• Albano SM
• Muller RD
• Fenton BT
• Schut SM
• Sites AR
• Lisi AJ

• Documentation / standards
• Medical History Taking
• Open Access Document
• United States. Dept. of Veterans Affairs
• Veterans
• Veterans Health Services

Objective: To assess Veterans Health Administration (VA) chiropractic consultation visits for the documentation of key history and examination elements.

Methods: A manual chart review of VA electronic health record data from a random sample of 1,000 on-station chiropractic consultation (new patient) visits between 10/01/2017-09/30/2018 identified the presence of select history and examination elements. Associations between patient characteristics and those elements were assessed using chi-squares, linear and logistic regression models (Stata, v18).

Results: Data were obtained from 978 visit notes, with low back pain (75.6%), neck (39.9%), and thoracic (25.5%) conditions most commonly reported as primary complaint. The most frequently documented history elements were quality/characteristics of symptoms (75.5%), provocative/palliative factors (71.0%), and symptom severity (70.0%). Range of motion (77.3%), observation (76.6%), and orthopedic testing (67.0%) were the most frequently documented examination elements. The number of history elements (linear regression coefficient: 0.46, 95% CI: 0.42, 0.51) and having no documented free text musculoskeletal diagnosis (linear regression coefficient: -1.21, 95 % CI: -1.78, -0.65) were associated with the number of examination elements in documentation. Visits containing ≥4 examination elements were more likely to contain ≥4 history elements (adjusted OR: 7.15, 95% CI: 5.26, 9.72).Similarly, visits containing ≥4 history elements were more likely to contain ≥4 examination elements (adjusted OR: 7.13, 95% CI: 5.25, 9.69).

Conclusion: We present an initial investigation of documentation of history and examination elements in VA chiropractic consultation visits. These results may inform future research and quality improvement efforts.

Author keywords: Chiropractic; Veterans Health; Medical History Taking; Medical Documentation

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