We all have to perform evaluations on patients. Most of us don't like doing it – exams take time, and worse it takes even more time after the evaluation to put together a narrative summary of the findings.Sometimes, this process becomes downright tedious. I spend more than a few hours every week just sitting at my desk doing reports. However, this is the standard of care for all healthcare practitioners. Appropriate, complete and accurate documentation is a necessary part of being in practice today.
Proper documentation involves a good case history including current symptom history, past history, family history, etc. Discussion of the presenting compliant follows the OPQRST format (Onset, Provocating factors, Quality of pain, Radiation of pain, Severity of pain, and Timing of pain). Objective findings include palpation findings, motion palpation goading, and orthopedic and neurologic testing. Obtaining and reviewing any relevant diagnostic or imaging studies is also important. Finally, all of this information is assimilated to provide a diagnostic impression. Based on the diagnostic impression, a care plan is then outlined.
During the patient questioning and objective testing parts of the evaluation, we are usually looking for positive responses. A positive SLR with pain down the back of the leg may suggest sciatica. Braggards test reproducing this pain then helps to nail down that diagnosis – reproduction of pain down the sciatic helps isolate the problem. But if Braggards test does not reproduce traction pain down the sciatic, then you need to look at other possibilities including hamstring spasm or pelvic dysfunction.
In the above example, Braggards test is a pertinent negative. Pertinent negatives are negative findings that help you rule out suspected problems. They also indicate that a thorough and complete examination and history were performed. Pertinent negatives will vary with each patient interaction, and in many cases, they are just as significant as positive orthopedic findings.
If a patient presents with back pain, the questions in the interview are important. Does the pain radiate? Is there any loss of bowel or bladder function? Is there numbness or paresthesia into the legs? A positive finding warrants further investigation – in the case of loss of bowel or bladder function, you must suspect cauda equina issues and refer for orthopedic intervention. But when the patient denies these issues, the indication is to look for other contributing factors – joint dysfunction, muscle spasm, etc.
Pertinent negatives are just as clinically important as any other exam finding and should be documented. With care, there should (hopefully) be more negative findings on re-evaluation. If there is a new injury or change in status, you may have new positive findings – but you cannot make the comparison of a new positive finding if you did not previously document the negative. Such notes are invaluable when documenting your patients' complaints and the extent of the irritation. These extra notes help document the severity of the patients' complaints and show the progressive response to care.
This extra documentation can also help make the difference if you must justify your diagnosis to an insurer or third party. As my instructor in diagnosis taught – you should have at least three positive orthopedic indicators before confirming a musculoskeletal diagnosis. Basing a diagnosis or treatment plan on the finding of one screening maneuver is below the standard of care for any practitioner. Negative findings are clinically significant and should be properly documented. There is no quick shortcut in a good examination - take the extra few seconds to document your negative findings along with the positive.
Click here for more information about Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT.