Good records tell the story of care.
The association recommends aligning the appointment, clinical record, and billed service. Its guidance emphasizes individual reassessment and a clear reason for each visit.
| Session | Published pricing example |
|---|---|
| 60 minutes | 100% of the base fee |
| 30 minutes | Approximately 60–70% |
| 20 minutes | Approximately 50–60% |
Administrative work and overhead explain the non-linear example. Two 30-minute visits may allow appropriate care; three 20-minute follow-ups require particularly clear individual documentation. These are association recommendations, not insurer approval or universal fee rules.
Follow-up structure
- Interval reassessment: changes since the previous visit.
- Objective findings: movement, palpation, and function.
- Clinical reasoning for today’s treatment.
- Regions and techniques used.
- Response, next steps, and reassessment plan.
Generic notes that only mention pain, treatment, tolerance, and a return visit do not explain these elements. Audits may examine medical necessity, individual reasoning, measurable findings, patient volume, and alignment with billed time.
Recordkeeping checklists
Initial assessment & treatment record
- Personal medical and health history
- Ongoing/past illnesses and operations
- Allergies and drug reactions
- Prescription, herbal, vitamin and OTC use
- Chief complaint
- Signs and symptoms
- Treatment principles and strategies
- Modalities, frequency and duration
- Advice to patient
- Referring regulated professional name, address and phone
Follow-up treatment record
- Date of visit
- Progress inquiry
- Treatment plan modification
- Adjunct modalities/treatment/procedures and specifics
- Patient reaction
- Follow-up recommendations
Consent discussion
- Nature of treatment
- Expected benefits
- Material risks
- Material side effects
- Alternative courses
- Likely consequences of no treatment
- Voluntary agreement without misrepresentation or fraud
The original standards discuss consent, substitute decision-makers, and the Health Care Consent Act, 1996. Consult the complete source and applicable requirements.
20–30-minute follow-up template
Use the source template as a documentation aid.
- Since last visit
- Pain level current and previous
- Functional change
- ROM/mobility
- Palpatory findings
- Functional observation
- Findings consistent with
- Treatment indication
- Regions treated
- Techniques
- Immediate response
- Objective change
- Next visit timing
- Next treatment focus
- Planned reassessment