October 2018

October 2018

Initial Visit Documentation

The Groundwork for Success

For many doctors, documentation can be a daunting and cumbersome chore. After all, who has time for all these details when there are patients to treat? However, annoying as it may seem, documentation is a facet of your practice for you to embrace and even become more proficient at. Ideally, initial visit documentation should lay the groundwork for the successful execution of your treatment plan.

According to the ACA:

“Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the History and Physical and the anticipated Patient Treatment Plan. The initial Treatment Plan, except in chronic cases, should not project beyond a 30-45-day interval.“


Initial Visit Requirements can generally be categorized as:

  • Relevant History of Patient’s Condition with Detailed Description of the Present Condition

  • Evaluation of Musculoskeletal/Nervous System through Physical Examination

  • Diagnosis

  • Treatment Plan

  • Recommended Duration and Frequency of Visits (example: 3x per week for a period of 4 weeks)

  • Specific Treatment Goals

  • Functional Limitations – Activities of Daily Living (ADL)

  • Date of Initial Treatment

Requirements vary from state board to state board, and from Medicare to insurance carriers. Be sure you know whose rules you’re following. When reviewing your documentation, it should be easy to demonstrate medical necessity. Your documentation must provide a complete record of the patient’s treatment, as well as, a chronological recording of the patient’s care. As reflected in the requirements listed above, be sure any pertinent facts, observations about the patient’s health history, exams, diagnostic testing, treatments, and outcomes/prognosis are recorded. Your documentation should also provide a means of communication with other health care providers. These are the compliance standards you are obligated to meet, even if operating a cash-based practice.

What Does Your Documentation Say About You?

Take a moment to review some examples of your documentation, and ask yourself if the system currently in place makes it easy to complete these requirements. 

If you are receiving a fair amount of denials, then you are likely not recording all the required pieces of information. Take a look at these final considerations to help determine if your documentation is lacking:

  • Still using a multi-visit Travel Card? Then it is not likely that you are collecting all of the necessary information.

  • Nervous about the threat of a Post Review Audit? Then you likely know that your documentation system needs an upgrade.

The great news is that The Paperwork Project can help!