• Schneider MP

• Association of Chiropractic Colleges / congresses

Methods: During the Spring of 2003, 38 random patient files were selected. Each file was reviewed by a single reviewer for content, accuracy and compliance to practice guidelines. The individual items reviewed were the patient entrance data form, history, examination, radiography request form, diagnostic impression worksheet, narrative, problem management list, soap documentation, patient care errors, documentation errors and intern remediation necessary.

Results: Incomplete patient entrance data forms were found in 49% of files. Patient histories were either incomplete or inadequate in 94% of files. Examinations performed were either incomplete or inadequate in 23%. Positive examination findings were not verified by clinic faculty in 37%. Diagnostic impression worksheets were either inadequate or incomplete in 84%. Patient narratives were inadequate in 39%. Problem management lists were inadequate in 50%. Daily SOAP documentation was inadequate in 61%. Patient care errors were identified in 21% of files. Significant documentation errors were found in 66%.

Discussion:In general this retrospective review demonstrated a lack of appreciation for acquiring complete information. The data also evidenced a lack of follow-up by the supervising faculty when positive examination findings were recorded by the student intern. Taken together, the incomplete and inadequate information and lack of follow-up may have led to patient care errors. As a result of the file reviews 68% of student interns involved in the care of these patients were referred for remediation. Clinic faculty involved were referred to their respective clinic directors. It is the opinion of the author that this process is integral in developing and maintaining a means of improving the quality of patient care and the documentation of patient files.

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