This section was compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
This page is devoted to a full description of what is considered “complete” patient file documentation, as described by National Associations and Third party Payors. It is the intention of this page to inform our profession of the most efficient means of communicating patient information, as well as outlining what is considered adequate documentation.
Vertebral Subluxation in Chiropractic Practice
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Clinical Impression starts on page 60 of 318.
Guidelines for Chiropractic Quality Assurance and Practice Parameters
~ a.k.a. The Mercy Conference Refer to Section VI
Articles About Clinical Impression and Diagnosis
The Content of Chiropractic Practice
Chiropractic in the United States: Training, Practice, and Research
AHCPR Publication No. 98-N002 December 1997
Two studies of national scope have tried to describe what chiropractors actually do in practice. The first was a national survey of over 5,000 practicing chiropractors (Christensen, 1993), which asked what conditions patients presented with or had concurrently. The second, using data collected from the office records of a cluster sample of chiropractors, looked at the presenting symptoms the chiropractors recorded in charts and at diagnoses recorded for insurance purposes .
Diagnoses and Treatment Recommendations on Workers Compensation Medical Certificates for Back and Neck Pain
Medical Journal of Australia 2000 (Oct 16); 173: 419–422
In recent years, national and international guidelines and systematic reviews -- some evidence-based -- have established standards for diagnosis and treatment of people with back or neck pain, 5-10 including the most recent National Health and Medical Research Council (NHMRC) guide to acute pain management 11 and the definitive publication on classification of pain by the International Association for the Study of Pain (IASP).12
Proactive Care Through an Evolving Diagnosis: A Case Report
David D. Juehring, D.C., D.A.C.R.B.
Proper case management and treatment comprise the ongoing interplay of the patient's subjective complaints and objective findings. These components should be continually monitored to follow the progression of symptoms needed to arrive at a flexible and evolving working diagnosis.