Medical Documentation:

Essential Best Practices

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Anthony Von der Muhll, L.Ac., DAOM, DNBAO, FAIPM

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Webinar Etiquette

• Please keep your mic muted unless invited to speak
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Accessing Webinar Videos

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• (Annual subscription to the Ebook and videos may be renewed after the first year)

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To obtain your PDA & CEU certificates:

1. Log in to www.aomprofessional.com and go to “My Account”
2. Find your class under “Courses”
3. Open up each “lesson” to view slides, videos, or notes, and mark each as “complete”
4. Live classes and webinars: complete the 1-question “quiz,” using a code that will be supplied at the end of class. You must be logged in and attending the end of the webinar to receive the course completion code and obtain your certificate! “Make-up” codes will not be supplied at a later date.
5. Distance-learning courses: you must complete the course quiz.
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7. When you have completed the eval, you can download and print your CEU certificate, which will also be stored in your account under “Certificates of Completion.”)
8. Please note that PDA points are provisional. We report to your completion to the NCCAOM as soon as possible after the class, but the official PDA Certificates are issued directly through the NCCAOM and archived in your NCCAOM account.

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Comments or Questions?

• Live webinars: please type in chat window. Questions will be monitored by the moderator, and asked at an appropriate time. I will seek to answer all questions within the webinar’s schedule.
• For distance-learning classes: (or if we don’t get to your questions during a live webinar), here is my preferred method of receiving questions/comments:
1. Log in to www.aomprofessional.com and go to “My Account”
2. Find your class under “Courses”
3. Open up the slideshow and find slide(s) where you want to ask questions/ make comments, and use the “comment” icon in the upper right corner to post (Read the Guide: “How Interactive E-books work” for more detail)
4. I (and other students) will see your post, and I will respond ASAP
• (You can also email me at info@aomprofessional.com, but I prefer posted questions, they help facilitate discussion and improve the slideshow for all users)

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AOM ⇒ AIM, TEAHM

“Acupuncture & Integrative Medicine”

“Traditional East Asian Herbal Medicine”

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• “Oriental” (as in “Acupuncture and Oriental Medicine (AOM)) has both historical and contemporary pejorative and racist uses by Euro-American colonialists in the Far East.
• Many US-based medical organizations (including AOM Professional) have historically used “Oriental” and “AOM” as standard terminology without ill intent, but now recognize that they must be replaced by terms intended to better describe without offending.
• In the absence of broadly-recognized alternative, I have decided to begin replacing “AOM” with “AIM” & “TEAM” in class notes to describe modalities (including acupuncture, cupping, gua sha, tui na, and herbal medicine) that originated in or were developed into distinctive forms in China, and elaborated into diverse styles in Japan, Korea, and Vietnam, before the arrival of medical modalities originating in the West.
• I am monitoring discussions about appropriate terminology before beginning the process of changing my business name, as such a change is resource-intensive and would affect website domain names, webpage URLs, social media accounts, email addresses, etc., potentially inhibiting student access to courses for an uncertain period of time..
• I invite feedback and commentary on this issue, and offer my apologies to anyone I have unintentionally offended by use of “AOM,” and thank all for their patience with the process of making such changes.

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Documentation & Reporting (D&R)

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• Documentation: recording and retaining information
• Report-writing: presenting and communicating information
• 1-step process: document as if reporting to your entire audience at every visit, regardless of whether you’re billing insurance
• Report-writing for Managed Care is a more complex topic, addressed in detail in the 2nd class of this series

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Where this material comes from

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• Clean Needle Technique Manual, 7th ed.: sets standards for L.Ac.s in US, including regarding medical documentation and record-keeping
• My professional experience: reviewing chart notes from LAcs & physicians
• Practicing acupuncture continuously since 2003, including:
• On a referral basis with, & working in, physician-lead clinics
• Serving as a Secondary Treating Physician in the California Workers Compensation system
• Contracted provider with Kaiser, Sutter, & American Specialty Health managed care networks
• Serving as an expert witness in 20 + malpractice litigation cases
• Serving as a Subject Matter Expert for the California Acupuncture Board, 2009-present
• Serving as a consultant to acupuncturists defending themselves in insurance audits and regulatory board complaints

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• Text in RED indicates critical documentation!

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Purposes and Benefits of High-Quality D&R

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For quality of care and patient-practitioner relationship:

• Enhanced patient education, compliance, rapport
• Improved tracking of medical conditions and treatment responses
• Support for patient in their litigation (eg, motor vehicle accidents), disability applications
• Coordination of care with other providers

For practice-building and sustainability:

• Referral-building and enhanced professional reputation (indirect marketing)
• Increased insurance treatment authorization and reimbursement

For the LAc profession and public good:

• Contribute to research regarding treatment efficacy
• Public health: infectious diseases, epidemiology

In case of alleged harm or malfeasance:

• Demonstration of compliance with laws, ethics, and acupuncture standards of care
• Defense in case of alleged malpractice and complaints to regulatory boards

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Ethics, Laws, & Standards of Care

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Laws: voted on by legislatures

Regulations: adopted by public agencies to implement laws

(Specific to jurisdictions; changeable by politics)

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Standards of care: “What a reasonable professional would do” (profession- and locale-specific, but not majority rule). An amalgam of:

• Laws and regulations
• Ethics and “common sense”
• Textbooks and high-quality (peer-reviewed) journals and publications
• Professional guidelines (e.g. CNT Manual)
• Instruction: Masters’, Doctorate, CEUs & PDAs
• Expert opinions in complaints and suits
• Legal contracts (e.g. w/insurers, employers)
• Industry guidelines (e.g. coding and insurance guidelines, employee and clinic manuals, etc.)

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Ethics: adopted by professional associations (NCCAOM) to define, encourage ethical practices

(largely transcend person, time, place)

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Values

NCCAOM Code of Ethics

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“As a Diplomate of the NCCAOM, I hereby pledge my commitment to the following principles:

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• Allow my patients to fully participate in decisions related to their health care by documenting and keeping them informed of my treatments and outcomes.”

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(Emphasis added)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Medical Documentation is the Law in Most States

Example: California Acupuncture Board Regulations

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• “Sec. 1399.453. Record keeping. An acupuncturist shall keep complete and accurate records on each patient who is given acupuncture treatment, including but not limited to, treatments given and progress made as a result of the acupuncture treatments.”
• Emphasis added: we must document progress
• In this context, “progress” means changes in the patient’s conditions and status, whether or not they are improvements
• Know your state’s laws and regulations regarding documentation!
• Failure to comply = significant legal jeopardy

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

CNT Manual Sets Standards for Documentation

“There are 9 parts of any chart...”

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“1. Patient information

2. Past medical history

3. Allergies and adverse reactions

4. Family history

5. Dated and signed records of every visit

6. Flow sheets for organization of health maintenance, chronic conditions, wellcare visits

7. Narrative notes describing conversations with patients regarding treatments (accepted and refused) and preventative testing

8. Consent documentation

9. Flow sheets or narratives indicating that unresolved problems from previous office visits are addressed in subsequent visits”

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We will review these standards in detail below.

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Standards of Care in Malpractice Suits

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To prove malpractice and prevail in a lawsuit, a plaintiff must demonstrate:

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1. A professional standard of care exists that guides the performance of a procedure or duty--including record-keeping
2. The acupuncturist failed to uphold or follow the standard of care
3. The substandard care resulted in harm to the patient

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How could inadequate record-keeping result in harm or malpractice?

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

How Substandard Documentation Can Be a Factor

in Malpractice and Regulatory Board Complaints

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1. Inadequate record-keeping directly results in harm
2. Patient alleges harm; your records are inadequate for your defense
3. Inadequate record-keeping can be used by plaintiff attorneys and expert witnesses as additional evidence that your practice is sub-standard, in violation of laws/regs, etc.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

1. Inadequate Records Can Directly Result In Harm

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Lack of an adequate record-keeping system for a patient’s urgent/serious medical conditions can result in failure to:

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• Order appropriate diagnostic studies
• Render and communicate a diagnostic impression
• Conduct timely follow-up and re-assessment
• Recognize worsening of a condition
• Refer out for further assessment, diagnosis, and treatment
• Provide emergency services personnel with timely information regarding patient’s medical conditions, allergies, medications, etc.

