by Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | 12/21/2017 10:34:14 AM
As we at ChiroCode worked to find an example of the perfect daily treatment visit note, we came across many authoritative sources. For your convenience, we have included them here. The four sources here include Medicare, a chiropractic network, one state board's rules, and one insurance company's requirements. At first glance they may appear to be very different, but, there are many similarities. For the 2018 ChiroCode DeskBook, we considered all these sources and created a SOAP note format that we believe captures all of these requirements so that you can use the same layout for all payers and circumstances. You can read about it in Chapter 4.3 in the 2018 ChiroCode DeskBook.
1. Medicare (proposed as of 9/2017):
Documentation Requirements: Subsequent Visits
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History (an interval history sufficient to support continuing need; document substantive changes)
- Review of chief complaint;
- Changes since last visit;
- System review if relevant.
2. Physical exam (interval; document subsequent changes; a full repeat P.A.R.T. is not expected)
- Exam of area of spine involved in diagnosis;
- Assessment of change in patient condition since last visit;
- Evaluation of treatment effectiveness;
3. Documentation of treatment given on day of visit. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.2.2B)
4. Documentation of how the day’s treatment fits within the plan of care (e.g. “visit 4 of planned 7 treatments”) and any way the treatment plan is being changed.
2. A Large Chiropractic Network:
- Patient identification (name and DOB)
- Date of encounter and visit # in treatment plan (e.g. visit 3 of 8)
- Chief complaint/rationale for visit (NMS condition)
- Updated patient-specific measurable subjective and objective attributes
- Assessment of functional changes (patient specific)
- Current diagnosis
- Procedure specifics (service performed, location, rationale, time)
- Plan (next treatment date, next re-evaluation)
- Provider ID and signature, with date/time stamp
3. Colorado State Board of Chiropractic Examiners, Rule 22
Established Patient Visit:
- Subjective Complaint: The patient’s description of complaints should be recorded at each visit indicating improvement, worsening, or no change.
- Objective Findings: Changes in the clinical signs of a condition should be described by the chiropractor at each visit.
- Assessment or Diagnosis: It is not necessary to update this category at each visit. However, periodic clinical re-evaluations should be performed, specifically documented and recorded in the daily entries. Changes in the patient’s diagnosis should be recorded in the daily entries when clinically indicated. Prognosis and/or outcome expectations should be updated periodically consistent with the clinical presentation.
- Plan of Management: A provisional plan of management should be recorded initially and further entries should be made as this plan is modified and/or as a patient enters a new phase of treatment or has a diagnosis change. Changes in procedures should be documented and based on clinical assessment and reasoning.
- Procedures: Daily recording of procedures performed should include a description of type and location of procedure. Units of time should be recorded when appropriate.
4. Optum, United HealthCare
Daily visit notes:
- A subjective record of the patient complaint i.e., location, quality, and intensity
- Physical findings to support manipulation in a region or segment e.g., regional/segmental asymmetry or misalignment, range of motion abnormality, soft tissue tone and/or tenderness characteristics
- Assessment of change in patient condition, as appropriate
- A record of the specific segments manipulated
So, here you see how there are many definitions of what should be part of a daily note. But that does not mean that you have to come up with multiple formats and change your records for each of these groups. Instead, we recommend using the new SOAP Template which is part of the 2018 ChiroCode DeskBook.
Learn more from Dr. Gwilliam about this topic by joining us March 9 - March 11, 2018 at Mohegan Sun. Dr. Gwilliam's presentation “Learn to Document and Code Like a Medicare Auditor” will be held on Saturday 3/10/18 at 8am. (For complete conference information and schedules, click here.) Join the conversation online by using the hashtag #NYSCA18.
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