The term “Routine Office Visit” describes treatment visits where the patient is being seen for the execution of the written treatment plan at the beginning of the Episode of Care. The documentation of these visits contains the details of patients’ progress, or lack thereof, as they advance through the stated plan. The record shows the reader the patient’s status at that point within the plan’s goals and time frame. As such, this format is best applied to active treatment, regardless of payer class, rather than documentation of a maintenance or wellness visit.
Most ROV notes begin with the patients’ subjective assessment of their experience since their last visit. It should focus on their progression toward the meaningful-to-patient functional goals set forth at the beginning of the plan. Therefore, it can be risky to allow the patient to sign in and check in at a front desk kiosk where they freely list every current complaint even if new to the episode. This information is better collected by a team member or the doctor to ensure the new information is immediately flagged. It is acceptable to include the patient’s assessment of pain, usually expressed on a scale of 1-10, but it is far more significant to chronicle the return to pre-episode function in this portion of the note. If the patient is being treated for complaints in multiple spinal regions, it’s prudent to assess the functional goals assigned to each region. Note that in this context, “subjective” is different from the “history” collected within the Evaluation and Management (E/M) style visit and has a different purpose in the medical record.
The subjective information collected above provides the practitioner with valuable information to take into the objective portion of the note. As providers evaluate patients objectively, they document the quantitative findings unique to each visit and each spinal region. If the patient is a Medicare patient, although not blatantly required visit to visit, the PART process of documentation provides a simple formula for objectively demonstrating medical necessity. It’s expected that any spinal or extraspinal region being treated will have findings in this section of the note. Additionally, the patient may have asymptomatic areas that are to be addressed as secondary compensations, and these findings are noted here.
If the Subjective and Objective portion of the note are considered inputs for the provider, the assessment portion is the output. Using the information collected in the above sections, providers document the facts learned about patients and their progress. For example, comments should include whether the patient is staying the same, progressing, or regressing for each complaint being addressed. They should also include a nod to what additional treatment is required, if any. If the patient has suffered an exacerbation or other setback, this is the place in the note it can be clarified. Most importantly, the Assessment substantiates the need for the current and future care within this treatment plan.
Although many payers do not expect the diagnosis to be repeated on each daily visit of an episode of care, some want it there and consider the note incomplete if it’s missing. For this reason, many Electronic Health Record (EHR) software programs automatically include the diagnosis. It should be noted, however, that this is not the assessment. The diagnosis should stand alone and carry forward until a more formal re-evaluation is performed to document the update.
In an ROV, the plan is very different from the treatment plan set forth at the beginning of the episode of care. The purpose of this section is to outline the exact treatment performed on the visit. Theoretically, it will follow the original plan, but it may include additions or deletions from the plan based on the provider’s decision making. Documentation of Chiropractic Manipulative Treatment (CMT) should include the segments treated for the active conditions as well as the asymptomatic areas that were addressed as secondary compensations. This ensures that the findings in the Objective section match the treatment provided. Treatment modalities, whether supervised or constant attendance, must be listed along with individual and total time spent. Any counseling, such as dietary and nutritional advice, and/or coordination of care, referrals, or consults to any other providers should be documented here with the rationale relating back to the original plan.
The ROV note follows the form of the traditional SOAP note but must also include details that support the medical necessity of ongoing care. The documentation of each ROV note within the patient’s episode of care supplies the details necessary to weave together the story of the clinical appropriateness and medical necessity of the treatment provided. Make sure your ROV notes are succinct and to the point but packed with the important information necessary to tell the story of your patient’s episode of care.
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