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The above may constitute “errors of omission”, e.g. failures to uphold professional responsibilities within the scope of practice.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

2. Inadequate Records Can Fail to Defend You

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A patient alleges harm, and your record-keeping fails to document all the measures you took to uphold the standard of care, such as:

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• Screening for contraindications, cautions, and risk-elevating factors
• Adapting treatment as needed to address any of the above
• Obtaining informed consent prior to treatment
• Following CNT Manual during performance of all procedures
• Managing and referring out for urgent/serious medical conditions
• Etc.

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In other words, you didn’t commit malpractice--but your records don’t show that you didn’t.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Failure to Document Compliance with Standards of Care...

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• Allows a plaintiff to credibly allege that informed consent, risk management strategies, remedial actions to manage an adverse event, etc. never happened, e.g.:
• “They never performed any physical exam, ordered any tests, or provided me with a diagnosis!”
• “They never told me it could hurt or I could get injured!”
• “They put in a needle in my shoulder, and soon I started having difficulty breathing, but they didn’t ask me what was going on!”
• “I showed them the burn from the moxa, but they dismissed it!”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

3. Substandard Records are Illegal, Unethical…

And add to an impression of negligence…

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• The LAc was sloppy, careless, and performing below the standard of care regarding their legal and professional duty to document
• If they didn’t document…
• Why not? Are they just lazy? Or trying to cover up malfeasance?
• What else might they have done wrong?
• What other laws and regulations might they have violated? Ignored?

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Good documentation is your best defense!

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• Greatly assists defense attorneys and expert witnesses in demonstrating that you:
• Screened for contraindications, cautions, and risk factors
• Obtained patient’s informed consent
• Adapted treatment for patient’s safety
• Managed any suspected harm safely and professionally
• Are knowledgeable of professional standards, and uphold them in performance of their duties

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Potential Audiences for D&R

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1. The patient and their family and associates
2. Yourself
3. Outside medical professionals (including other L.Ac.s)
4. Attorneys (cases involving motor vehicle accidents, workers’ compensation, malpractice and licensing board complaints)
5. Licensing boards
6. Social Security (disability claims), law enforcement, other public agencies
7. Researchers and publications
8. If you bill insurance: utilization reviewers, claims adjusters

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

1. The Patient & Their Family/Associates:

Enhanced Rapport, Education, Compliance

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• Visible act of attention to detail, thoroughness, etc., demonstrates caring
• Providing patients access to their records: (a feature of many EHR systems)
• Further educates patient regarding their conditions
• Can help them understand the rationale for your treatment plan
• Supports patient agreement with and follow-through with your plan
• Allows patient to review your assessment of outcomes (increased ROM, etc.)
• Allows patients to correct errors and provide additional information
• May stimulate questions and discussions
• Builds trust through transparency

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Legally, records belong to patients, who have an absolute right to them at any time.

We are “custodians” and may (and should) retain a copy.

Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

1. Support for the Patient

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• Disability agencies (State, Federal) may request records when reviewing patient disability applications
• High-quality records can help the patient in litigation (motor vehicle accidents and other personal injury claims)
• Documentation of and reporting suspected or known abuse of patients to law enforcement and social work agencies

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2. For Ourselves and Our Clinical Practice:

How we D&R both affects and reflects how we think

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• Shapes our questions and physical exam
• Focuses our attention on critical topics
• Allows us to review and reflect on findings
• Clarifies our thought process
• Identifies gaps in information
• Exposes inconsistencies/contradictions

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

2. For Ourselves and Our Clinical Practice

Tracking health status, responses to treatment etc. helps us to:

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• Analyze and learn from our patient’s conditions and treatment responses
• Identify need for change of diagnosis, treatment plan, expert consultation, and/or referral out, etc.
• Identify external factors that affect patient’s symptoms, etc.
• “Treatment was the same, so it must be something else….”
• Compare objective findings with patient’s subjective reporting
• Can help us identify complicating, perpetuating and distorting psycho-social factors that may need to be addressed
• Provide accuracy and confidence in prognosis
• Enhances patient confidence and outcomes

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3. Other Medical Professionals

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• If your patient has a 911 medical emergency (stroke, pneumothorax, slip & fall fracture, etc.) at your clinic…
• Paramedics will need to immediately access records to help determine care
• Are your records sufficiently organized, accessible, comprehensible, complete?
• Standard medical/ICD-10 diagnoses? Problem list?
• Rx meds, allergies, implants, hx adverse reactions to care?
• Clear, concise, precise, and easy to understand notes in medical terminology accessible to the reader assists other providers with understanding your care, and providing their care

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Good Documentation Saves Lives!

3. Other Medical Professionals

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• Those with whom the patient requests that you share records
• Those that refer to you, and those to whom you refer or want to refer
• Of equal or greater licensure/degree status
• Of lesser status, if you wish to give them information/direction
• Any provider you want to cultivate a referral relationship with

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Can other medical professionals (including other LAcs) understand your history, exam, assessment, treatment?

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The Medical Licensure Hierarchy

In California--know your state’s hierarchy!

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PHCP; no supervision requirements

PCP; indirect physician supervision required

Allied health

Physicians

Practice only under direct supervision

Non-PCP; indirect physician supervision required

Mid-level providers

Assistants, aides

Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Provide referring physicians with initial visit note

A best practice--and free, powerful, very efficient marketing!

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• Common courtesy among medical professionals
• Shows respect for their practice, your appreciation of their trust in your care, your desire to stay in communication as a participant in the patient’s care team
• Allows you to demonstrate your skills in history-taking, physical exam, assessment, treatment planning, and medical care
• Assists with coordination of care and tracking patient’s status
• You’re the kind of L.Ac. that a physician would want to refer to!
• (Some physicians may also want periodic status reports, discharge summaries, or a specific report format–check upon receiving a first referral)
• Possible to build a thriving practice thru this method--w/no social media marketing!

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Courtesy in Salutations and Conclusions

Examples:

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• Salutation: “Dear Dr. Smith, thank you for kind referral of Ms. Jones, whom, as you know, is a 66-year old gentlewoman presenting with a chief complaint of neck pain with your diagnosis of cervical spondylosis with radiculopathy. Medical records provided by your office were reviewed prior to today’s evaluation and treatment.”
• (Contents of your history, physical exam, assessment and plan).
• Conclusion: “Again, thank you for entrusting Ms. Jones to my care, and please do not hesitate to contact me at 888-555-5555 with any questions or concerns. Regards, Ms. Needlem, L.Ac.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Please do not use exact copies of these examples in your D&R!

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• I am sharing examples of charting language on an honor/trust basis. Please don’t copy/paste the examples verbatim!
• The examples have taken me years to develop and refine, and are a work in progress, and I do not guarantee them as fail-safe methods. I continue to change my own templates as I see fit.
• I encourage you to study, understand, and internalize the concepts and principles, so you can apply them flexibly to your own practice and update them as needed
• If you want to use my examples as a starting point, please significantly edit and modify!
• If large #s of L.Ac.s start using my exact language, we all look like we’re all doing D&R on a rote basis, rather than describing what we’re actually doing in our clinics.
• Rote charting erodes credibility, and potentially hurts me, you, and our profession.
• Also, please do not distribute or sell examples, these class notes are copyrighted!

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4-5. Legal and Regulatory Audiencies

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• Attorneys and expert witnesses that may represent you and/or the patient in malpractice cases
• Judges and juries
• Arbitration panels (if your patient has agreed to binding arbitration)
• Regulatory agencies (e.g., California Acupuncture Board)

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6. Researchers and Research Publications

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• High-quality documentation may be useful to researchers (with patient consent and identifying data expunged)
• High-quality documentation may be publishable as case studies, series reports
• (If you are a DAOM student, these D&R practices will make case studies, capstone projects etc. familiar and easier!)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

7. Documentation When Billing Insurance

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• Documentation best practices when billing any type of insurance are covered below in slides
• Documentation and reporting for managed care insurance is a specialized topic covered in the sequel class:
• Report-writing for Managed Care: HMO, Personal Injury, Workers Compensation

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3 Golden Rules of D&R

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• #1: Document what you do, and do what you document.
• #2: Report unto others as you would have them report unto you.
• #3: Completeness, thoroughness, honesty and transparency are always the best practices.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

What makes for a good medical record?

