The Doctor’s assessment is the element most frequently missing in routine visit chiropractic documentation. It’s common to use brief comments regarding a patient’s improvement, or lack thereof, but what’s necessary is to clarify the thought process behind the rationale for current and continued care. A well-documented assessment tells the story of the patient’s return…
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This Rapid Tutorial provides a high-level overview of the purpose and intention of this important part of a daily SOAP note. Assessment is not just a restating of the diagnosis. It’s where the doctor explains the patient’s progress or lack thereof. It provides the context for HOW the patient is doing, and WHY s/he may…
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Download Reference Document Medicare publishes helpful documents and alerts to keep providers in the know about important topics. We’ve included the document below that relates specifically to documenting Chiropractic care and medical necessity. This tool relates to the elements of Chiropractic documentation and the rulebook for Medicare policy (The Benefit Policy Manual). CMS Job Aid…
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Download Support Tool For approximately two decades, Chiropractic practice has used PART for objective evaluations of the Vertebral Subluxation Complex. PART can be used in conjunction with the PART Applied to the ROV Objective Documentation webpage or as a stand-alone tool. It deconstructs PART into its components and gives the doctor a selection of options…
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PART and ROV The PART process, an examination method intended to quantify the presence of a subluxation for Medicare, has been used for over two decades. The application of PART, as noted below, is critical in the initial visit of an episode of care to formulate the basis for medical necessity. However, when documenting the…
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Objective ROV The Objective portion of the ROV documentation plays a part in the reasonableness of care and medical necessity. If you consider that the subjective portion of the note offers the patient’s subjective assessment of his/her progress or lack thereof, the objective portion allows the provider to quantify that assessment. Keep the SOAP format…
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