PROPOSED RULEMAKING
STATE BOARD OF CHIROPRACTIC
[49 PA. CODE CH. 5]
Patient Records
[36 Pa.B. 5979]
[Saturday, September 30, 2006]The State Board of Chiropractic (Board) proposes to amend §§ 5.1 and 5.51 (relating to definitions; and patient records) to read as set forth in Annex A.
Effective Date
The proposed rulemaking will be effective upon final-form publication in the Pennsylvania Bulletin.
Statutory Authority
The proposed rulemaking is authorized under sections 302(3) and 506(a)(15) of the Chiropractic Practice Act (act) (63 P. S. §§ 625.302(3) and 625.506(a)(15)).
Background and Need for the Amendment
A licensee who ''[f]ail[s] to maintain chronological documentation of patient care in accordance with regulations prescribed by the Board'' is subject to disciplinary action under section 506(a)(15) of the act. Section 5.51(c) currently requires that ''[t]he patient record shall contain sufficient information to document the clinical necessity for chiropractic care rendered, ordered or prescribed.'' This language does not provide licensees with clear guidance as to what information would be sufficient to document clinical necessity.
Description of the Proposed Amendments
The proposed rulemaking amends § 5.51(c) to set forth in more detail what must be included in the patient record, to document diagnosis, as well as the clinical necessity for care and any treatment provided. In general, the record must contain sufficient information to document that treatment, care or service provided: (1) was reasonably expected to improve the patient's condition at the time it was rendered; (2) prevented the onset of any permanent disability; (3) assisted the patient to achieve maximum functional capacity in performing the patient's daily activities; (4) alleviated the patient's pain; (5) mitigated the severity of the patient's symptoms; (6) ameliorated the patient's condition; (7) prevented the worsening of the patient's condition; (8) slowed the natural progression of the patient's condition or disease; (9) was appropriate for the patient's symptoms, reinjuries, exacerbations and diagnoses of the patient's conditions or injuries; (10) was provided consistent with the treating doctor's diagnosis; or (11) was provided consistent with the patient's active symptomatology or abnormal physical findings, or both. The record concerning diagnostic tests must address: (1) the doctor of chiropractic's rationale for ordering the diagnostic test so that without the diagnostic test the doctor of chiropractic could not establish a differential diagnosis to a reasonable degree of chiropractic certainty; (2) the extent to which the diagnostic test facilitated the doctor of chiropractic's proper or effective management or control of the patient's condition, including monitoring of condition which may result in a change of treatment; or (3) how the diagnostic test quantified an objective status of the patient's condition or functional capacity.
The proposed rulemaking requires that the patient record contain documentation sufficient to demonstrate that therapeutic treatment, care or services was reasonably expected to improve, restore or prevent the progression of an illness, injury, disease, disability, defect, condition or the functioning of a body member. The record must demonstrate that any elective care was provided to enhance human performance and the sense of well-being. The record must demonstrate that any maintenance care sought to promote health or maintain functional status, or both. The record must demonstrate that any palliative care was rendered to relieve continued pain and to positively affect the patient's symptomatology, as well as demonstrate the need for the frequency of palliative care. The record for preventive service must include a history and documentation of examination, counseling and risk factor reduction. Finally, the record must demonstrate that supportive care was provided following an aggravation, exacerbation or recurrence following at least two trials of therapeutic withdrawal that have failed to sustain previous therapeutic gains, though the record need not demonstrate functional improvement beyond the previously established maximum therapeutic level.
Additionally, the proposed rulemaking amends § 5.1 (definitions) to define the terms ''elective care,'' ''exacerbation,'' ''maintenance care,'' ''palliative care,'' ''preventative service,'' ''recurrence'' and ''supportive care'' for use in applying the proposed standards.
Regulated Community
The Board solicited input from and provided an exposure draft of this proposed rulemaking to professional associations, interested parties and other stakeholders. In addition, the Board considered the impact the proposed rulemaking would have on the regulated community and on public health, safety and welfare. The Board finds that the proposed rulemaking addresses a compelling public interest as described in this preamble.
Fiscal Impact and Paperwork Requirements
The proposed rulemaking will have no adverse fiscal impact on the Commonwealth or its political subdivisions. The proposed rulemaking will impose no additional paperwork requirements upon the Commonwealth or its political subdivisions. The proposed rulemaking will not impose additional paperwork requirements on the private sector, other than the regulated community.
Sunset Date
The Board continuously monitors the effectiveness of its regulations. Therefore, no sunset date has been assigned.
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on September 20, 2006, the Board submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the Senate Consumer Protection and Professional Licensure Committee and the House Professional Licensure Committee. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey any comments, recommendations or objections to the proposed rulemaking within 30 days of the close of the public comment period. The comments, recommendations or objections must specify the regulatory review criteria which have not been met. The Regulatory Review Act specifies detailed procedures for review, prior to final publication of the rulemaking, by the Board, the General Assembly and the Governor of comments, recommendations or objections raised.
