A new patient comes to you for an initial visit. You perform a chiropractic adjustment based upon the patient’s complaints and much to your surprise, the patient develops increased pain or has an adverse reaction to treatment and must be referred to another provider for further workup and treatment. While this scenario doesn’t happen often, it can and does happen. And when it does, it can lead to a lawsuit against the chiropractor.
In reviewing these types of claims, not all the complications could have been avoided and the chiropractor’s care could be defended. However, there is a common denominator in the claims where the chiropractor was found to be negligent and that is: failure to obtain and document a thorough history and physical examination prior to initiating treatment.
Tips for What to Include in the History
If treatment is provided prior to obtaining a thorough history and performing a thorough physical examination, you run the risk of providing treatment that may be contraindicated causing injury or making the patient’s condition worse.
An appropriate history includes (but is not necessarily limited to):
- The patient’s chief complaint
- Medical and surgical history
- Dietary habits
- History of other treatments (chiropractic, osteopathic, medical, and other)
- Occupational history
- Psychosocial history
You would also potentially need to include any other areas that require further investigation based upon the patient’s response to the above list. Additionally, the patient’s family history should be obtained.
Then, a thorough orthopedic and neurologic examination should be completed, and further diagnostic testing performed, if indicated. Document both positive and negative findings and address any negative findings.
Does the patient have a history of spinal fusion, history of stroke, an acute fracture, cauda equina syndrome, congenital deformities, degenerative joint disease? These are just a few conditions that require either immediate referral for further testing and treatment or modification of chiropractic treatment so that the patient is not at undue risk.
Diagnosing, Treating, and Documenting
Based upon the patient’s history, physical exam findings, diagnostic testing, and your clinical judgment, a diagnosis or differential diagnosis can be made. If chiropractic treatment is appropriate, review treatment options with the patient and develop a plan of treatment based upon the patient’s history, co-morbidities, lifestyle, and other factors.
By performing and documenting the patient’s history and physical prior to initiating treatment, documenting your thought process for additional testing or referrals and your treatment decisions, documenting your conversations with the patient regarding the plan of care, and obtaining and documenting the patient’s informed consent for treatment you can reduce both the risk of a poor patient outcome and the risk of a lawsuit.
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“OUM” and “OUM Chiropractor Program” do not refer to a legal entity or insurance company but to a program or symbol of a program underwritten, insured, and administered by ProAssurance. The information contained on the OUM Chiropractor Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.