Initial Visit - Quality and Character of Symptoms/Problems

This item is very important. We need to know what kind of pain the patient is experiencing, how long they've had it, and whether the pain radiates.

Example: Patient complains of sharp stabbing pain that is rated as an 8 on a scale of 1 to 10.

Scales

While a pain scale is not required, it is an easy way to gauge progress. The scale you use is up to you, but ensure you explain the scale in your documentation.

Example: If the patient in our example returns after 3 weeks of treatment and reports pain at 4, progress is demonstrated.

Abbreviations

If you use abbreviations in your documentation, submit a key of the abbreviations every time you submit documentation. Without the key, your meaning will be unclear when the documentation is reviewed.