Question: If orthopedic tests are negative, do you need to still list them in your treatment notes?
Answer: Yes. Any tests which are performed by a healthcare provider, regardless of the result, should be documented in the patient record. This record is the only way that a reviewer or another provider will know that they were performed. It supports the medical necessity of services performed and firmly establishes the extent of the examination portion of the visit.
Also, don’t forget to document any negative or non-positive changes as well. Even if you only state ‘no change’, this establishes the quality of care and that the service(s) were performed.
See Chapter 4 of the ChiroCode DeskBook for more information about quality documentation standards.
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