Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 31
"Federal SOAP Guidelines"
Through the years, I have always documented each patient encounter by listing the region of the spine I treated. That is no longer allowable under federal guidelines. The basic rule of caring for patients is that if you satisfy the federal standard of care and documentation, you will meet every local requirement, as the federal standard is usually a higher standard. In addition, most states follow federal language.
The Center for Medicare Services (CMS) has published guidelines for every carrier in every state. Empire Medicare for New York, which reflects the Federal standard, says:
- The precise level of subluxation must be specified by the chiropractor to substantiatea claim for manipulation of the spine, including that the level of spinal subluxation must bear a direct causal relationship to the patient's symptoms, and the symptoms must be directly related to the level of the subluxation that has been diagnosed.
As a result, I have altered the SOAP Note template that is located in the “Communication Materials” section of the Web site to reflect this standard. If you are using the SOAP note, change your template. If you are using a different system, please make sure that it reflects the federal standards.