Recently I read an article in Acupuncture Today titled “The Devil is in the Details” written by acupuncturist Douglas Briggs, who is frequently called upon to give his opinion on standard care in depositions for malpractice cases. Briggs has experience with the legal demands that determine standard patient care, including proper case documentation.

In a recent case where he was called for his opinion, Briggs listed various questions asked to determine proper patient care, which gave insight into how the legal realm looks at patient records. Apparently during a deposition an attorney can ask anything about your care of a patient, whether you wrote it down or not. What you “think” or “remember” is not credible. If it’s not written down, it’s not part of the record!

While this deals with licensed practitioners, it also applies to all health care providers including those who practice complementary medicine. As these modalities become more mainstream and integrate with conventional ones, our practice methods are also scrutinized and are expected to come into line with highly recognized practices. This will eventually include herbalists as they become more acknowledged. This means herbalists not only need to include proper referrals to other practitioners, but also keep adequate documentation.

Good case notes are obviously helpful for treating your patient. If it’s been weeks, months or even years since you’ve last seen someone, of course you treat what presents in the moment. However, thorough notations provide important reminders of the patient’s history, background, prior assessment and treatment, and other factors that are helpful for choosing your current procedures.

While at the East West School of Planetary Herbology we have long stressed the importance of charting TCM/Ayurvedic/Western assessment, treatment strategy and remedies/protocols, there are several other factors that must be documented. Doing so not only helps your treatment of the patient but also prepares you for unforeseen future needs. When you record such information as patient name, contact information, history, symptom/signs, lifestyle habits, and diet, keep these additions and considerations in mind:

• Not only is good record-keeping legally viewed as providing good care but also NOT providing good documentation could be seen as potentially harming the patient. In other words, good documentation is seen as necessary for the patient’s safety.
• Keep your own notes and don’t depend on other people’s, even if from another respected practitioner.
• Document when you referred someone and to whom, including full names and dates. If you request information from another practitioner, note when and from whom. This protects you, the patient, and the other practitioner.
• Be specific about your recommendations and treatments. If you do any form of bodywork, record what you did, including any points you held or body areas treated with adjunct therapies such as cupping or moxibustion. Do not just state “massage” or “full body care.”
• List your treatments and recommendations in the order performed as this shows a flow of care and not just a list of procedures.
• When you record a follow-up session, your comments about the patient’s progress must be specific. Rather than write that a patient is “better” or “worse,” note what specifically has changed since your last session. For example, record how their range of motion is different or what their pain level is now on a scale of one to 10 as opposed to what they reported last time.
• Give a straightforward rationale for your treatment. This is the basis for doing a TCM/Ayurvedic/Western assessment, which also then determines your treatment strategy.

These are the kinds of micro-details that can make a difference. While it may seem nit-picky and time-consuming, it actually takes very little extra effort to comprehensively record what you are doing. In the end, this not only serves you but also gives your patient better care.