“What do we need to document for our maintenance patients?”
Let’s first define what we mean by “maintenance” patients. Some of these patients come in with no symptoms – they just like to get adjusted periodically. Other patients, though, have some level of chronic pain or discomfort that never seems to go anywhere – it just stays the same all the time and they find that getting chiropractic care keeps it from getting worse. The type of care these patients get is called “supportive care.”
For the asymptomatic maintenance patients, we still need to document a SOAP note for them. Here’s what I recommend:
1. For Subjective Complaints, you can simply document “Patient X is here today with no symptoms, for the purpose of a maintenance adjustment.”
2. For Objective Findings, if you plan on adjusting them, document the restrictions/subluxations, but at specific levels, like C3, T4 and so on. If there are any muscle spasms or trigger points, make sure you document them.
3. For Assessment, there are no metrics to consider, so there’s no need to compare to the prior visit. However, you should still document the diagnoses, both code and description.
4. For Plan, document what you did. If you adjusted the patient, make sure you document the specific segments adjusted.
For patients receiving “supportive care,” you should still document the metrics of pain intensity and pain frequency, even if they don’t change much. Document your daily findings (Asymmetry/Misalignment, Range of Motion Abnormality, Tissue/Tone Changes). If you are adjusting the patient, definitely document the spinal/extremity restrictions (asymmetry/misalignment). If you perform any other treatment, make sure each procedure is properly justified in your SOAP notes. Document the Assessment, which should include complicating factors and diagnoses.
Does anyone actually PAY for supportive care anymore? Every now and then, but not too often. Workers Comp has paid for supportive care in the past, but they’re starting to move away from it. This is something the patients should pay for out of their own pocket.
Be BulletProof.