Summary
In the Documentation Requirements module, we covered the following topics:
- Documents and forms
- Initial visit
- History
- Symptoms prompting visit
- Family history, if relevant
- Past health history
- Mechanism of trauma
- Quality and character of symptoms/problems
- Onset, duration, intensity, frequency, location,
radiation of symptoms
- Aggravating or relieving factors
- Prior interventions, treatments, medications,
secondary complaints
- Description of present illness
- Evaluation of musculoskeletal/nervous system through
physical exam
- Diagnosis
- Supporting terms for primary diagnosis
- Documenting level of subluxation
- Billing for appropriate level of service
- Treatment plan
- Recommended level of care
- Specific treatment goals
- Objective measures to evaluate treatment effectiveness
- Date of initial treatment or date of exacerbation
or reinjury of the existing condition
- Subsequent visit
- 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
- Signature requirements
Remember: Clearly address all the documentation requirements found
in the policy. If something in the policy is not addressed or not applicable,
indicate so. Treatment goals should be specific and measurable.