Documentation of Modalities and Procedures

Meticulous Detail is Required from Beginning to End

When charting compliant documentation, you and your staff should always have a complete, thorough, compliant final patient note in mind. The doctor, during the examination, follows a ‘walk through’ utilizing an expert knowledge base beginning with the initial evaluation, recommendation of chiropractic care and physical medicine procedures, and the written treatment plan.

Compliant Chiropractic Documentation Includes Modalities, Procedures, and Therapies

In every step, meticulous detail is required, establishing medical necessity for modalities, procedures, and therapies, which promise the desired functional improvement to the patient. Keep the functional deficits and functional goals in mind when you document your patient’s care.

Back to: Documenting Routine Office Visits