Subsequent Visit

You must document the following for subsequent visits. The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination.

• History
  • Review of chief complaint
  • Changes since last visit
  • System review if relevant
• Physical exam
  • Exam of area of spine involved in diagnosis
  • Assessment of change in condition since last visit
  • Evaluation of treatment effectiveness
• Documentation of treatment given on day of visit
• Any changes in treatment plan