Question

Does every single visit need to document quality and quantity of pain and an update to the treatment plan?

Answer

Any relevant subjective changes should be documented at each encounter. Completing the Verbal Numeric Rating Scale and documenting it at every visit is quick, easy, and satisfies MIPS Quality Measure #131 for Medicare. While this might not change from one visit to the next, it could easily change before a re-exam scheduled two weeks out. For typical daily visits we recommend that you note any variation from the plan and the response of the patient. In other words, it is not necessary to repeat the plan at every visit. Instead, you reference it, which allows you to submit the plan should you receive a records request. This keeps the daily notes concise, but still provides the detail necessary for a fair chart review.