Documenting Subjective Complaints
-Gregg Friedman, DC
Who makes up the rules for documentation? The answer is…
Centers for Medicare and Medicaid Services
And that applies to all patients who are 18 years old or older, not just your Medicare patients. Most insurance companies are following the Medicare requirements, and most state board are following that plan.
So what do they want from us? It’s pretty simple, really. They require just three things from us.
The First Thing…
They want us (actually, they require us) to assess pain for each condition that we’re treating, and on every visit, but with a “standardized tool.” The standardized tool used to assess the patient’s pain must be documented in the medical record, except if you’re using the Numeric Rating Scale, like 5/10. For this, we don’t have to document the actual tool name when assessing pain for intensity.
Centers for Medicare and Medicaid Services (CMS) defines a standardized tool as “an assessment tool that has been appropriately normalized and validated for the population in which it is used.” Some examples of a standardized pain assessment tool include, but are not limited to, Brief Pain Inventory (BPI), Faces Pain Scale (FPS), Numeric Rating Scale (NRS), Visual Analog Scale (VAS) and the Verbal Numeric Rating Scale (VRNS).
So, Which One Should We Use?
The common denominator for all of these is that they are all measurable in some way. I think the easiest and most powerful one we can use is the Verbal Numeric Rating Scale (VRNS). It seems easy enough to ask a patient to rate the intensity of their pain from 0 to 10, with 10 being the worst, but most patients don’t seem to understand that. I start by asking the patient if the pain is mild, moderate or severe. I explain that severe pain is typically the kind of pain that would send you to the hospital. In my experience, most (not all) patients who see a chiropractor have mild or moderate pain. I define for them that mild pain is between a 1 and a 3 and moderate pain is between a 4 and a 7. If they tell me their pain is moderate, I ask them for a number between 4 and 7, which seems much easier for them to handle than 0 to 10.