Documentation, Patient Evaluation, and Plan of Care
Domain 3: Documentation, Patient Evaluation, and Plan of Care
This domain tests whether the record supports the diagnosis, medical necessity, and the care actually delivered. The Board expects contemporaneous, legible, and authenticated records.
Core documentation
- Initial evaluation: chief complaint, history, relevant review of systems, physical/orthopedic/neurologic examination, imaging or labs when indicated, diagnosis, and a plan of care.
- The plan should state goals, treatment frequency and duration, modalities, reassessment intervals, and referral or co-management triggers.
- Progress notes should record subjective response, objective findings, assessment, and changes to the plan-not cloned text.
- Informed consent, risks and benefits, and patient instructions should be documented.
- Retain records for the period required by Board rule and preserve records involved in a complaint or lawsuit.
Worked example
A patient reports 80% improvement, but the file contains identical weekly notes and the same six-week plan with no re-examination. On audit, the record does not support continued medical necessity. The fix is a documented re-evaluation with updated findings, a revised diagnosis, and a new frequency and duration-or discharge with a home program.
Traps that cost marks
- Charting treatment tolerated well as the only progress note.
- Backdating or altering a record after a complaint; this creates a separate credibility problem.
- Billing for services not documented or not medically necessary.
- Omitting informed consent and red-flag screening.