Basic Routine Office Visit Documentation

Minimal Documentation is Basic, Enhanced Documentation is Necessary

While states require minimum documentation requirements for chiropractors, many states require chiropractic-specific details. While it is not recommended that you only do the minimum to scrape by, there might be times when you only need to document to the level of meeting the state requirement. Enhanced documentation is recommended for the level of care you desire to provide to your patients. Better documentation means better patient care and better patient outcomes.

Documentation of Routine Chiropractic Office Visit

In your chiropractic practice, you must attain state specific minimum documentation requirements or greater by establishing standards for documentation defining your policy requirements and your standard operating procedure (SOP). These will include an explanation of the use of your patient’s subjective data, the provider’s objective findings, the assessment, and the treatment rendered.

Back to: Documenting Routine Office Visits