Documenting the Daily Objective Findings

Posting Date:  Jun 28, 2019

There seems to be some confusion among chiropractors as to what objective findings we need to document on our daily visits.  I, and others, have been teaching for a number of years to follow the PART format of documentation for ALL of our patients.  This PART format is what is REQUIRED by Medicare, and, to be honest, it works quite well for ALL of our patients.

So, let’s review what PART is.  The P of PART stands for Pain/Tenderness.  As I wrote in a previous article, documenting the metrics of pain intensity and pain frequency will satisfy this component of PART, and it gives us two metrics we can track over time.

The A of PART stands for Asymmetry/Misalignment.  For this, there are 3 categories:  posture, gait and restriction/subluxation.  We only are required to document ONE of these, and, if you plan on adjusting your patient, I recommend choosing the restriction/subluxation to document, which makes posture and gait optional.

The R of PART stands for Range of Motion Abnormality.  No one expects us to actually measure range of motion on every visit – we can save that for the exams.  On the daily visits, though, we can simply do a visual assessment of range of motion, noting if there is an increase in pain for each plane of motion or not.  Don’t make up fake measurements – there’s no need to do that here.  If cervical flexion increases the pain when compared to neutral, it’s positive.  That’s it.

The T of PART stands for Tissue/Tone Changes.  Quit talking about the paraspinal muscles here.  Instead, be more specific for the muscles, like left trapezius, right levator scapulae, bilateral supraspinatus, etc.  There’s no requirement to grade the spasms or trigger points – just note which muscles are involved.

Medicare then tells us that we don’t necessarily have to document all four of these on each visit, but that we HAVE to document at least 2 of the 4, with 1 of the 2 being Asymmetry/Misalignment or Range of Motion Abnormality.

To make this easier (hopefully), we need to make sure that everything we do from a treatment perspective must be justified by what you documented as your findings for that visit.  For example, if you are doing passive modalities on your patients, like hot packs and electrical muscle stimulation, you’re probably doing that to decrease pain and muscle spasms/trigger points.  Make sure that you’ve documented pain and spasms in your notes.  If you’re performing manual therapy on a patient, you’re probably doing that to relieve pain and muscle spasms/trigger points.  Make sure you’ve documented that.  If you’re having your patients perform therapeutic exercises, you’re probably doing that to decrease pain with certain motions and improve function.  Make sure you’ve documented that.  But here’s one that’s been catching my attention lately in the many record reviews I perform each month.  I’m talking about the spinal and/or extremity restrictions/subluxations.  Too many of you are documenting the segments you adjusted but are NOT documenting the restrictions/subluxations in your objective findings.  You may be thinking it’s implied or assumed, but it’s NOT.  As a reviewer, I assume nothing.  What you’ve documented is what you’ve documented.  If you documented that you adjusted C3, C5, T4 and L1 but you did NOT document that there were restrictions with those segments, I will point out that you did not document a justification for those adjustments.

So, here’s how it could look:

You perform spinal adjustments and hot packs and electrical muscle stimulation – you need to document the pain (P intensity and frequency), spinal restrictions/subluxations (A) and muscle spasms/trigger points (T).

You perform spinal adjustments and manual therapy – you need to document the pain (P), spinal restrictions/subluxations (A) and muscle spasms/trigger points.

You perform spinal adjustments and therapeutic exercises – you need to document the pain (P), spinal restrictions/subluxations (A) and increased pain with certain planes of motion (R).

You perform spinal adjustments, manual therapy and therapeutic exercises – you need to document the pain (P), spinal restrictions/subluxations (A), increased pain with certain planes of motion (R) and muscle spasms/trigger points (T).

That way, every treatment that you perform is justified in your notes.  In my EMR, when I document the spinal/extremity restrictions in my objective findings and then click on spinal/extremity adjustments in my treatment plan, the restrictions from my objective findings automatically populate, and the same goes for manual therapy and therapeutic exercise.  This is how I blend exceptional documentation with technology to create a great and compliant SOAP note in the least amount of time.


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