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Every chiropractic encounter should document Treatment goals and expected duration Patient response to treatment since last visit Spinal regions treated (by name, not just quantity) Technique used (diversified, Gonstead, activator, etc.) Subluxation diagnosis with supporting findings (for Medicare) Functional limitations and objective measurements (ROM, pain scale, ADL impact) ICD-10 diagnosis linked to the CPT code (M99.xx for subluxation, M54.5 for low back pain, M54.2 for cervicalgia) For time-based codes (97110, 97140, 97112), the note must include total treatment time per code
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That is why every program begins with a medical intake
