Documenting Medical Necessity – Daily Treatment Notes
After the initial treatment plan and goals are established, the notes required for each daily visit documentation can be brief - provided they identify key components:
- Review of the chief complaint – improvement or regression since last visit
- What was the response to previous care?
- Indicate findings of pre/post adjustment examination
- An assessment of change in the patient’s condition since the last visit
- Evaluation of the effectiveness of the care given
- Details of exactly what treatment is preformed
- Any changes to the plan of care
By utilizing the Medicare model of P.A.R.T. as part of your S.O.A.P., your notes will be standardized and your documentation sufficient for not only Medicare but commercial, workers compensation and personal injury patients.
The S(ubjective) portion of the daily note records the patient’s description of their problem. It should include the current status of the symptoms, an interim history of how the patient has done since their last appointment and how the pain has changed. Document how they are following your recommendations and how their activities of daily living have been affected.
The O(bjective) portion of the daily note should contain the PART documentation – or examination findings.
- P – Pain and Tenderness can be identified using one or more: observation, percussion, palpation, visual analog scale and questionnaire or by asking the patient to grade their pain.
- A – Asymmetry/Misalignment can be identified on a sectional or segmental level by one or more: observation, static and dynamic palpation or diagnostic imaging.
- R – Range of Motion Abnormality can be identified as an increase or decrease in segmental mobility using one or more: observation, motion palpation, stress diagnostic imaging or range of motion measuring devices.
- T – Tissues, Tone Changes can be identify by one or more: observation, palpation, instrumentation or test for length and strength.
Example: Active range of motion measurements in the lumbar region of the spine were observed to be restricted to a marked degree, with pain. Patient stated pain was 7 on the 0 – 10 scale.
The A(ssessment) should monitor the patient’s progress, and record comments concerning outcomes.
Example: Since starting care two weeks ago, the patient has shown a noticeable improvement in both her symptoms and objective findings. Current treatment appears to be effective and no modification of the treatment plan is required at this time.
The P(lan) should identify the treatment done today and to what areas. If the treatment includes physical therapy modalities, record the type, location and timing of therapy. While your full treatment plan addresses the reasoning behind the prescribed care, the daily note must contain specific details about what services were provided.
Example: Patient was adjusted at T8 and T11 with diversified technique. EMS was applied to the thoracic area for 14 minutes set to patient tolerance. Home exercises given to the patient on a previous visit were reviewed to ensure thorough understanding of their importance and to confirm they are being correctly performed.
Your daily notes fill in the details of the visits between your examinations. They also document the exact care given and the progress the patient is making by following the plan you create with each exam. Give careful attention to the details you present to insure that your records provide a clear understanding of your patients care.