COVID-19 Chiropractic Documentation

COVID-19 Chiropractic Documentation—Creating a TPP

In the era of COVID-19, chiropractic practices are facing many challenges. The rapid changes to practice guidelines, restrictions, and recommendations can be overwhelming and present a new area of personal and professional vulnerability. 

This article presents a basic outline for the creation of a Transmission Prevention Plan (TPP) as a formal epidemic response plan for your office. If an event like COVID-19 can happen once, it can happen again. Whether it’s a local outbreak or a global pandemic, it’s important to be prepared and document your efforts to mitigate risk on multiple fronts.

The outline offered here is, by no means, complete or perfect. It is merely a starting point. Your plan must be customized to fit the specific needs of your office, as well as your state and local regulations. If Federal regulations pertaining to this issue expand to include chiropractic facilities, it will also need to be modified to meet those requirements.

The general TPP outline is as follows:

Transmission Prevention Plan (TPP)
Practice Name:
Practice Address:
Document Creation Date: 
  (1) Definition and purpose. 
  (2) Written procedures and standards. 
        a. Cleaning procedures
              i. Products. 
             ii. Frequency. 
            iii. Disposal. 
            iv. Instructions.
                    1. General Procedures.
                    2. Restrooms.
                    3. Other patient areas/rooms.
                    4. Other employee-only areas/rooms.
                    5. Equipment.
                    6. Fixtures/Furniture.
                    7. Other. 
         b. Hand Hygiene.
         c. Personal Protective Equipment (PPE). 
         d. Procedural changes.
               i. Patient intake procedures. 
              ii. Employee/patient interactions. 
             iii. Gowns. 
             iv. Laundry.
              v. Adjustment techniques. 
             vi. Examination procedures.
            vii. Laboratory testing.
           viii. Imaging Procedures.
             ix. Therapies and Modalities. 
         e. Temporary Signage.
          f. Employees.
         g. Staff/Employee Health Monitoring.
         h. Staff/Employee Training. 
  (3) Records.
         a. Training records.
         b. Cleaning records.
         c. Daily staff health monitoring records.
       d. Plan Implementation and Change Log (PICL). [This is a log style record of the significant events pertaining to the plan: when and why the plan was put into action, when modifications were made, any deviations that occurred, and when the plan was discontinued. Think of it as progress notes for your office while the TPP is in effect. Additions should be dated and signed.]
     e. Incident Reports (IRs) and the Corrective and Preventive Action (CAPAs). [Describe how and when these reports will be used and how they will be maintained. Use an IR to describe any critical events that occur. Use a CAPA to describe what has been done to prevent the issue from happening again.] 
  (4) Designated TPP Manager. [Name the person responsible for creating and maintaining the TPP, associated documents, and activities.]
  (5) Annual Review. [Describe how, when, and by whom the plan should be reviewed.]
 (6) Document Maintenance. [Describe where, how long, and in what format these documents should be maintained.]
  (7) Signatures/Dates. [Named reviewers should sign and date the document as indicated.]

As with any other office plan, a TPP will grow and change over time in response to experience and circumstance. When updates or changes occur, a statement of the changes must be created, signed, dated, and permanently attached or stored with the original document. If the plan must be significantly changed or rewritten, a new version of the entire plan document should be created. The new version will supersede its predecessor. It must be clearly identified as a replacement for the original with appropriate dates and signatures, and all versions of the plan must be maintained together. 

Should your TPP be a physical or electronic document?

At this stage, it doesn’t matter. The most important thing is to develop your TPP and put it into practice. A paper manual is a simple way to get started. In the long run, an electronic TPP and electronic versions of the associated records and updates may be easiest to maintain with appropriate electronic signatures and audit trails. 

Why should I bother when a TPP isn’t required?

Chiropractic is not typically a passive form of practice. While we can successfully utilize use tools like telehealth appointments to communicate with our patients, our interactions most typically happen on a personal level—face to face, hand to spine, and so on. It is incumbent upon every member of our profession to take measures to prevent the transmission of potentially harmful communicable diseases through robust hygiene and sanitation practices. Adequate documentation of these practices is critical to demonstrate those efforts, and the TPP can be referenced in your patient notes to document your cleaning procedures.

If it isn’t written down, it didn’t happen. 

In many cases, documentation is more complex than simply writing down a few sentences. Proper documentation usually needs to be legibly noted, signed, dated, maintained, and retrievable. Otherwise, our ability to defend our actions is limited. 

Most often, patients seek chiropractic care because their bodies are injured, sick, or in pain. This means that their systems (including their immune systems) are not functioning at their peaks. It’s our mandate as healthcare providers to do everything in our power to protect them and help them heal. Proper sanitation and hygiene practices are important components this mandate. As a profession, we must be prepared and consistent with our actions. We do not want our offices to be unjustly viewed as vectors of transmission. The creation and implementation of a TPP will provide your practice with a well-considered, documented path forward through this uncertain and stressful period. 

Remember, documentation is not just about getting insurance to pay for patient visits. It’s about protecting you, your practice, your employees, your patients, and our profession as a whole. Over the next few weeks, more information on TPP documentation and tools related to this subject will be posted on the main ChiroLogika website. As we move forward together through COVID-19 and beyond, let’s all be healthy, safe, and united for the future of Chiropractic and for the patients who need us.

Author: Kirstin A. Counts, DC
June 10, 2020
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Reference Note:
The information suggested here is loosely based on information found in the Code of Federal Regulations, or CFR. The complete CFR with updates can be accessed here: 
https://www.ecfr.gov/cgi-bin/ECFR?page=browse&mc=true&SID=3676b23e49b9605f3ef5ed5f80b0395a

​Additional Resources:
https://www.osha.gov/SLTC/covid-19/
https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html
https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/businesses-employers.html
https://www.cdc.gov/coronavirus/2019-ncov/hcp/us-healthcare-facilities.html