Pennsylvania Code › Title 49 - PROFESSIONAL AND VOCATIONAL STANDARDS › Part I - DEPARTMENT OF STATE › Subpart A - PROFESSIONAL AND OCCUPATIONAL AFFAIRS › Chapter 5 - STATE BOARD OF CHIROPRACTIC › Subchapter E - MINIMUM STANDARDS OF PRACTICE › Section 5.51a - Patient records-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
This section provides guidance to licensees of how
						clinical necessity for chiropractic care under §
											5.51(c) (relating
						to patient records) may be documented.
(1)
Definitions
. As used in
					 this section, the following words and terms, have the following meanings,
					 unless the context clearly indicates otherwise:
Acute condition
-A patient's condition
						where the onset of the condition or symptoms, or both, has occurred or
						substantively worsened within a 6-week period prior to presentation and which
						is caused by some intervening event or trauma whether known or unknown.
Chronic care
-Treatment of a chronic
						condition that is not expected to improve or resolve the chronic condition but
						is nonetheless expected to result in improvement in the patient's functional
						status that has regressed after a withdrawal of care.
Chronic condition
-A patient's condition
						when the condition or symptomatology has existed for longer than 6 weeks.
						Classification of a condition as chronic in no way affects the expectation of
						whether the condition can be resolved or improved with treatment.
Elective care
-Treatment delivered in
						the absence of symptoms or positive findings following examination or
						testing.
Exacerbation
-A sudden, marked
						deterioration of the condition being treated, which causes a marked worsening
						in the patient's functional status, and which is caused by some intervening
						event or trauma, whether known or unknown.
Maintenance care
-Treatment after maximum
						therapeutic benefit has been achieved from a course of treatment or care
						rendered for a chronic condition, which is not reasonably expected to improve
						substantively the patient's condition or functional capacity. Maintenance care
						is generally rendered on a predictable frequency and includes care for which
						the outcome is preventative, palliative or elective.
Palliative care
-Treatment for an acute
						or chronic condition that is not reasonably expected to resolve or
						substantively improve the underlying injury, disease or defect and that is
						rendered with the sole expectation of ameliorating the patient's symptoms as
						opposed to significantly improving the patient's condition or capacity to
						function.
Preventive service
-Service provided
						with the expectation of preventing worsening in a patient's chronic condition,
						preventing the onset of a condition, or reducing the risk of recurrence in a
						condition that has been treated and resolved. A service provided based upon
						findings uncovered during a preventive service examination is not a preventive
						service.
Recurrence
-A return of an acute
						condition which was previously treated and resolved or stabilized and which has
						been quiescent for a period of time.
Restorative care
-A course of active
						care provided that is reasonably expected to substantively improve the
						patient's condition or the patient's capacity to function.
Supportive care
-Treatment for a
						condition once maximum therapeutic benefit has been established and after
						therapeutic treatment has been withdrawn two or more times with the patient
						failing to sustain previous therapeutic gains.
(2)
Restorative care.
The
					 patient record regarding restorative care should contain documentation of the
					 development of the patient's symptoms to include the mechanism of onset and the
					 functional limitations associated with the presenting symptoms. The
					 documentation should additionally detail the diagnostic test results and
					 examination findings/indications (diagnosis) that form the objective basis for
					 the symptoms and functional limitations. The course of treatment necessary to
					 ameliorate the patient's condition should be identified to include the specific
					 therapeutic modalities or procedures to be utilized. The documentation should
					 also identify the specific functional results or goals of treatment that are
					 planned. Subsequent documentation should identify changes in the patient's
					 subjective or objective state that provide evidence of the provider's
					 continuing expectation that additional improvement will occur with additional
					 treatment. Any changes in the plan of care or anticipated outcomes should be
					 identified to include the clinical rationale for these changes. When the
					 patient reaches a functional plateau, the documentation should detail the
					 results obtained and whether the patient was transitioned to another form of
					 care or was discharged. When the patient self-dismisses or otherwise terminates
					 care, the documentation should so indicate and identify the rationale for
					 termination and the results achieved, if any. Documentation of restorative care
					 and necessary chronic care should contain information to support that it
					 satisfies at least one of the following:
(i)
					 It was reasonably expected to improve the patient's condition at the time it
					 was rendered.
(ii) It assisted the
					 patient to achieve maximum functional capacity in performing daily,
					 recreational, social or occupational activities.
(iii) It improved the patient's
					 condition.
(iv) It was provided
					 consistent with the treating doctor's diagnosis.
(v) It was provided consistent with the
					 patient's active symptomatology, functional complaint, or abnormal physical
					 findings.