HNS Policy  

A properly prepared and properly documented treatment plan for the improvement of the patient’s condition must be included in the patient’s healthcare record.  

• The patient's health care record will include a treatment plan for each episode of care.
  

   

• Each treatment plan should be individualized and specific to each patient's presenting complaints.
  

   

• Treatment plans must be consistent with the chief complaint, clinical findings and diagnoses documented in the health care record.
  

   

• Each treatment plan must include objective, measurable, and reasonable treatment goals intended to improve a functional deficit related to the patient's present condition.

   

Services to be provided and the number and frequency of visits included in the treatment plan must be supported by the chief complaint, objective clinical findings, and diagnoses documented in the health care record. 

As a reminder, re-evaluations must be done every 4 weeks or 12 visits, (whichever comes first) in order to evaluate effectiveness of treatment, progress towards treatment goals, and the appropriateness of additional care.  Treatment plans should not exceed 4 weeks or 12 visits.

The patient’s treatment plan must include recommended level of care (duration and frequency of visits), and specifically include the chiropractic manipulation therapy (CMT) recommended, including specific areas to be manipulated with reference to frequency and duration.

The patient’s treatment plan must include objective measures to evaluate treatment effectiveness. 

The patient’s treatment plan must include phases of care pursued.

If modalities and therapies are included in the treatment plan, the plan must include the rationale for the services, areas of application, frequency, duration, and if time based therapy is used, the length of time the service will be provided should be included (ex. 15 minutes).

The treatment plan must include expected outcomes. 

All subsequent visits should reference the patient’s progress as it relates to treatment goals. 

Changes or alterations to the course of treatment that differ from the initial treatment plan must be clearly documented and must include rationales.

If there is a change to the working diagnosis or diagnoses, the provider must modify the treatment plan or prepare a new treatment plan. 

Patient instructions and home care and any recommended DME must be included in the treatment plan.  

Per the NC BOCE Practice Guides:

Treatment Plan 

Each patient is unique, and each patient's complaints, injuries and circumstances are distinct. It is the physician's responsibility to develop a treatment plan individually tailored to the patient's condition. The goals of the treatment plan should be to restore motion, improve strength and function, and reduce pain. 

At the outset of treatment, the physician should provide the patient with estimates of the time within which to expect initial improvement and the time within which to expect maximum therapeutic benefit. The physician should adequately explain to the patient the nature of the patient's condition, the goals of treatment, and the treatment strategy. Because the patient's active participation in the treatment plan is essential to success, the physician should refer or discharge a patient who fails to comply with treatment recommendations. 

During each office visit, the physician should inquire as to the patient's presenting complaints, perform the treatment called for in the treatment plan, and monitor the patient's clinical picture through the use of objective tests such as range of motion, segmental range of motion, presence or absence of spasm or swelling, presence or absence of positive orthopedic findings, and pain assessment. 

The physician should re-evaluate the appropriateness of further care after whichever comes first, approximately twelve office treatments or four weeks of care (i.e., one treatment cycle). 

If the patient shows improvement, the physician may recommend another treatment cycle. For as long as improvement can be objectively demonstrated, the patient may continue treatment cycles. 

However, if re-evaluation fails to demonstrate additional improvement after any two consecutive treatment cycles, the physician should assume that maximum therapeutic benefit has been reached. Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release.

Once the goals of treatment have been realized, the patient may continue to need supportive care in order to prevent deterioration or relapse.