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Documentation

Learn how to tell your patients story

Telling a good story through chiropractic documentation of each patient visit is essential. Whether recording important, clinically appropriate data to meet minimum chiropractic documentation requirements or clarifying the medical necessity of the treatment for a payer or auditor, your notes have the power to make or break you.

Documenting Chiropractic Medical Necessity

Medical Necessity is only a concern with a third-party payer, like Medicare. A large differentiator between medically necessary and clinically appropriate care is if a functional deficit exists and can be resolved through proper treatment.

Documenting Chiropractic Patient Intake and History

Taking a history on a chiropractic patient is a required component of the Evaluation and Management service (E/M) that will establish the episode of care, whether it is a new patient, new condition, or new episodes of care.

Documentation FAQ

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Documenting Treatment Plan

Understanding Requirements of the Chiropractic Treatment Plan
Your treatment plan is required for every episode of active care with your patient.

Documenting Routine Office Visits

The majority of patient charting in a chiropractic setting include routine daily visits during active, medically necessary care visits.

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