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OM_documentation - Evidence-based chiropractic and...

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Evidence-based chiropractic and documentation
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Good clinical documentation A record of a patient’s subjective  complaints, objective findings,  assessment, and plan for case  management  Should represent the thought processes  involved in patient care  Provides evidence of the patient’s  progress
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Good clinical documentation (cont.) Practitioners are able to monitor patient  progress accurately using good clinical  documentation Facilitates making the best possible clinical  decisions  May alleviate problems associated with  third party record reviews and  medicolegal issues 
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The value of valid & reliable outcome measures (OMs) Beneficial to Patients, because they are more likely to  receive appropriate care  Practitioners, who use the information to  formulate diagnoses and plan care Third-party payers and patients, who will be  more likely to receive legitimate services in  return for monetary expenditures
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Utility of OMs The utility of a test refers to its  usefulness in meeting the needs of the  patient, referrer, and payer An OM should be sensitive to change  It should change in direct association with  actual changes that occur in the patient  characteristic being measured  Responsiveness
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Clinical practice guidelines Systematically developed statements to  assist practitioner and patient decisions  about appropriate health care for specific  clinical circumstances   Developed by experts in a field using an  organized process  Evidence is assembled on the management  of the kinds of conditions handled by  practitioners
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Clinical practice guidelines development Best evidence is located to give  clinicians tools to provide optimal  patient care  Steps in guidelines development 1. The subject area of the guideline is identified 2. Guideline development groups are assembled 3. Evidence is obtained and assessed 4. Evidence is shaped into a clinical guideline  5. The guideline is reviewed externally 
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Guidelines may have disadvantages Evidence on a condition or treatment  may be unavailable or of low-quality In which case guidelines may only serve to  inform clinicians about the lack of evidence  Guidelines only address one condition  at a time However, in practice patients often present  with several complaints
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Guidelines - disadvantages (cont.) Recommended treatment options may  not always be appropriate  Each patient is unique  There may be contraindications to treatment Patient preferences must be considered Consequently, guidelines should never  be utilized as a treatment “cookbook” 
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Best practices The organizational use of evidence to 
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