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• Legibility, clarity, language accessibility
• Audience sensitivity, respectfulness
• Relevance, pertinence
• Thoroughness, completeness
• Appropriate level of detail and specificity
• Organization and presentation of data

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Essential Contents: Medical Chart

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1. Demographics
2. Financial agreements, billing and payments records
3. Insurance information and treatment authorizations or denials
4. Referrals to and from other medical providers
5. Medical correspondence and communications, including records and special study reports from other providers
6. Visit records: HPIs, SOAP notes, PR/DRs

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Color-Coding to Help You Find Topics:

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• Slides with orange background also contain red text: critical documentation to comply w/laws & standards of care, & avoid insurance audits--risk management
• If the title is in Red text, the entire contents of the slide should be considered critical
• Yes, there are many such slides & text--this is a critical, under-appreciated subject!
• Slides with blue backgrounds: “Subjective,” aka History
• Slides with green backgrounds: “Objective,” aka Physical Examination & Records Review
• Slides with light purple backgrounds: “Assessment,” aka Diagnosis
• Slides with cyan/blue-green (“qing”) backgrounds: “Plan,” aka Treatment
• Slides with yellow-green backgrounds: insurance-related documentation

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Demographics

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• Full name
• Sex assigned at birth, gender identity
• Date-of-birth
• Contact information, including marital status, emergency contacts and next-of-kin
• Race/ethnicity
• Language competencies (presence of translator)
• Occupation and student/employment status

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

HPIs, SOAPs, PRs, DRs?

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• History of Present Illness (HPI): initial visit record. See example.
• Subjective Objective Assessment and Plan (SOAP) Note: follow-up records.
• See example.
• Also referred to as a “Progress Note,” a designation which confounds with:
• Progress Report (PR): a periodic report of changes from baseline:
• Typically required by managed care, workers compensation or auto-med-pay insurers at the end of a course of authorized treatment
• Required to justify medical necessity for further treatment
• Please see companion course: “Report-Writing for Managed Care: HMO, Personal Injury, Workers Compensation” for more information regarding PRs
• Discharge Report (PR): final SOAP note + summarizes reasons for discharge and any additional plan (referral, recommendations for follow-up or return to care)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Essential Contents of an HPI/Medical Chart

Importance of documenting these is proportionate to the degree to which we function as a stand-alone PHCP

List pertinent negatives--do not leave fields blank

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• Past medical history, including your review of medical records (detail on next page)
• Medications and supplements, including any history of adverse reactions
• Implants, prosthetics, assistive devices, disabilities
• Results of imaging studies/labs/special tests
• Health habits: smoking, alcohol and substance use, exercise, diet, sleep, sexual activity, etc.
• Allergies: foods, medications, supplements, environmental etc.
• Adverse reactions to prior care
• Immunizations, scheduled/preventative screening tests
• Family medical history: record status of similar/ related illnesses
• Social history (employment, education, housing, domestic safety, home health-care, etc.)
• Hazardous exposures: occupational, environmental such as asbestos, lead, solvents, etc.
• Problem list: tracking medical conditions, treatment outcomes, health maintenance, preventative testing and screening

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Subjective, Objective, Assessment, & Plan

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• Subjective: Anything reported by patient (and associates)
• Objective:
• Your physical exam
• Medical records and written reports (not including patient notes)
• Assessment: Your diagnostic impressions
• Plan: Anything you do in the clinic or by referring out

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Subjective

Reported by patient (and any associates)

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• Symptoms, history, prior diagnoses, labs, imaging etc.
• Anything written by the patient (medication lists, their notes from a doctor’s visit or scribbled on their records, symptom journals etc.)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Self-Dx is Subjective!

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• A common error among beginning practitioners is to document patients’ self-reported study results and diagnoses as is under “Objective” or “Assessment”
• Patients may be inaccurate, biased, confused, have misunderstandings or memory lapses, etc.
• Patient’s conditions may have changed since prior studies, diagnoses
• Self-diagnoses from “Dr. Google” do not belong under “Objective” or “Assessment!”
• By definition, if it’s reported by the patient/associates, it belongs under “Subjective”--even if it correlates with medical records, and you end up agreeing and repeating under “Objective” or “Assessment”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Patient’s intake forms are not

A substitute for a documenting a verbal history!

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• Electronic intake forms make it easy to gather lots of information in advance, but…
• Patients often report different things differently on intake forms vs. in-person discussion
• It’s our responsibility to both offer an intake form and conduct an in-person verbal inquiry prior to examination, diagnosis and treatment

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Past Medical History

Including dates and locations

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• Diagnostic procedures and findings
• Surgeries, invasive procedures: complications, outcomes
• Hospitalizations, transfusions, in-patient treatment; discharge status
• Therapies: on-going? outcomes?
• Follow-up: are there other providers that monitor?
• Particularly critical with serious conditions that can have relatively mild symptoms, e.g. cancer, hypertension, lupus

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Review of Systems (ROS)

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• The place to document all current (not past) symptoms at 1st visit
• Critical: screening for urgent/serious active or latent conditions that alter AOM treatment and/or need referral, management or monitoring (see below for detail)
• Document symptoms for each body system (East + West), regardless of how closely-related or not they seem to the patient’s chief complaints.
• At a minimum, documenting critical negatives or “no additional findings” for each body system shows due diligence
• On forms, leaving fields blank, without comment, can appear as negligence, rather than just asymptomatic.
• Remember that ROS is required to justify Level 3+ E&M coding

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Review of Systems: Best Practices

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• Conduct both through intake forms, and verbal interview
• Document patient’s reporting of symptoms in their own lay person terminology
• Use “quotes” around any patient reporting that you are documenting verbatim
• Avoid use of Eastern or Western medicalese and diagnostic terms, unless the patient uses such terms themselves
• Patients may or may not be a reliable source of their “diagnoses”-- it’s more important and reliable to ask what they feel in the way of symptoms
• Initial and date intake forms to indicate your review
• Best to transfer critical findings from intake forms into your HPI
• Some EHR systems may do this automatically

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Review of Systems: General

Not comprehensive--adapt for your practice focus

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• Weight loss Weight gain General weakness Fatigue or drowsiness Fever Headache Dizziness Abnormal sweating Swelling Cramps Difficulty sleeping Moodiness Irritability Depression Anxiety Panic Attacks Obsessive thoughts or habits Memory loss Confusion Difficulty concentrating Eating disorders Loss of motivation

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(Tip: putting psychiatric symptoms under “General” on intake forms greatly increases likelihood of self-reporting, as patients are often reluctant to indicate mental symptoms when listed under “Psychiatric” or similar labels that have a social stigma.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Review of Systems: Continued

There are many ways to organize ROS--adapt for your practice focus

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Cardiovascular and pulmonary: Heart disease Chest pain or pressure Uncomfortable heartbeat or murmurs Asthma Pneumonia Wheezing Difficult/painful breathing Cough Bloody sputum

Gastrointestinal: Trouble swallowing Reflux Bloating Abdominal pain Loss of appetite Change in thirst Nausea Vomiting Black, tarry, or bloody stool Diarrhea, urgent stool, loss of bowel control Food intolerance Hemorrhoids Constipation

Urinary and Reproductive: Change in frequency of urination Pain, dribbling, hesitancy on urination Urinary urgency/ incontinence Nocturnal urination Bloody or discolored urine STDs Perineal pain, numbness or tingling Menstrual difficulty, pain

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Review of Systems: Continued

Adapt for your practice focus

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Musculoskeletal & Neurologic: Weakness or paralysis Numbness or tingling sensations Tremors or involuntary movements, loss of control Joint pain, swelling

Skin and Lymphatic: Rashes Lumps Sores Dryness Itching New moles or growths Changes in moles or growths Infections Dishcarge

Head/Eyes/Ears/Nose/Throat: Vision changes or difficulty Ear ringing Hearing changes or difficulty Vertigo Frequent colds or flus Nasal discharge or bleeding Sinus/nasal problems Difficulty chewing, swallowing

Endocrine: Thyroid disorders Parathyroid disorders Other endocrine disorders

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Screening for Presentations that ↑ Risks of AOM Modalities

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• Any presentation that potentially affect safety, cautions, contraindications, choice of modalities, techniques, locations, etc. for AOM modalities, including:
• Pregnancy and lactation
• Spastic and seizure disorders
• Easy bruising or bleeding, clotting disorders
• Immuno-compromise (HIV, diabetes, lymphedema, immuno-suppressive drugs, etc.)
• Congenital variations or acquired deformities that alter anatomy: spina bifida, sternal foramen, organ enlargement or displacement, lung disease, etc. (see next 2 slides)
• Recent sprains/strains, fractures until unionized
• Surgeries or other invasive procedures
• Prosthetics, implants, joint replacements, pacemakers, other medical devices, etc.
• Osteoporosis, osteopenia
• Sensory loss d/t neural or vascular conditions, decreased peripheral vascular circulation
• Reactive skin diseases, metal or other allergies

