chiropractic standard of care leslie m. wise, d.c. professor of clinical sciences sherman college of...

Chiropractic Standard of CareLeslie M. Wise, D.C.Professor of Clinical SciencesSherman College of Straight Chiropractic

Presented to the Palmetto State Chiropractic AssociationAugust 10, 2008

Standard of Care

•The level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances.

Standard of Care

•The minimal level of competency, knowledge, and judgment for which a physician can be held liable and legally accountable in tort law.

Standard of Care

•The standard is determined by the reasonable diligence, skill, competence, and prudence as practiced by minimally competent practitioners in the same area of specialty or general field of practice who have similar facilities, services, equipment and options available to them.

Standard of Care

•The standard of care is generally established through the testimony of experts.

•Exception: res ipse loquitur cases. No expert necessary.

Standard of Care

•Breaching the Standard of Care = Negligence

•Negligence & Injury = a significant part of the formula for establishing malpractice

Standard of Care is derived from:

Scope of Practice (law)

thus location may alter the standard of care

varies from state to

state

What is taught in colleges...

but CCE tries to insure uniformity

varies from college to

college

What is tested...

is created by college experts and field practitioners, so uniformity is by consensus

on NBCE (and state

tests)

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What chiropractors actually practice

How do we know?

NBCE Job Survey, 2005

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Case Law

The verdicts in all previous casesset precedence forstandard of care.

Guidelines and Documents

•CCP Guideline

•Mercy Guidelines

•ICA Clinical Protocols

•State Standard of Care documents

Standard of Care considerations include:

Initial EvaluationInitial Evaluation

history

palpation

range of motion

leg checks

instrumentation

ortho/neuro exams

ImagingImaging

right angle views

area of complaint (?)

CT / MRI referral

Assessment (clinical Assessment (clinical impression or impression or diagnosis)diagnosis)

differential diagnosis

rule out

working diagnosis (subject to change)

Plan of CarePlan of Care

appropriate for diagnosis

individualized for the patient

includes reassessment and “Plan B”

flexible in nature

Informed Consent (risk Informed Consent (risk notification)notification)explanation of procedures

alternate procedures

benefits to be expected

explanation of material risks

offer to answer any questions

notification of freedom to withdraw consent

Clinical ProceduresClinical Procedures

standard procedures (taught in colleges)

evidence-based procedures

notification of experimental procedures

performed with reasonable skill

Documentation

•minimum = S.O.A.P format

•legible

•dated and signed

•document consent

Documentation, cont’d.

•document non-cooperation

•phone call documentation

•outside test results

•concurrent care

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Re-assessment

•do examinations to document progress•document lack of progress•change care plan accordingly

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Referral

•discuss referral with patient•refer to competent providers•explain concurrent care

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Protection for subluxation-based

chiropractors

•Patient education•Notification of scope limitations•Cooperation with other providers•Adherence to a Guidelines document•http://www.ccp-guidelines.org/guideline-2003.pdf•http://www.icabestpractices.org

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Questions / Comments

Lwise@sherman.eduwww.LeslieWiseDC.com