Clinical Impression and Diagnosis

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.

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Association Recommendations

   Clinical Impression and Diagnosis
           Clinical Guidelines for Chiropractic Practice in Canada.



   Clinical Impression           
           in Adobe Acrobat PDF (28 KB)      OR
           as a Word document (61 KB)
           ICA's Clinical Protocols and Guidelines for the Practice of Chiropractic.



   Clinical Impression
           Vertebral Subluxation in Chiropractic Practice
This is an Adobe Acrobat file (358 KB).   Chiropractic Examination starts on page 70 of 130.



   Clinical Impression
           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


   The ICD-9 Diagnosis Page
            Here's most of the codes you are likely to use, arranged by category.


   Proper Use of ICD-9 Codes for the Chiropractic Profession
            Alan Lyons, D.C.
            The importance of proper coding of a diagnosis cannot be overstressed. Accuracy is essential to reimbursement for services rendered and to protection from both malpractice and civil litigation.


   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.

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Since 2-18-2001

Updated 10-11-2011