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Screening for Presentations

that Elevate Risk of Pneumothorax

​

• History of spontaneous pneumothorax
• COPD, emphysema, tuberculosis, cystic fibrosis, sarcoidosis, lung cancer, asthma or other chronic respiratory disease
• Smoking any substance
• Medications: corticosteroids
• Rare: Marfan’s syndrome, homocystinuria, or endometriosis
• Age (progressive past middle age)
• Tall, thin body type, little tissue over thorax

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Screening for Organ Enlargement

​

• CNT Manual identifies the following diseases as contributory to organ enlargement:
• Heart: chronic hypertension, congestive heart failure.
• Liver: alcoholism, chronic active hepatitis, hepatocellular carcinoma, infectious mononucleosis, Reye’s syndrome, primary biliary cirrhosis, sarcoidosis, steatosis, or cancer
• Spleen: infectious mononucleosis, AIDS, malaria, anaplasmosis (formerly known as ehrlichiosis); cancers, including leukemia and both Hodgkins and non-Hodgkins lymphoma; and diseases associated with abnormal red cells such as sickle cell disease, thalassemia, and spherocytosis.
• (Lung conditions addressed in previous slide)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Anything Else?

​

• Intake forms and verbal interview should allow for open-ended self-expression of any concerns not previously covered
• Document your use of open-ended questions, as well as patient’s response, e.g.

​

“Patient denied any other current presenting symptoms or medical concerns, other than as already discussed above.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Chief Complaint

The patient’s (and any associates’) descriptions of the problems

​

1. Reliability of source(s)? (e.g, mental status of patient, role and name of any professional or family interpreters, etc..)
2. All pertinent symptoms, including critical negatives (“patient does not have headache”) that reduce likelihood that any urgent/serious conditions are present.
3. Onset and chronological development, location, qualities, palliative and provocative factors, severity, timing, associated symptoms or conditions, life impacts
4. Patients’ reports of other providers’ diagnoses and treatments, results of labs/imaging tests, etc. belong here under “Subjective,” not “Objective”
5. (Reports of family members, legal guardians, friends, etc.)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Subjective Functional Capacity Assessment

Particularly helpful in reporting to Managed Care, Work Comp

​

• Questionnaires: standardized, research-validated re:
• Functional capacity, disability indexes (examples on next slide)
• Quality of life questionnaires (MYMOPS, Short Form-36, etc.)
• Patient-reported disabilities, limitations
• Activities of Daily Living (ADL): basic self care, family roles
• Employment, education
• Travel, recreation, sports, social life
• Sleep, sexual function

​

57

Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Research-Validated Functional Capacity Surveys

Some commonly-used examples

​

• Neck Disability Index
• Oswestry Low Back Disability Index
• Shoulder Pain and Disability Index
• Elbow, Wrist and Hand Disability Questionnaire
• Quick DASH form: entire upper extremity, useful for carpal tunnel syndrome
• Harris Hip Score
• Lysholm Knee Scoring Scale
• Lower Extremity Functional Scale
• Many are available as free .pdf downloads.
• Studies of quality, validity, and best uses can be found on PubMed

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Objective

What you find from examining the patient, and their records

​

• Findings from our physical exam, organized by body system
• Include pertinent/critical negatives
• Diagnoses, reports and assessments, either written, or otherwise communicated directly to us by other medical professionals
• Written results of labs/imaging and other special studies
• Your mark-ups, underlining, commenting etc. shows your careful review--a best practice that can be important in suits and complaints
• At least, initial and date each page of such reports
• (Verbal descriptions of reports provided by patient belong in “Subjective;” they may be inaccurate)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Exam: Best Practices

Similar principles to ROS

​

• Critical: screening for urgent/serious active or latent conditions that alter AOM treatment and/or need referral, management or monitoring (see below for detail)
• Document findings for each body system (East + West), regardless of how closely-related or not they seem to the patient’s chief complaints
• Document methods of examination, e.g. palpation, inspection, stethoscopic auscultation, etc.
• (Exam of 8+ body systems needed to justify Level 3+ E&M coding)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Exam: Negative Findings

​

• Document negative findings that are critical for assessing/ruling out urgent/serious conditions that alter AOM treatment and/or need referral, management or monitoring
• Document critical negatives by describing what you are looking for and not finding, e.g. “inspection of eyes finds no discoloration, swelling, asymmetry, foreign bodies, exudate, or abnormal lachrimation”
• At a minimum, documenting “no additional findings” for each body system shows due diligence
• On forms, leaving fields blank, without comment, can appear as failure to perform physical exam for that body region--potential “error of omission” in malpractice allegations

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Physical Exam Findings: Examples

Adapt for your practice focus, patient conditions

Quantify whenever possible

​

• Vital signs, height, weight
• Heart, lung, abdominal sounds (mention stethoscope if used for auscultation)
• Mini-mental status exam or other standard tests of cognitive function, memory, etc.
• Reflexes (0-4 scale), sensory function (2-point discrimination) and other neurologic tests
• Head, ears, eyes, nose, throat inspection, functional evaluation
• Tongue, pulse, auscultation, olfaction
• Palpatory findings, tenderness (1-4 scale), skin, hair, and nails, lymph nodes
• Joint range-of-motion, strength , other orthopedic tests and exam findings
• Other special examinations and tests for specific body systems/regions
• Measurements (limb girth, size of swellings, skin lesions, etc.)

​

​

62

Deep Tendon Reflex Scale

63

Objective: Tenderness Scale

Not a direct indicator of functional capacity, but helpful in documentation

​

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Critical Negatives from Physical Exam

Rather than adapt for your practice focus…

Best to screen/document all patients equally for at least the following:

(Educational example, please use your own language:)

​

• General: Patient appears well and not in acute distress.
• Eyes: PER, EOMI, no discharge, discoloration, or swelling apparent to inspection.
• Head, Ears, Mouth, Throat: Normocephalic, atraumatic, no asymmetry, paresis, drooping noted. PER, EOMI. Speech unremarkable. No discharge, sputum, redness, hematoma, skin lesions, or swelling apparent to inspection.
• Neck: Supple, AROM grossly WNL. No hematomas, skin lesions, or swelling noted on inspection.
• Respiratory: Normal effort, no rales, wheeze or cough to unaided auscultation.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Critical Negatives from Physical Exam

Best to screen all patients equally (rather than adapt for your practice focus)

​

• Cardiovascular: No jugular distention, limb swelling or varicosities noted on inspection.
• Neuro-musculoskeletal: Gait, movement and posture are unremarkable, no antalgia, ataxia, instability or incoordination noted. No bony hypertrophy, deformity or asymmetry, joint swelling or redness, or muscular atrophy noted on inspection.
• Skin: No discharge, redness, rashes, macules/papules, hematomas, lesions, infections, abnormal growths or moles, lumps or swellings, discoloration or abnormalities in skin texture, moisture or turgor or hair growth apparent to inspection.
• Psychiatric: Speech comprehension and expression, orientation, cognition and fund of knowledge unremarkable. Affect and demeanor are communicative, responsive and cooperative, without agitation or apparent acute distress. No flight of ideas noted.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Critical Negatives from Physical Exam

Rather than adapt for your practice focus, best to screen all patients equally

​

• Abdomen: No distension, lesions, scars, skin abnormalities or asymmetry to inspection. Bowel sounds normoactive to stethoscopic auscultation. No swellings, masses, tenderness to palpation and rebound testing. No tympany to percussion.
• (As L.Ac.s we do not generally perform routine screening exams of the anus, breasts and genito-urinary body systems; however, if the patient’s condition warrants examination of these body regions, documenting both positive and critical negative findings is appropriate.)
• AOM-specific pulse, tongue and other exam findings are probably best organized in their own sections, rather than mixed in with other body system sections.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Assessment: Essential Contents

What you think the problems are that establish “medical necessity”

​

• Diagnoses: in standard medical terms, complemented w/AOM pattern(s)
• To use an ICD-10 code to bill insurance is to make a diagnosis
• Best practice re prior diagnoses by physicians: repeat in our SOAPs
• Acknowledge their professional judgement and higher level of training/licensure status within the US health-care system
• Add additional diagnoses sparingly, if/as supported by evidence, and pertinent to what we are treating, or to draw their attention to an additional concern
• Avoid disputing with or subtracting from physician diagnoses
• Remember that patient’s report of prior diagnoses belongs in “Subjective”

68

Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ www.aomprofessional.com

​

Diagnose to Highest Level of Specificity

As supported by evidence: findings from Subjective and Objective

​

• Avoid under-, over-, and mis-diagnosis. Example:
• Subjective: insidious-onset low back pain in a patient w/history of prostate cancer
• Objective: normal exam except for palpable mass near lumbar spine
• Diagnoses:
• M54.5 Low back pain
• R22.2 Localized swelling, mass, lump in trunk. “Elevated concern for possible malignancy.”
• Diagnosis of “cancer” is not (yet) supported by evidence.

