Perhaps one of the biggest mistakes with our documentation is the…
Assessment.
I know, I know. This is the one part of the SOAP note that everyone seems to take for granted. What you may not realize, though, is that there are some requirements that most chiropractors are missing.
One item that is often missing from the Assessment are the diagnoses. With all of the records I review, I’m amazed at the trouble many chiropractors have with coming up with appropriate diagnoses. First, you want to document both ICD-10 code AND the description, not one or the other. Second, we’re required to have a diagnosis for each complaint. That means, if your patient has a complaint of neck pain, you should have a diagnosis of cervicalgia. The same goes for the other complaints. If there are radicular complaints, those should be diagnosed, and if there are imaging findings, those should be diagnosed. If you plan on adjusting the spine and/or extremities, make sure you use the appropriate diagnoses that justifies the procedure. This is easy – you can use the M99 codes, which are segmental and somatic dysfunction of the various spinal or extra-spinal regions.
The second thing that’s often missing from the Assessment are complicating factors. Anything that could slow the patient’s progress should be documented, but be specific for each condition. For example, obesity is a complicating factor for low back pain. Prior surgery may be a complicating factor for neck pain. You get the idea.
And then there’s the big two.
We are required to document, on EVERY VISIT…
“How is each condition responding since the previous visit?”
That means, once you’ve documented for today’s visit, you need to go back to the previous visit and compare, then go back to today’s visit to document the changes.
The second big thing is called Evaluation of Treatment Effectiveness. You want to document some treatment effectiveness on each visit, but the bigger deal is to document the treatment effectiveness every 2 to 4 weeks. And this has little to nothing to do with your ortho/neuro exam.
There’s an easy way and a hard way to do this. I do the easy way. It takes me ZERO time and ZERO effort.