Documenting Therapeutic Exercises

This outline of therapeutic exercise verbiage is provided as a BASIC level of therapeutic exercise instruction to use when documenting the patient encounter.  If you are including billable therapeutic exercises you MUST include the time the patient started and the time they ended using proper CPT time guidelines.  These MUST be supervised by YOU THE DOCTOR if the code dictates, make sure you KNOW.   The content here represents the bare minimum when documenting the incorporation of active care recommendations into your treatment. This outline is designed to document home care instructions.  If you are trained in a specific technique or rehabilitative procedure, categorize your recommendations into one of the three categories. Moving from range of motion to isotonic exercises is the basic shell of any program. Since many doctors of chiropractic discuss these concepts with patients but do not document them in treatment notes I have posted these here. MDs, carriers and attorneys want to see that you instructed on active care and it was documented rather than multiple pages of canned exercises. This verbiage is basic and is designed to give you a level of documentation that shows you have instructed the patient on self care and are incorporating active therapies into your treatment plan. What you do from there is completely up to you and your office techniques.   If you are documenting “supervised therapeutic exercise” that are provided “in office” you will need to fulfill additional CPT documentation requirements.  That will be posted in another section.  THIS IS FOR ACTIVE HOME CARE INSTRUCTIONS, it is designed to meet the requirement but also be basic.  It is not designed to protect you from an audit OR to be the BE ALL/ END ALL of documentation.  Please make sure that you have a compliance review with me within the first 2 weeks of starting the program. 


EMR Forms and Samples 

It doesn’t matter what you call it, there has to be an initial patient report (this is NOT A NARRATIVE REPORT, a narrative report is a medical-legal document in admissible format designed to be used in court). This is a sample of a report that went out from my office on a referral from a MD. This is a proper initial report (E/M – Evaluation and Management) that will increase the trust between you and the MD. The re-evaluation (30 days later REGARDLESS of number of visits) is in the same format but you are spending less time with the patient since unless the information has changed, you documented the major E/M categories at the initial visitation. 





Getting Started Forms

This area contains the 3 forms that are necessary to launch the MD Relationship Program from the front desk.  These forms were outlined in the “Implementing the Program from the Front Desk”, which is posted in the Training Modules Section.  




How to Build a Curriculum Vitae

Your curriculum vitae is a critical document in the medical-legal arena and your practice. An accurate document is critical for admissibility and with the right credentials, you will open the door for referrals for the lifetime of your practice. The Academy of Chiropractic has partnered with the US Chiropractic Directory to help you create your CV. The US Chiropractic Directory has create the first ever CV builder for chiropractors and it is free for you. Without an admissible CV and relevant credentials to personal injury, lawyers will NOT work with you. STEP 1: Download the “Guide” below to understand the 5 W’s (who, what, where, when and why) of CV building. Get the Guide for Creating a Curriculum Vitae by Clicking Here. STEP 2: Click on the link below to go to the US Chiropractic Directory and build your CV. I also urge you to sign up for the a “Preferred Listing” in the Directory. It is $22 and you will be exposing your practice to 10,000’s of people per day. Go to the US Chiropractic Directory by Clicking Here and once you are on the site, go to “Doctors register your practice” on the left side.

Records Release Template

This template was formulated by a Personal Injury attorney in New York State to ensure my office was compliant with Records Requests.  It is mandatory that you have an attorney in your state review this information prior to use to ensure you are compliant. 


 MD Lecture Program

The “What is Chiropractic” presentation is approved from the University of Buffalo School of Medicine and Biomedical Sciences to offer Category I AMA credits to medical professionals in the next few weeks.  This is available to you based on your knowledge base and your clinical skills.  At the present time the only Advanced placement in this program along with Trauma Team qualifications and/or Fellowship enrollment qualifies you to provide lectures approved through the medical school.  This is what the medical school requires to vet our instructors, this approval is a privilege and I want to protect it.  It is good for chiropractic.  

This process will “Credential” you as a CME presenter for the Academy of Chiropractic with the above stated criteria.  This is a CV entry and a HUGE credential to have, not to mention the ability to provide this presentation for CME to MDs, NP, PA in outpatient offices, surgical centers, ERs and specialty medical groups.  I provide these on a regular bases to market my own practice, I currently, including myself, have 4 DCs in my practice.  For more information on this process, please email Jody at and she will guide you on the process. 


Many states mandate that you have your patients sign an informed consent prior to rendering care. Most insurance carriers also require this. I am not a lawyer and my formal disclaimer is that I am not rendering legal advice; you should confer with legal counsel as to the exact language for your practice. However, the form attached is the “best-of-the-best” from around the country sent by doctors that conferred with both lawyers and insurance carriers.


HIPAA Patient Privacy Statement

It is federal law to have all patients sign a HIPAA privacy policy about how you handle their protected health information. Please save these documents in your patients’ files, as if challenged, you will need to produce them.   


Language for Ordering Testing

(When clinically applicable)

In response to today’s verification requirements with insurers and licensure Boards, it is recommended that the clinical rationale be articulated in every report when a diagnostic test is ordered. The following is suggested language and needs to be customized to your patient’s clinical presentation.

To download Language for Ordering Testing


Comprehensive Evaluation Form

This template was designed over a 3 year period and includes every body part and function for all patients, with the personal injury and workers compensation patients in mind. It includes normal’s in range of motion of every joint in the body, motor, sensory, and orthopedic tests and has “built in” areas for determining necessity for testing to ensure payment. It is extremely thorough and designed to “walk the doctor through” the evaluation process in the shortest time possible without compromising clinical accuracy. This document was also designed to be forwarded to attorneys and MDs without being typed, with the understanding that an evaluation is not a substitute for a narrative.


Initial Report Dictation Template

Download this form and use it as a template when dictating, if you are using an EMR (which you should be), this is the FORMAT that your Evaluations (Initial and Re-evaluations) should be in.  The information that you are dictating is form the Initial Evaluation and Re-evaluation Form based on Software Motif EMR, but this template will assist you in making sure you put everything in the proper order.  It works best if you put a copy into a “dictation” binder inside clear sleeves.  You stack the charts you need to dictate, open the dictation template and start dictating.  Very simple and quick.  Most doctors get to a point where they no longer need this, but it is extremely useful when you are starting out.


Sample Initial Report – After Dictation 

Here is a sample initial report on a WC case.  This was a pretty straight forward case and this correlates with the Audio Sample in the Audio Section of the site.  Please call or email if you have any questions. 



One of the most important part of the “Getting paid” process is to code correctly. Doctors have somewhere between zero and “0” training in coding and do not understand things such as relative weights, E-codes and DRG’s. These issues are critical in the coding and reimbursement process and are used both for and against you in determining reimbursement by third party payors.

We created a diagnosis form for you to use a few years ago and after months of research, have updated the form for you to implement into your practice taking into account all of the issues you need to maximize fair reimbursement for the care of your patients. The form is designed to simply copy and insert in your evaluation without having to figure out what to do or choose beyond correlate the diagnosis to your clinical findings.


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