Let’s Be Objective

Written by Billing Dynamix

Gregg Friedman, DC
www.GotDocumentation.com
www.TheBulletProofChiro.com


One of the issues that seems to come up in the many chiropractic records I review is,

 “What objective findings am I supposed to document for my patients on a typical visit?”  

This is answered, quite nicely, by our friends at Centers for Medicare and Medicaid Services (CMS).  As I’ve mentioned many times before, even if you never see Medicare patients, CMS still makes the rules for all of us and all of our patients.  Here’s what they tell us:

We are to use the P.A.R.T. format of documentation on every visit.  The “P” of P.A.R.T. stands for Pain and Tenderness, and that falls under the Subjective part of our SOAP note.  Let’s talk about the other parts.

The “A” of P.A.R.T. stands for Asymmetry/Misalignment, and it includes posture, gait and subluxation/restriction.  If you plan on adjusting the patient, I recommend that you document the spinal/extra-spinal restrictions, since we need to document them anyway in order to justify the CMT procedure.  However, CMS requires that we document the specific segments, such as C3, T4 and L2.  Documenting “cervical, thoracic, lumbar” would be insufficient.

The “R” of P.A.R.T. stands for Range of Motion Abnormality.  There are two ways to assess range of motion.  One way is to perform a visual assessment of range of motion noting pain, and the other is to actually measure range of motion.  While measuring range of motion is a pretty good functional outcome assessment for some patients, I don’t think any of us would want to go to the trouble of measuring on every visit, and it isn’t necessary.  Performing a visual assessment of motion takes less than a minute.  I simply tell the patient to notice what their neck/low back feels like in neutral, and then I have them move into the different planes of motion.  For each plane of motion, I ask them if that increases the discomfort compared to what they felt in neutral, or does it stay the same or make it better.  If the discomfort increases, I document that.  If it stays the same or feels better than what they felt in neutral, it’s negative.

The “T” of P.A.R.T. stands for Tissue/Tone changes.  For this, we can simply note the presence of muscle spasms or trigger points.  Rather than documenting this in the cervical/thoracic/lumbar paraspinal muscles, it’s better to document more specific muscles, such as trapezius, levator scapulae, supraspinatus, etc., and document if it’s on the left side, right side or bilateral.  Also, consider that muscle spasms are typically more of an acute finding, while trigger points tend to be subacute or chronic.  There is no need or requirement to give this finding a metric, such as +3.

Documentation of these daily objective findings should only take you a few seconds, in most cases.