Public Comment
Interested persons are invited to submit written comments, suggestions or objections regarding this proposed rulemaking to Deborah L. Smith, Administrator, State Board of Chiropractic, P. O. Box 2649, Harrisburg, PA 17105-2649 within 30 days following publication of this proposed rulemaking in the Pennsylvania Bulletin. Reference No. 16A-4313 (patient records) when submitting comments.
JONATHAN W. MCCULLOUGH, DC,
ChairpersonFiscal Note: 16A-4313. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 49. PROFESSIONAL AND VOCATIONAL STANDARDS
PART I. DEPARTMENT OF STATE
Subpart A. PROFESSIONAL AND OCCUPATIONAL AFFAIRS
CHAPTER 5. STATE BOARD OF CHIROPRACTIC
Subchapter A. GENERAL PROVISIONS § 5.1. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * Elective care--Treatment delivered in the absence of symptoms or positive findings following examination or testing.
Exacerbation--A marked deterioration of the patient's condition due to an acute flare-up of the condition initially or currently being treated.
* * * * * Maintenance care--Treatment after maximum therapeutic benefit has been achieved, which:
(i) Does not positively affect the patient's symptomatology.
(ii) Is not based upon abnormal clinical findings.
(iii) Has not resulted in an improvement in the functional status.
(iv) Has not been established as justified for palliative or supportive care.
* * * * * Palliative care--Treatment for a chronic or permanent condition that does not cure or make further improvement in the underlying injury or disease and is rendered without goals of functional improvement or expectation of slowing the natural progression of the condition.
* * * * * Preventive service--Service provided for a patient without symptoms or for a patient that has reached maximum improvement and does not need supportive or palliative care. A service provided based upon findings uncovered during a preventive service examination is not a preventive service.
* * * * * Recurrence--A return of the symptoms of a previously treated condition that has been quiescent.
* * * * * Supportive care--Treatment for a condition once maximum therapeutic benefit has been established and after therapeutic treatment has been withdrawn.
* * * * *
Subchapter E. MINIMUM STANDARDS OF PRACTICE § 5.51. Patient records.
* * * * * (c) The patient record [shall] must contain sufficient information to document the diagnosis and the clinical necessity for chiropractic care rendered, ordered or prescribed, and any treatment, care or service provided.
(1) Documentation of treatment, care or service provided must contain information that the treatment, care or service satisfies at least one of the following:
(i) Was reasonably expected to improve the patient's condition at the time it was rendered.
(ii) Prevented the onset of any permanent disability.
(iii) Assisted the patient to achieve maximum functional capacity in performing the patient's daily activities.
(iv) Alleviated the patient's pain.
(v) Mitigated the severity of the patient's symptoms.
(vi) Ameliorated the patient's condition.
(vii) Prevented the worsening of the patient's condition.
(viii) Slowed the natural progression of the patient's condition or disease.
(ix) Was appropriate for the patient's symptoms, re-injuries, exacerbations and diagnoses of the patient's conditions or injuries.
(x) Was provided consistent with the treating doctor's diagnosis.
(xi) Was provided consistent with the patient's active symptomatology or abnormal physical findings, or both.
(2) Documentation concerning diagnostic tests must address at least one of the following:
(i) The rationale for ordering the diagnostic test so that without the diagnostic test the doctor of chiropractic could not establish a differential diagnosis to a reasonable degree of chiropractic certainty.
(ii) The extent to which the diagnostic test facilitated the proper or effective management or control of the patient's condition, including monitoring of condition.
(iii) How the diagnostic test quantified an objective status of the patient's condition or functional capacity.
(3) Documentation must be sufficient to demonstrate that any therapeutic treatment, care or service was reasonably expected to improve, restore or prevent the progression of any illness, injury, disease, disability, defect, condition or the functioning of any body member.
(4) Specific treatment or care must be documented as follows:
(i) Regarding elective care, the patient record must demonstrate how human performance and the sense of well-being was enhanced.
(ii) Regarding maintenance care, the patient record must demonstrate how health or functional status, or both, was sought to be promoted.
(iii) Regarding palliative care, the patient record must demonstrate how the care was intended to relieve continued pain and to positively affect the patient's symptomatology, and to demonstrate the need for the frequency of palliative care.
(iv) Regarding preventive service, the patient record must include a history and documentation of examination, counseling and risk factor reduction.
(v) Regarding supportive care, the patient record must contain documentation of at least two trials of withdrawal of therapeutic treatment that have failed to sustain previous therapeutic gains following an aggravation, exacerbation or recurrence. The patient record need not demonstrate functional improvement beyond the previously established maximum therapeutic level.
* * * * *
[Pa.B. Doc. No. 06-1904. Filed for public inspection September 29, 2006, 9:00 a.m.]
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