69

Diagnose to Highest Level of Specificity

​

• Suppose the patient then begins complaining of pain and numbness radiating to right leg?
• Exam findings:
• Lumbar AROM is grossly normal, except for extension which is pain-limited and exacerbates patient’s right leg pain
• Sensory loss in L 4-5 dermatomes on alcohol swab and 2-point discrimination testing
• Motor strength is grossly normal throughout all leg myotomes

70

Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ www.aomprofessional.com

Diagnose to Highest Level of Specificity (cont.)

​

• Essential: New diagnosis of “M54.16 Radiculopathy, lumbar region.”
• Optional, advisable:
• “Findings consistent with right-sided neuro-foraminal impingement at L 4-L 5 levels, and resultant moderate sensory loss. Concern for progression to motor loss.”
• “A mass of unknown origin is palpated at the right lumbar spine.”
• “The possibility of nerve compression from tumor or disc lesion is considered.”
• “AOM pattern: bone bi, qi and blood stagnation and deficiency in right leg taiyang and shaoyang jing-jin. Concern for possible 恶性肿瘤 Èxìng zhǒngliú”

71

Anthony Von der Muhll, L.Ac, DNBAO, FAIPM ☯ www.aomprofessional.com

Diagnose to Highest Level of Specificity (cont.)

​

• Patient returns with report from biopsy of lumbar mass, which shows metastasis of prostate cancer to lumbar spine.
• Add new diagnosis of “C61 malignancy of metastasis from prostate.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Assessment: Optional but Advisable Contents

​

• Differential diagnosis: a list of other possible diagnoses, in order of declining probability
• AOM patterns and diagnoses
• Degree of severity/urgency
• Additional concerns, impressions, or possible diagnoses that need to be assessed/ruled out

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Plan: Essential Contents

What the provider (1) intends to perform and (2) did perform on this date

to remedy the problems; and (3) outcomes

​

​

74

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Integrative Acupuncture Orthopedics Program ☯ Professional Ethics & Risk Management

​

Documenting Informed Consent (IC):

Patient’s signature on a form is not enough

​

• Who among us can say they read all the fine print on intake forms?
• To be defensible--and to lower likelihood of complaints/suits--IC must be both:
• Verbal, face-to-face, and specific for each procedure
• Documented in your chart note for the specific date in which it was obtained
• Having patients sign an IC form without initiating a verbal discussion is inadequate--despite what CNT says!
• It’s safer and more ethical to practice above the CNT’s SOC
• Review instructions to jurors regarding what constitutes IC
• Never perform treatment for which IC has not been given!
• It may be legal, but it’s unethical, sub-standard, and high-risk

76

Essential Elements of Informed Consent

Verbal, face-to-face conversation with patient and/or guardian regarding:

1. Disease diagnosis and pathomechanisms, including any reservations or uncertainties
2. Prognosis with vs. without treatment
3. Description of your proposed treatment plan and modalities
4. Known common and/or significant risks and side-effects of proposed treatment:
1. Those risks and consequences of which the provider has, or reasonably should have, knowledge
2. Not necessary to disclose every potential minor risk or side effect
3. Appropriate to disclose those risks which occur more than 1% of the time for a given procedure
4. Known risks of serious adverse events such as infections, burns, pneumothorax or other organ puncture should be discussed regardless of their frequency
5. Education regarding recognition, reporting and management of perceived adverse effects
6. Projected duration, frequency and costs of treatment
7. Anticipated benefits and outcomes; goals and benchmarks; re-evaluation timelines
8. Alternatives to your proposed AOM treatment plan, including any referrals to other providers/modalities, regardless of whether or not they are your personal preference

77

Informed Consent (IC) is procedure-specific

​

• Known risks should be disclosed and discussed prior to each new procedure (e.g., acupuncture, gua sha, cupping, moxa, herbs, exercises, etc.)
• Best practice: also disclose transient side-effects that may be distressing to the first-time patient
• Once given, IC is assumed to continue (no further repetition needed), unless/until withdrawn

78

Example: IC to filiform acupuncture is obtained and documented on 1st visit. On 6th visit, IC re: 7-star acupuncture and cupping is obtained and documented. On 7th visit, patient reports dislike of post-cupping bruises, withdraws consent to further cupping

Documenting Patient’s Consent

Record the following:

​

1. Patient’s or guardian’s capacity (or any limitations in their capacities) to understand your explanations of the above
2. Whether all the patient’s or guardian’s questions or concerns were addressed to their satisfaction, and
3. Patient’s or guardian’s voluntary request to proceed with plan as proposed

or

• Any postponement or rejection of any aspect of the plan

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Integrative Acupuncture Orthopedics Program ☯ Professional Ethics & Risk Management

​

Example of Documentation of Informed Consent

• “My proposed treatment plan, as well as associated risks and side-effects, including bruising, skin irritation or infection, increased pain and tenderness, infection, injury to nerves, blood vessels and vital organs, including pneumothorax, and dizziness and fainting, as well as costs of and alternatives to my proposed treatment, were discussed and agreed upon with the patient, who showed a clear understanding, and requested continuation with treatment as described. I educated the patient regarding recognition, reporting and management of any perceived adverse events. The patient expressed a good understanding of my diagnosis, proposed treatment, risks and potential side-effects and their recognition, reporting and management, as well as frequency, duration, and costs of, and alternatives to my proposed treatment. The patient voluntarily requested continuation with my treatment plan as proposed. I advised and the patient agreed to avoid moving body regions with needles inserted to minimize the risks of needle bending or breakage. I advised the patient to eat and drink non-alcoholic, non-caffeinated beverages within 1-2 hours prior to acupuncture treatment to minimize risks of fainting and pain upon needle insertion. I inquired as to the patient's most recent meal and hydration status, and offered water prior to treatment. The patient stated they were well-fed and hydrated prior to commencement of acupuncture.”
• Please do not copy this verbatim! You may modify it to suit your practice and how you actually communicate verbally with your patients. Copying it verbatim hurts you, me and profession by making it look rote, rather than real.

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Patient’s Goals, Objectives, Benchmarks

​

Examples:

• “Sleep without pain interruption”
• “Return to full-time employment at regular duties”
• “Run 5 miles without flare”
• “Reach overhead without pain”
• “Increased control over urinary frequency and urgency”
• “Reduced abdominal pain and flatulence after eating”
• “Reduce needs for medication”
• “Reduced stress and anxiety”
• “Tonify my spleen qi” (yes, if the patient uses TCM terminology, document it!)

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Practitioner’s Treatment Principles and Goals

--Usually overlaps with or repeats patient’s goals

--Establishes rationale for use of procedures

​

Examples: Standard Medical Terminology

• “Decrease inflammatory and allergic reactions to environmental allergens.”
• “Improve shoulder range-of-motion and joint tracking in abduction.”
• “Restore sensory function in the affected left leg dermatomes.”
• “Reduce nocturia episodes to 1/night.”
• “Normalize vascular flow and perfusion to extremities.”
• “Increase capacity for psycho-social stress management.”
• “Normalize post-prandial peristaltic activity.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Practitioner’s Treatment Principles and Goals

​

Examples: Acupuncture and Oriental Medicine

• “Nourish Heart Fire.”
• “Tonify Dampness in Middle Jiao.”
• “Stagnate Liver and Gallbladder qi.”
• “Dispel everything.”
• This part is easy, no?

