assessment – KMC University

Routine Office Visit (ROV) Assessments in Action

Examples of Assessments for Comparison

Daily (A)assessment is a key element that is often missing from ROV documentation. The daily assessment is the provider’s opportunity to provide context to the findings of the visit. What is learned in the Subjective and the Objective portion of the visit is then interpreted and affirmed by the provider to confirm the status and/or progress of the patient. By reading the assessment portion of the note, a third-party observer should be able to follow the story of the patient’s progress through the episode of care

HOW and WHY

It is important to document HOW the patient is improving and how you reached that conclusion. Functional improvement is a great sign. From there, document WHY the treatment was administered, WHY the patient requires more care, and whether the plan is changing. The summary of this process is the equation S+O = A, (what was found in subjective and objective yields assessment) – (A) can still include the response to the current treatment.

Assess progress:

- TODAY’s findings (S and O)
- TOMORROW’s plan or follow-up (What we want the patient to do after today)

Specifically, note and summarize the clinical thinking:

- Subjective functional progress toward the specific goals
- Subjective pain levels
- Objective – PART(S) – findings’ progress
- Doctor’s assessment of patient’s overall progress toward achieving his/her functional goals
- Patient’s response to the plan
- Do we need to maintain the same plan or change it? Why?

Examples to Review

Below are some limited examples that show different ways to state Assessments for various ROV scenarios. Note the focus on (S)-function and (O)-PART to explain “WHY” the patient was treated today. Note also, the clinical decision statements of the plan for the patient to follow tomorrow or until the next visit.

If the Patient is Improving

Current Condition	Next Steps
Increased ability to sleep through the night and sit at computer without pain for 15 minutes at a time	Maintain current goals and plans
Increased tolerance for laying down and talking on the telephone for 15 minutes at a time	Maintain current goals and plans
Patient can sleep 30 minutes at a time or longer before pain wakes her up	Continue plan to reach long-term goal of sleeping up to 8 hours without being awakened by pain
Patient currently able to sit or walk for 30 minutes. She is on course to meet her short-term goal of at least 60 minutes within 30 days of the most recent treatment plan.	Continue plan as ordered
Patient can get dressed more easily and has less pain when raising his arms over his head.	Maintain current goals and plans
Patient is on course to meet his STG of 4 hours of uninterrupted sleep within 30 days; lumbar muscle spasms are abating	Continue with current plan
Patient is improving although pain level is unchanged. I noted improved objective findings in the lumbar area.	Continue this treatment plan
Patient can lift, pull, and push 50 pounds and has met all STGs as of today. This is earlier than anticipated.	Start working on long-term goals
Progress is consistent with our plan of care.	Continue as Rx
I am seeing appropriate progress with this treatment plan.	To reach the intended goals, care should continue as ordered
Patient displays slight improvement of 3% in her LB ROM. This indicates that her condition is improving.	Maintain current plan
Patient is having functional difficulty observed as he walked to the room. He may experience variations in progress throughout the plan given the complicating factors (x, y, and z). We should see progress with adherence to the current plan.	Evaluate the need to modify goals (particularly those addressing his ability to walk 20 ft without pain) at his next reevaluation.

If Worsening / Change of Treatment / Exacerbation

Current Condition	Next Steps
Patient’s condition has worsened and is inconsistent with objectives set forth in the plan of care.	Change the adjustment technique and physiotherapy modalities. Carefully monitor progress over the next two visits; if no change, discuss a referral to an orthopedist for a second opinion to prevent deterioration of condition, function, or to potentially diagnose a more serious organic disease.
Patient still struggles to control the swings in her pain and functional ability.	Continued care is necessary because she responds positively to the care. Because patient can’t take time off work to heal, progress is slower than it might be in a less complicated case. I expect the patient to continue to make therapeutic and functional gains with further conservative treatment but with the understanding that we may move to less frequent treatments for a longer period which is what the patient can manage.
Patient experienced a fall last week that further exacerbated her lower back pain.	An increase to three visits this week and a change in modalities is warranted to keep patient on track with current goals and plans. I will assign additional gentle stretching exercises to complement home treatment.

