The Goal of a Masterful Treatment Plan is Restoration of Your Patient to Full Functional Status or Pre-presenting Condition
This goal must be clearly identified in your documentation in order to adhere to Medicare’s very specific guidelines. Utilizing Medicare standards in all documentation, because they are the most stringent, delivers a uniformity of care and documentation beneficial to your patients and your practice and includes a complete treatment plan as part of the initial Evaluation and Management (E/M) documentation.
Chiropractic Documentation Requires These Components for a Masterful Treatment Plan
The treatment plan mastery begins with the doctor’s decision for treatment as a result of the evaluation and is documented from the beginning of the presenting episode and updated at re-evaluations or in light of a new presenting condition.
Medicare Treatment Plan Requirements Include:
- A Record of the Plan’s Start Date
- Documentation of Recommended Levels of Care (Duration and Frequency of Visits)
- A Record of Specific and Functional Goals
- Documentation of Evaluation of Treatment Effectiveness (OATS – Outcome Assessment Tools is Recommended)
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