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Quantifiable Benchmarks and Outcomes

​

• Vital signs
• Mini-mental status exam or other standard tests of cognitive function, memory, etc.
• Reflexes (0-4 scale)
• Sensory function (2-point discrimination)
• Tenderness (1-4 scale)
• Joint range-of-motion (degrees, measurement method)
• Strength (0-5 scale, dynamometer readings)
• Algometer readings (painful pressure tolerance)
• Measurements (limb girth, size of swellings, skin lesions, etc.)
• Values from labs, imaging and other special studies

​

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Qualitative Objective Findings and Outcomes

​

• Qualities of:
• Heart, lung, abdominal sounds
• Tongue and pulse
• Affect, demeanor
• Speech, cooperativeness, alertness, cognitive function, memory, orientation
• Skin, hair, nails: texture, turgor, temperature, vascularization, etc.
• Pain absence/presence and severity upon provocative testing
• Findings of special examinations and tests. Examples:
• “Decreased acromio-clavicular joint hypermobility to passive stress.”
• “Increased odor identification to olfactory testing.”
• “Bilaterally-symmetrical hearing to Weber’s and Rinne’s tests.”

​

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Health Education

​

• Document your explanations and their understanding of their condition. Ex:
• “I explained my impressions to the patient in layperson’s terms, as well as the signs, symptoms and risks of radiculopathy including progressive and irreversible nerve damage, pain, numbness, and disability, and that acupuncture alone may be insufficient to prevent such developments, and further evaluation and treatment may be required. The patient expressed a good understanding of my explanation, and agreed to promptly inform all attending medical providers of any worsening of symptoms including pain, numbness, weakness, and loss of function. All the patient's questions in this regard were answered to their satisfaction.”

​

86

Plan: More Essential Contents

​

• Special diagnostic studies advised or ordered
• Referrals for further evaluation and treatment
• Treatment, diagnostic studies that have been deferred or declined, as well why (e.g. “per patient preference,” “pending further eval” etc.)
• Frequency, duration, and re-evaluation timeline.
• Example: “6-8 visits over 3-4 weeks, followed by re-evaluation.”
• Home/self-care, ergonomic and lifestyle modifications, etc.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting In-office Procedures

​

• Patient’s room (as applicable) and body position during treatment
• Body systems, regions, tissues, locations treated
• Guidelines, standards or protocols followed (e.g. “per Clean Needle Technique Guidelines”)
• Therapeutic rationales and goals of procedures Examples:
• “Gua sha was applied to increase elasticity and vascular flow in the affected L hip extensors.”
• “Acupuncture was applied to decrease spinal pain and psychosocial stress.”
• “Therapeutic exercises were prescribed to strengthen the core trunk musculature and improve diaphragmatic respiration.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Preparation for Treatment

.

• Patient preparation: should have already been discussed during informed consent, but may be repeated here
• Inquiring and advising patient regarding eating and drinking prior to arriving so as to minimize risk of fainting
• Advising patient not to move while needles are inserted to avoid bending, breaking needle
• Skin preparation: ETOH swab, betadyne, chlorhexadine, etc.
• Patient position on table (or chair)
• Any provision of draping to maintain patient’s comfort and privacy

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Acupuncture Documentation Basics

.

• Needle type: filiform, 7-star, lancet, 3-edged, intradermal
• Locations:
• Classic xue or “points,” and/or anatomical description
• Indicate if located by palpation/tenderness in a region, rather than classic cun measurements or reference anatomical landmarks
• Laterality (unilateral, bilateral)
• Stimulation methods:
• Manual
• Electroacupuncture: device, mode, frequency, calibration of amplitude
• Warming

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Locations with Risk of Organ, Neurovascular Injury

Documentation of Needle Angle, Direction and Length is Critical

​

• Clean Needle Technique Manual, 7th ed.: sets the standard of care for safe needle angle, direction and length for locations with risks of injury to internal organs, brain and spinal cord, major blood vessels and nerves.
• CNT Manual prevails over other sources (textbooks, teachers, colleagues, personal opinions and experience) in malpractice litigation.
• In other words, there is no substitute for reading, knowing, practicing and documenting according to the guidance of the CNT Manual, 7th ed.

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Locations with Risk of Organ, Neurovascular Injury:

Documenting Needle Length is Critical

​

• Specify length of needle used, rather than depth of insertion
• Needles can migrate inwards during treatment up to their handle
• Length of needle indicates maximum possible depth of penetration

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documentation of Needle Angle and Direction

Critical at High-Risk Locations: Torso, Spine, Head

​

• Document measures taken to locate and avoid critical structures, e.g. palpation for arterial pulse, or organ enlargement/displacement, prior to needle insertion
• Angle: document transverse, oblique, or perpendicular
• Direction: any of the following methods of documentation may be used
• By anatomical direction: UB 41 angled in a medial and caudal direction
• By landmarks: UB 41 angled towards the spinous process of T 5
• By “threading”: e.g. UB 41 threaded towards UB 16

93

Locations w/Highest Risk of Pneumothorax

Document needle length, angle

​

• Clean Needle Technique Manual, 7th ed. identifies the following locations as most frequently associated with pneumothorax injury:
• Jianjing (GB 21; 30%)
• Feishu (BL 13; 15%)
• Quepen (ST 12; 10%), and Tiantu (Ren 22; 10%)
• Infrequent events occurred at Ganshu (BL 18), Jiuwei (Ren 15), Juque (Ren 14), Jianzhen (SI9), Quyuan (SI 13), and Dingchuan (EX-B1)
• Peuker & Grönemeyer identify risk points ST 11 (Qishe) and ST 12 (Quepen), LU 2 (Yunmen), ST 13 (Qihu), KI 27 (KI 22-27), and ST 12-18.

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Locations with Highest Risk of Vascular Injury

Critical to document palpation & needle angle, length to avoid bleeds

​

• Clean Needle Technique Manual identifies the following locations over vessels:
• Lung 9 radial artery
• Heart 7 ulnar artery
• Stomach 9: carotid artery
• Stomach 12: supraclavicular artery and vein
• Stomach 13: subclavian artery
• Stomach 42: dorsalis pedis artery
• Spleen 11, Liver 12: femoral artery and vein
• Heart 1: axillary artery
• Bladder 40: popliteal artery

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Other Critical Acupuncture Documentation

​

• Withdrawal of needles and needle count--including needles discarded due to failed insertion attempts or improper placement, or otherwise not retained for duration of visit
• If needles are embedded for retention after patient leaves clinic (not recommended, a high-risk procedure), any patient education and measures taken to avoid injury
• Any post-needling measures: applying pressure for hemostasis, cleaning/bandaging skin, etc.

96

Documenting Manual & Exercise Therapies

​

• Both:
• Tissues treated: joints, muscles, tendons, ligaments
• Duration of treatment in office
• Manual: techniques, depth, direction of force
• Exercise:
• Demonstration? Instruction? Supervised performance?
• Home program: handouts/videos?
• Recommended repetitions, frequency, duration

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Heat and Cold Therapies

Burns are the most common source of lawsuits!

​

• Document:
• Informed consent regarding risk of burns!
• Protective measures taken to prevent burns
• Moxa shields
• Position, distance, and duration of heat lamp
• Towels placed between hot/cold pack and skin
• Verifying temperature with your hand before leaving room
• Checking in on patient, etc
• Request to patient to alert staff to any perceived overheating/freezing
• Your observations of the condition of the skin after treatment

​

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Patient Referrals and Special Studies

​

• Referrals and orders for labs, imaging, other special studies
• To which medical providers, labs? Which studies?
• What time-frame, level of urgency?
• How provided: business cards, faxed, emailed, phone, etc.
• Whether patient expressed a good understanding of the need for referral/studies, and intention to follow up in a timely fashion
• In the event of non-compliance, document any further conversations, advice, measures taken etc. to seek compliance, refer out, discharge, etc.
• Document verbal/in-person education, advice, questions addressed
• Document any materials provided: handouts, books, CDs/DVDs, links to audio/video or web-based resources, etc.

99

Document Health Education, Advice

​

• Document verbal/in-person patient education, advice, questions and concerns addressed
• Document any materials provided: handouts, books, CDs/DVDs, links to audio/video or web-based resources, etc.
• Document any recommendations regarding lifestyle, habits, ergonomics, exercise, group classes, diet, sleep, stress management, etc.

100

Discharge Report

A final SOAP note that also summarizes:

​

• Reasons for discharge, such as
• Condition resolved
• Treatment not showing efficacy
• Further treatment contraindicated
• Patient does not want to or is not able to continue
• Any additional plan
• Referral for further evaluation/treatment
• Recommendations for
• Home/self-care
• Follow-up timelines and process
• Symptoms/signs indicating need to return for further care

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document for All Procedures

.