Resolved and Stable

Current Condition	Next Steps
Patient appears to have reached maximum functional improvement for this condition as evidenced in today’s subjective and objective evaluation.	Conduct a reevaluation during the next visit to confirm discharge
Based on the results of today’s subjective and objective evaluation, no additional active treatment is necessary for this condition.	Discharge patient from active care today. Ask patient to call or schedule a visit at this office if function, symptoms, or loss reoccur.

These examples provide general guidance to meet the requirements needed for the Assessment portion of ROV documentation. They are not specific examples to copy or paste. Instead, use them to prompt solid statements of assessment as you progress through the patient’s episode of active treatment.

Adding Variety to a Routine Office Visit (ROV) Assessment

When a patient is in active treatment, it can be difficult to properly document progress without repetition or using canned language in the software. Watch this brief, informative video on how to translate your clinical thoughts into brief Assessments for each visit. Doctors know how their patients are coming along and what they want to do with the patient each visit—especially when the patient is seen frequently over a short period (e.g., 3-4 times per week for 2 weeks). After review, consider how to communicate your ideas to a 3^rd party or committee who may be assessing the patient’s chart.

Routine Office Visit Daily Assessment

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 to pre-episode status, and in turn, provides the needed detail to verify medical necessity.

Components of Routine Office Visit (ROV) Assessment

The ROV assessment conveys what the doctor is thinking during the visit, based on what was learned in the subjective and objection portion of the note. Documenting this “doctor thinking” enables 3^rd-party readers to see what is going on—include:

Improving ROV Assessment Easy as 1-2-3

The first step in creating a robust assessment is to use PART to supplement your documentation as it relates to the patient’s function. What you learn in the Subjective + what you learn in the Objective is interpreted to become P + ART= Assessment
- Guide and train your patients to tell you about changes in their Activities of Daily Living (ADL’s) and functional improvements and to provide other measurable information.
- Use the patient’s description of his/her condition:
  - Compare the ART of the visits to the patient’s statement—what does it tell you about the effectiveness of your treatment?
  - Indicate the progress being made toward the patient’s goals (include adherence to patient-related instructions).
  - Discuss factors that modify frequency or intensity of intervention and progress toward anticipated goals; modify or set new goals if
- Use Outcomes Assessment Tools (OATS) during initial examinations and at periodic intervals (e.g., re- examinations). Use these findings to clarify why the patient needs continued
The next step in improving daily assessment is to refrain from repeating the diagnosis in the Assessment portion of the SOAP The diagnosis during an episode of care is usually the same as the diagnosis documented in the initial visit of that episode. It’s not necessary to repeat it UNLESS a specific carrier you’re billing asks for it. (This is very rare)
The final step is to choose the content of your assessment carefully. Remember, the purpose of this part of your SOAP note is to help the 3^rd-Party reader know what you, the provider, are
- Limit the use of vague terms (e.g., same, better, or worse) without adding qualifying terms that explain how you know this. For example, saying the patient is the same as last visit, or continuing to progress as expected, does not let the reader into your clinical mindset. Comments about a patient who is slightly improved since the last visit because she was able to sleep an extra two hours before being awakened by neck pain, paints a more vivid picture for the Avoid terms like guarded prognosis, good progress, or as expected without adding qualifying terms.
- Expand the description by using terms like gradual, slow, complicated by, worse than previous, about the same, or exacerbated by—remember to include how you know

The daily ROV assessment can make or break your documentation. Well-written and communicated assessments convey the doctor’s thoughts about the patient’s progress. It can succinctly and clearly indicate how much change has taken place, when changes occurred, and why further care might be indicated. Master daily assessment and you’ll go a long way toward mastering documentation of medical necessity.

The Mechanics of Assessment in Routine Office Visits (ROV)

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 or may not need more care.

Because the assessment can seem redundant when there are multiple visits in one week, this brief training outlines the best practices for including the most important, specific elements. A well-written daily assessment provides the perspective needed as one works through the active episode of care to tell the story of the patient’s return to health.

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