When documenting our Plan, as in what treatment was performed today, it’s important to remember that every form of treatment we provide must be justified by our objective findings. That’s pretty easy when it comes to ice, heat and other passive modalities, like electrical stimulation and ultrasound. Pain and/or muscle spasms are typically enough to justify these modalities. However, the treatments that tend to raise my eyebrows when I review chiropractic records are:
Chiropractic Manipulative Therapy
Manual Therapy
Therapeutic Exercise
I’m pretty sure that if I were to ask you what one finding would justify Chiropractic Manipulative Therapy, ALL of you would answer with restriction or subluxation or some other word. Amazingly, though, I’ve been seeing more and more chiropractic records lately in which these are NOT documented. I think there’s an assumption that if you document that you adjusted C3, T4 and L1, it’s obvious that those segments were restricted/subluxated. Don’t assume anything. Let’s start with Chiropractic Manipulative Therapy. If you document in your Plan that C3, T4 and L1 were adjusted, make sure that those segments were noted as restricted/subluxated (other words are OK, too) in your objective findings. The same goes for the extremities. If you adjust the right shoulder, make sure your objective findings reflect a restriction of the right shoulder. So, what about Manual Therapy? This procedure is typically some type of muscle work, so the justification must have something to do with the muscles, such as spasms or trigger points. Stay away from the “paraspinal muscles” when documenting these, though. Be more specific for which muscles, like left trapezius, right levator scapulae, bilateral subscapularis. There’s no requirement to “grade” these spasms or trigger point, so don’t bother wasting your time on that. If you document in your Plan that you performed Myofascial Release, make sure that you name the muscles that were worked on. These same muscles must be noted in your Objective Findings as having spasm or trigger points, though. Make sure you document the amount of time and the reasons why the procedure was performed. How about Therapeutic Exercise? This one has to do with movement, so you’ll want to document which movements/planes of motions the patient was working on, like cervical flexion, cervical left lateral flexion, etc. The justification for this could be as simple as documenting pain in cervical flexion, cervical left lateral flexion, etc. Just like Manual Therapy, make sure you document the amount of time and the reasons why the procedure was performed. Can this be done easily and in very little time? You bet it can. In my EMR, I designed it do this for me. In the Objective Findings part of my SOAP note, I’ll document the spinal and/or extremity restrictions. In the Plan section, I’ll just document spinal/extremity adjustments and my EMR will automatically bring in the specific segments/extremities. When I document the muscle spasms/trigger points in my EMR, I’ll just document Manual Therapy in my Plan and the EMR will automatically bring over the muscles I had already documented in the Objective Findings. When I document pain in various planes of motion in the Objective Findings, I just document Therapeutic Exercises in Plan and the EMR will automatically bring over planes of motion that were previously noted in Objective Findings. Documentation can be easy and exceptional and fast. We just need to know how to justify.
Gregg Friedman, DC, CCSP, FIACA
Creator of The Bulletproof Chiro EMR