• Use of gloves when examining or treating near the groin, pelvic floor, genital or breast areas (e.g. CV 1)
• Document if you stay with patient in the room throughout the visit
• If patient is left alone in a room, document the provision of a call bell or other method of calling for help, as well as your response if called
• Note changes in symptoms, status observed during or at the conclusion of procedure

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Herb/Supplement/Product Rx

​

• Inquiry into current allergies, supplements and medications
• Informed consent regarding risks and side-effects
• Education and recommendations to avoid/manage potential allergic, adverse, and herb-drug interactions
• Dosages, frequency, administration, course of treatment
• Name and vendor/source of prescription/product
• Therapeutic rationale and goals
• Options for purchase (should include multiple outside vendors to avoid appearance of unnecessary prescription and self-dealing)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Avoiding Appearance of Self-Dealing/Unnecessary Rx

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• Sample language to include in handout and reference in documentation:
• “Jane/Joe Doe, L.Ac. does not independently sell nutritional supplements or other products. Our provision of nutritional supplements and other products is a courtesy to patients receiving our care. You are free to acquire nutritional supplements and other products that we prescribe or recommend from any source of your choosing, and are not required to use nutritional supplements and products provided by this office. Please let us know if you would like referral to another vendor for our recommended supplements.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Document Post-Tx Status, Management

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• The patient’s general status: Well-appearing? Alert and oriented x 3? Distressed?
• Symptom aggravation or relief? Any new pains, problems, etc.?
• Any difficulty with breathing? Any signs or symptoms that could signal adverse effect of treatment?
• Any dizziness, vertigo, or other problem interfering with upright posture, gait, coordination, etc. that elevates risks of slips and falls?
• Post-treatment measures taken to assess/manage any perceived adverse effects
• Patient education regarding self-care, activity restrictions, predicted side-effects
• Questions or complaints, or lack thereof
• Patient agreement to contact your clinic for guidance or seek physician care in the event of any perceived adverse effects, or other questions or concerns

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Example of Documenting Post-Tx Status

(No adverse effects)

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“All procedures were well-tolerated and the patient denied increased pain, dizziness, light- headedness, malaise or shortness of breath at the conclusion of treatment. The patient was able to sit up and walk without assistance or loss of balance. I reminded and educated the patient regarding known side-effects of acupuncture, including soreness, pain and bruising, difficulty breathing, light-headedness and generalized fatigue, as well as appropriate reporting and management should such side-effects occur. The patient denied exacerbation of symptoms, and agreed to contact my office for instruction in the event of increased pain or other difficulties in the symptomatic or treatment regions or elsewhere, or other new symptoms following acupuncture treatment. The patient departed alert and oriented x 3.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Patient Report of Adverse Effects

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• Note the symptoms or complaint
• When patient noted the suspected adverse effect(s)
• What the patient attributes the adverse effects to
• Any possible other confounding or contributory factors
• What steps they have taken or intend to take to manage it
• Current status: resolved? Improving? Stable? Worsening?
• What they are requesting

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Management of Adverse Effects

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• Your investigation into the complaint
• Your explanation to the patient of what you think happened and what you attribute their symptoms to
• What remedial steps you have taken, or intend to take
• Recommendations regarding self-care, management
• Patient’s understanding of/agreement with your management plan
• Current status: resolved? Improving? Stable? Worsening?
• Any follow-up, referrals, plan, timeline

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documenting Post-Tx Status

Example: Post-needling Soreness

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“The patient reported local soreness at site of needling, but denied exacerbation of symptoms, or any new pain or other symptoms. I examined the area and no bruising, bleeding or swelling were notable. I reminded the patient that local soreness is a known and generally self-limiting risk of procedures involving needles, and I advised home application of moist heat and light massage to the area should pain persist, and to contact my office for instruction in the event of increased pain in the symptomatic or treatment regions or elsewhere, or other new symptoms following acupuncture treatment. The patient expressed a good understanding of my recommendations in this regard.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Add to, But Do Not Tamper with Records!

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• In the event of a complaint or suit, our risk management strategies are only as effective as credible documentation of them
• Never alter or back-date with an intent to deceive or conceal!
• If using paper records, draw only a single line through text that needs to be corrected, so that your original writing is still legible
• If we must correct a record, date and sign our notation as a later addition
• Tamper-proof systems (such as digitally-signed electronic records) eliminate even the possibility, suspicion or appearance that our records might have been altered retroactively

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Checklists, Templates, Narratives, Graphics, etc.

Pros and Cons

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• Checklists are efficient, but can lack flexibility and appear perfunctory
• Templates that can be modified are almost as efficient, but allow for editing for the specifics of the encounter
• “Copy and paste” without edits risks appearance of rote treatment/ documentation, inaccuracy, or falsification: Red Flag for insurance fraud!
• Narrative voice is preferable
• Abbreviations: use only common/standard, avoid personal/made-up
• I am deliberately not providing a list--abbreviations are a poor habit
• Graphics, charts, photos, audio/video recordings, etc. complement documentation

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Consistent Documentation of Critical Findings and Procedures

Use of standardized templates reduces omissions--critical for:

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• Review of prior records, labs, studies, etc.
• Informed consent
• Treatment goals and plans
• Compliance with CNT and other standards
• Procedures performed without complications
• Time spent on history, physical exam and treatment
• Condition in which patient left the office

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Complete and Sign-off on Date-of-Service!

• Every page should have your time/date stamp and signatures
• Memory and accuracy decline rapidly with each hour and day
• The farther the signature date from the date-of-service, the less professional and credible the record, if contested
• Medical records signed only after a complaint has been received strongly raise suspicion of falsification to cover up malpractice!
• If charting is not your forte, seek help!
• Acupuncture or pre-med students can be eager, helpful scribes
• Second pair of eyes/ears can result in a more accurate and complete record, with less practitioner time and effort
• Patients may appreciate the additional presence of a scribe/chaperone

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Paper vs. Electronic Systems

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• Paper records are rapidly becoming obsolete and viewed as sub-standard
• Electronic health records systems are proliferating and becoming more user-friendly, flexible and lower-cost in this highly-competitive market
• No advantages and many disadvantages to off-line systems
• May as well go directly to cloud-based systems
• Hybrid paper/hard-drive/on-line systems are possible with creativity
• For a more complete discussion of this complex topic, please visit:
• https://docs.google.com/document/d/1aR_QPTxYU4rCZxORpfP9o_SyECb7sDP8sQvdVKZlQxs/edit?usp=sharing

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

All insurers want to see “medical necessity”

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• “Medical necessity” (MN) is usually established by ICD-10 diagnosis
• ICD-10 diagnosis should match history, exam, study results, etc.
• I.e., don’t code M54.4 low back pain, when your documented history and exam findings are all about a cold/flu. Red flag for insurance fraud!
• Don’t omit history and exam procedures that you performed just to avoid the appearance of treating something other than your ICD-10 code.
• Documentation of functional disabilities supports MN
• AOM patterns alone do not (yet) establish MN
• (stay tuned for ICD-11)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Insurers want to see therapeutic rationale for treatment

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• What are the treatment goals and objectives of the procedure? E.g.:
• “Acupuncture was performed to reduce pain, relax muscle tension, and alleviate associated insomnia and anxiety.”
• “Myofascial release was performed to reduce trigger points and adhesions, and normalize vascular flow in the affected region.”
• Why this treatment, and not another?
• Consider including supportive research in any appeals, if your initial request for treatment authorization is denied

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

All insurers also want to see (cont.):

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• Outcomes obtained for procedures: what change in symptoms, physical exam findings were noted after treatment?
• Example: “patient reported decreased abdominal pain, distention and borborygmus after treatment.”
• Time spent performing evaluation/management and time-segmented procedures (incl. 97811, 97814, 97140, 97110, etc.).
• Example: “A total of 25 minutes was spent face-to-face performing acupuncture.”

