Third-party payers aren’t interested in your instinct or intuition. They want to know what your plan is and want it clearly spelled out in writing. In fact, a treatment plan is required any time you perform an evaluation and management (E/M) service. In the hundreds of documentation audits I’ve conducted for chiropractors, the treatment plan is the one item most likely to turn up incomplete, incoherent, or missing altogether.
What should be in your treatment plan? Each and every service you plan to administer, from your routine chiropractic adjustment, any therapeutic modalities or procedures you plan to use and any durable goods you plan to dispense. You’ll also want to include home care instructions, possible referrals you may make, and any restrictions to activities of daily living.
Although an updated treatment plan is part of your documentation, a treatment plan can also be changed and/or updated within your daily notes, outside of a formal E/M service, if appropriate. For example, due to quicker than expected progress, you may discontinue use of EMS therapy earlier than projected.
The treatment plan is the linchpin in your ongoing record of excellent documentation. Complete this routinely at the beginning of care, as well as after each re-evaluation, and make it a part of the patient’s permanent record. The Paperwork Project’s treatment plan template contains the prompts you need to avoid overlooking something essential. That way, when insurance carriers request your plan it's in writing, it's complete and it’s compliant.