Investigating the Review of Systems

Other Signs and Symptoms

Because chiropractors are naturally focused on the spine, it is not uncommon for other body systems to get overlooked. Or more commonly, other systems are examined but not documented because the findings do not seem relevant. Often, as chiropractors, we may be the only healthcare provider a patient has seen in quite some time. It is important to be on the lookout for signs and symptoms that may be ominous and require further evaluation and management by another provider. Just because we may not have the ability or interest to treat a certain condition or disorder, it does not absolve us of our duty to do no harm and provide excellent patient care and service

A proper Evaluation and Management service should include a review of the relevant body systems that could affect the patient’s care outcome or current complaint. This can help identify complicating factors or contraindications for the patient’s treatment.

A Review of Systems is simply a review of the systems related to the patient’s chief complaint. It is one element of the patient’s history. This process must be taken seriously and given the time necessary to uncover any underlying problems that may be associated with the presenting complaint. Further, other unassociated complaints could also be uncovered. Clues are typically present in the oral or written history, and the Review of Systems is a good place to start. When the doctor starts asking more questions or prodding for further explanations, this may lead to investigations that uncover uncontrolled blood pressure, mental health disorders, diabetes, and thyroid disorders as just a few examples.

But it’s not enough just to have the patient fill out the intake paperwork with the review of systems on it. It must be discussed with the patient and comments noted during the consultation. This can be done by either annotating the patient’s intake paperwork and adding your signature or by making notes in the electronic record within the initial visit note.

Review of System Elements to Consider:

• Is the noted condition ongoing, past, previously resolved, or current?
• Is another provider managing this system?
• Are these factors contributing to the patient’s condition?
• Are these factors a cause of the patient’s condition
• Are these findings indicative of a red flag that would require more immediate attention?
• Does the patient have a yet unrecognized or poorly managed condition?

Additional Benefits of the Review of Systems

Because the Review of Systems is so important in the care of the patient, it is important to take the time to get all the details and make sure that the information gets properly documented in the patient record. In addition to assuring the patient is well taken care of, a beneficial secondary outcome is to build a relationship with the patient’s primary care provider. They will likely appreciate your evaluation and referral for appropriate management of conditions that are out of your scope of practice. In addition to excellent patient care and practice building, a third benefit from performing a thorough Review of Systems during the health history is the avoidance of mismanagement or deleterious management of the presenting complaint that could result in legal action and/or harm to the patient. Many legal cases brought against chiropractors could be avoided if more attention were paid to seemingly unrelated findings, and more questions were asked before commencing care.

A thorough discussion of the Review of Systems can be performed relatively quickly. They must be documented and can provide numerous benefits for both the patient and the provider. Most of our diagnosis and management decisions are gleaned from and built from this important part of the patient care process.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.