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

All Insurance:

Elective Care is Not Generally Reimbursable

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• Absence of medical diagnosis/necessity. Examples:
• Facial rejuvenation
• Performance enhancement
• Unspecified/sub-clinical conditions, e.g. non-specific malaise
• Proposed treatment not approved/considered elective for diagnosis
• Example: Manual therapy for morbid obesity

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Managed Care Insurance:

HMO, Auto med-pay, Workers’ Compensation,

Any insurance that requires authorization before treatment

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• Referring physicians, nurse case managers, and utilization review panels want documentation re the diagnosis for which acupuncture was prescribed and authorized (in standard medical ICD-10 terms):
• Baseline measures, lab values of pathology and functional impairments
• Prior to re-authorization of a subsequent course of treatment:
• Measurable progress has occurred over a prior course of treatment
• A functional disability still exists, and requires more treatment

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Managed Care Insurance:

Maintenance Care May Not be Reimbursable

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• Maintenance care: on-going treatment provided without the patient getting better or recovering self-management, functional capacity
• Exceptions may be made on an appeal basis where:
• Other treatments have failed, are not available, or contraindicated
• The condition is:
• Considered incurable (e.g. palliative/hospice care)
• Not expected to improve (e.g. permanent disability has been established through Workers Compensation, Disability Insurance, Social Security, etc.)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documentation to Support Use of Time-Segmented Codes

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• Additional 15 (8+) minutes of acupuncture (97811, 97813) requires performance of, and a rationale for:
• Insertion of each additional “set” of needles (???)
• “Change of position” (???) (Limb? Axial body?)
• Document the rationale/necessity for the additional 15 minutes…
• Treatment of additional diagnosis?
• Different techniques to treat different aspects of same condition?
• E.G. lancet to reduce blood stagnation, followed by trigger needling to reduce myofascial trigger points, followed by electro-acupuncture for pain control
• Same principle applies for additional 15 (8+) minutes of manual therapy (97140), therapeutic exercise (97110), etc.: document your rationale

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Red Flags that can Trigger an Insurer to Audit Records

Routine and pervasive use across most or all claims:

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• Evaluation and Management (E&M) codes 9920x and 9921x at every visit.
• Use of 99205/15 (Highly Complex) E&M, which is reserved for urgent or life-threatening conditions that would be seen in ER or hospital.
• Routine use of multiple time-segmented codes (97811, 97814, 97140) that add up to appointment lengths in excess of 1 hour
• Prolonged and regular (e.g. weekly) treatment for the same condition without any re-evaluation, change of diagnosis or treatment, or treatment hiatus
• Particularly for diagnoses that are non-specific, innocuous, e.g.
• M54.5 low back pain
• J30.9 unspecified allergic rhinitis
• Mis-matches: diagnoses, treatment codes, demographics (e.g. billing tx of prostate disorder for a female)
• Does the time you are billing match professional standards (i.e., why do you need 5 x 15-minute segments of acupuncture to treat allergies, when your competitors in the same insurance network only need 1-2?)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

What Happens in an Insurance Audit?

Insurers can and will do any/all of the following:

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• Request any/all records of dates-of-service for which you have billed them
• Make unannounced visits to your clinic to review your records
• Analyze a subset of claims and records, and apply their conclusions to all claims you have submitted to them ever
• Contact patients, interview them regarding your diagnosis and treatment, and advise them to stop seeing you for treatment during the audit
• Suspend your listing or terminate your status on their panel (i.e. no new referrals)
• File complaints to regulatory boards, particularly if you obstruct or fail to cooperate with an audit. (Boards may investigate at your expense, and suspend/revoke licenses)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Insurers may demand return of payments made when:

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• Records are identical/near-identical across multiple visits and/or among multiple patients.
• Records appear cursory: checked boxes, vague, lacking clinically-significant detail, on-going treatment without any plan or re-evaluation timeline/measures.
• Records appear de-personalized, erroneous or inconsistent (e.g. patient is described as young/female in one part of record, but ICD-10 code is for elderly/male condition).
• Records lack documentation of time spent on time-segmented procedures, or therapeutic rationale/medical necessity for additional segments.
• Mis-match between ICD-10 and/or CPT codes on the claim, vs. the visit record.
• Records are missing, incomplete, or so disorganized/illegible as to be incomprehensible.
• Records appear altered or amended in an attempt to cover up insurance fraud.
• Records or amendments lack a credible, tamper-proof signature, time/date stamp.

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Potential Consequences of an Audit

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• Insurers can demand repayment of all payments they have made to you
• Courts can order repayment and garnish future earnings
• Insurers can terminate your network status, or place it on probation
• You may be dropped from other networks, and never be able to bill insurance again
• You may not be able to renew your malpractice insurance, hospital privileges, license
• Insurers and patients can file complaints with licensing boards, triggering investigation (at your expense), possibly leading to probation, suspension, revocation of your license
• Schools/agencies may terminate your status as an instructor/CEU provider
• Felony charges: criminal prosecution: trials, fines, jail time

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Responding to an Insurer’s Records Request

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• Comply promptly: turn over full and complete records, unaltered and as requested, without protest. A request for a single record may go nowhere
• Do not discuss audits with your patients, or attempt to influence or persuade them to testify on your behalf
• In the event of a large-scale audit/request for records, consider retaining an attorney who specializes in medicine and insurance to represent you
• Start planning for a cash-only practice, or a new career
• Work hard, pray, save money--I wish you well!

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Documentation of Evaluation & Management

When using E&M Codes to Bill Insurance

(992xx series)

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Example: “A total of 30 minutes was spent face-to-face evaluating the patient’s case including physical examination and baseline objective measures of functional status, records review, medical decision-making, coordination of care, and health education regarding diagnosis, prognosis, and treatment options, including side-effects, risks, and costs of acupuncture modalities.”

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★ This is a conclusion or summary which needs to be supported by and consistent with, and not a substitute for your prior documentation of your history, physical exam, assessment and treatment planning. ★

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Ownership of Medical Records: Joint Custody

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• Charts are the property of:
• Ourselves, as the professional author
• Any medical office that we work in or rent space from
• Patients, for whom we are serving as records custodian
• We are entitled to keep a copy, but do not destroy or remove originals from a medical office without written consent

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Storing and Disposal of Records

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• Charts must be maintained for a minimum of 7 years since the last date of patient contact, including phone consults
• For minors, until 7 years after their 18th birthday, e.g. age 25
• Store in a secure, HIPAA-compliant facility
• (Our attics and basements probably don’t qualify)
• Shred in office, or at a reputable, HIPAA-compliant facility (retain a receipt and documentation of shredding)

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Authorized Records Requests Must Be Honored

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• Records may be requested in full at any time by any patient, or by their authorized representatives:
• Their health insurers
• Other medical professionals
• Their attorney(s)
• The Acupuncture Board
• For minors/mentally incompetent: their parents/guardian
• The requestor will typically provide:
• A specific a timeframe, as well as penalties for non-compliance
• Signed authorization from the patient

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Responding to Authorized Records Requests

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• Check to verify your patient has authorized records release in writing
• Did the patient specify any restrictions? E.g. everything except drug use, STD history, etc.
• To document HIPAA compliance, keep a copy of patient’s written authorization to release their records in their chart
• A request without written patient authorization should never be honored
• (Sneaky attorneys can try to scare you into releasing records without authorization or payment)
• You may charge a “reasonable’ fee ($15-20) for records reproduction

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Best Practice: Do Not Send Records out of Clinic

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• You are liable if you fax, email or postal mail records to a wrong address--HIPAA violation
• The requester can misplace them and ask you to send them again--a nuisance
• The requester can make an appointment to bring a scanner, or pick them up
• They don’t like to do this, but they cannot force or require you to export records
• If they really want/need the records, stand your ground, and they will send someone to pick them up, along with a signed patient authorization and a check for you. If they don’t, you can ignore their threats.
• The patient can pick them up themselves, of course

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Integrative Acupuncture Orthopedics Program ☯ Medical Documentation and Report-Writing

Patient Release and Records Transfer

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• Best practices when terminating patient relationships for any reason (selling/closing practice, discharging patient, etc.):
• Inform the patient of the last date you will be available for appointments or distance consultations for their care, > 15 days from the date of the communication
• Inform the patient of how they may obtain their medical records
• Or, send patient a copy of records (certified mail)
• Providing complete records removes any legitimate grounds the patient or their representatives might have to arrive in person at your clinic--useful if in the event of harassments, threats, disruptive behavior, etc.

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To Further Hone Skills in D&R:

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• Request, read, study, emulate other medical provider’s reports
• Textbooks, on-line resources? Very little for L.Ac.s...
• Solicit supervisor/peer review
• Write and hone your own templates
• Volunteer/apprentice as a scribe for an L.Ac. or other medical provider whose clinical practice and D&R you like: a great way to simultaneously learn clinical and D&R skills!
• If you’re a student, you may be able to get externship credit!

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Thank you for your attention!

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For more education in Practice and Risk Management, and Integrative Acupuncture Orthopedics, we invite you to consider our:

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Live Classes and Webinars

Distance-learning/Self-study Courses

Interactive E-books

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Contact: info@aomprofessional.com or 1-800-499-1438

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