberate falsification, this is not the norm. Rather than assuming the patient's perspective to be biased or unreliable, competent evaluation should include psychosocial assessment and tests such as Waddell' s signs to determine the extent of somatization.
In summary, the database includes the patient's chief complaint, history (present illness, along with past family, clinical, social, and occupational histories), examination, and special studies. The history effectively represents the patient's "subjective" perception of the condition, whereas the examination and special studies represent the clinician's "objective" perspective of the current state of the patient. Clustering and interpreting the findings leads to the next "phase" of management — the clinical impression or diagnosis.
After a reasonable portion of the database is gathered, the doctor formulates a clinical impression or diagnosis. This may be a clear-cut diagnosis or may involve several differential diagnoses. It is important for the initial working impression and any subsequent modifications to be recorded in some accessible fashion in the chart. This second portion of case management serves as the assessment of the patient's condition. Based on this summary of patient status, the doctor develops a clear perspective on what interventions are needed to resolve the patient's problem(s). The impressions and diagnoses will be likely to change over time and, therefore, must be modified. Still, the doctor's thought process needs to be documented chronologically. A problem list can serve to organize a patient's diagnoses and conditions in summary fashion over time. If kept as a cover sheet in or on the patient chart, it is always readily accessible and can be quickly updated when appropriate. A sample problem list (Fig 5) can be found at the end of this chapter.
Written Case Management and Treatment Plan
Once the causes (or possible causes) of a patient's problem have been enumerated, the next phase of case management involves deciding what to do about them. In many situations, doctors are required to preauthorize some procedures through documentation of specific treatment plans, goals, and outcomes. It is obviously most efficient when this information is readily gleaned from existing records, rather than through administrative reporting, requests for additional information, etc. Legible and coherent charting may help to reduce this when clear diagnoses, causation, assessments, and treatment plans are consistent and readily identified in the chart.
In addition, multiple treatment options may need to be recorded. This may include further diagnostic work to monitor progress; clarifying and refining the initial impression; or a therapeutic trial of a particular procedure or set of procedures to see whether the condition responds.
Care plans consist of three basic parts:
Additional diagnostic procedures that may be necessary in caring for the patient.
"Passive" interventions that the doctor may provide for the patient.
"Active" or self-care interventions that patients may be directed to do or to participate in on their own.
The first portion of the written plan is usually the diagnostic plan. A therapeutic trial is frequently the least expensive and least invasive of further diagnostic possibilities. In nonlife-threatening situations, such a trial is often the most prudent diagnostic plan. It is also appropriate when there is minimal difference between available treatment options for various conditions. This is known as the Diagnostic Plan and is abbreviated here as DxP. Obviously, the therapeutic trial may overlap conceptually with other portions of the written plan, but by indicating that a trial of care will be used as a diagnostic tool, the doctor may help minimize the possibility of useless ongoing care.
A second portion of the written plan is the doctor's specific treatment plan. This includes procedures that the clinician or staff will actually be performing on the patient (for instance, spinal adjusting and modalities) and can be referred to as the Treatment Plan, or RxP. Although an oversimplification, things that the doctor does to the patient may be referred to as passive procedures, in that the patient is a "passive" recipient of care during the process.
Lastly, there are things that the patient can do, such as postural and exercise protocols, and lifestyle and dietary modification. This is known as the Education Plan, or EdP. This kind of care involves the active participation of the patient and is often referred to as active care. Many facilities provide classes in spinal and back care, spinal stabilization and exercise training, and work or fitness hardening programs that allow the patient to get into condition and to learn how to maintain pain-free and optimal function over the long term. The sample problem list at the end of the chapter includes space for documenting the various components of the treatment plan for the conditions being addressed.
In summary, on an initial workup of a new patient, the doctor collects a variety of information, consisting of several components. The patient's own perception of his or her situation is gathered in the history (and/or by self-administered instruments) and is traditionally considered "subjective" information. Examination and quantification of patient signs and symptoms provides a doctor's "independent" evaluation and is often termed objective information. These two kinds of information form the patient's database. The doctor then integrates this information to form a diagnosis or impression of the patient's current status. This is often termed the assessment. Finally, based on what is determined to be the patient's problem, a course of action is planned, consisting of further diagnostic procedures, passive care, and active care.
The right side of Table_1 illustrates how these various components of case management integrate to form the acronym SOAP (subjective, objective, assessment, and plan). This terminology has become quite standard in chiropractic practice to indicate various types of information found in patient charts. Because the magnitude of data gathering on a patient is usually the greatest during the initial workup, it has been characterized here as a mega-SOAP. [ 2 ] The next phase of the clinical process involves implementation of the plan and ongoing evaluation of the patient.
Upon identification of the patient's problems and potential solutions, the next step in case management is the initiation of the plan. This phase of care is known as case progress. In actuality, case progress is a microcosm of the first three phases of management (database, impression, and treatment plans). Normally, the chiropractor will schedule a series of treatments, then will reassess the clinical effectiveness of the procedures used. This creates two kinds of patient encounters, after the initial workup — routine visits and reassessment visits.
The routine patient visit involves briefly rechecking the patient's subjective status at that time, checking various objective chiropractic indicators and any relevant previously positive examination findings, then coming to an assessment of the patient's status on that day. Next, the doctor will proceed to render the appropriate care and to make any modifications in the patient's self-care recommendations. This visit displays the same characteristics of the initial workup but on a smaller scale: database gathering (subjective history, objective evaluation); assessment of patient status; and plan for treatment. This is commonly referred to as SOAPing the patient. [ 5 ] Because of the much shorter and more focused nature of a routine encounter, compared with an initial evaluation, the routine care visit can be characterized as a "mini-SOAP."
Routine subjective assessment typically includes updating what the patient has been experiencing since the previous encounter. Anchored pain scales or duration of symptoms represent some quick quantitative approaches that may be worth noting in this section of a SOAP note. Any changes or differences (or lack thereof) should also be indicated.
Typically, the objective documentation on routine chiropractic visits might include palpation findings, levels of articular dysfunction or subluxation, location of asymmetry, muscle tightness, etc. A "star" diagram is a commonly used and efficient way to document directions of restricted and painful motion (see Figure 1).