Treatment Records

Careful record-keeping of treatment is equally important. Complete records must be maintained of all therapeutic interventions - so that types of medication, doses, results and quantities prescribed can be visually tracked for each patient visit. A typical such record is presented in Figure 1. Similarly, visual tracking of the patients responses to treatment is very important. Figure 2 presents a typical form for following the patients range of motion. Tracking progress not only provides an objective means of determining the impact of treatment, but also in itself becomes a powerful therapeutic tool. Patients are highly motivated from participating in compiling this record of their own progress. Relatedly, involving the patient in keeping a record of their medication use and physical therapy is also very motivating and empowering. It provides a means for the patient to be in charge of their own treatment, which is psychologically very important. Figure 3 is a typical form for record-keeping by the patient. It also provides the physician with a valuable means of confirming patient compliance and for the quick detection of excessive medication usage. Figure 4 is a typical form for tracking physical  therapy for pain patients who suffer from orthopedic conditions. Its advantages are similar to form 3.  Significantly, with the increasing availability of computerized record keeping, it will soon be possible for the physician to automatically track patient treatment and progress. The entry of prescriptions in the computer record will immediately provide both rates of total and averages use of medication. In the interim, record keeping by hand will clearly confirm to the patient the realities of their treatment and medication use, and unarguably confirm the careful attentions of their physician to the course of their care.  In itself this is an important treatment tool.  With these techniques, there is little possibility of loss of control, excessive utilization, or injudiciousness in prescription, in the course of treatment of chronic or acute pain.