Record Keeping

This section is 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.

Jump to:    Association Recommendations      Articles About Record Keeping

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Association Recommendations

   Record Keeping
           Clinical Guidelines for Chiropractic Practice in Canada



   Record Keeping and Patient Consents           
           in Adobe Acrobat PDF (40 KB)      OR
           as a Word document (84 KB)
           ICA's Clinical Protocols and Guidelines for the Practice of Chiropractic.



   Record Keeping ~ Case History
           Vertebral Subluxation in Chiropractic Practice
           This is an Adobe Acrobat file (358 KB).   Record Keeping starts on page 12 of 130.



   Record Keeping
           Guidelines for Chiropractic Quality Assurance and Practice Parameters ~ a.k.a. The Mercy Conference   Refer to Section V

Articles About Record Keeping

   What Data to Collect When Making a "New Patient" 99203 Evaluation
           Thanks to Fred Deutsch, DC, DACRB of Deutsch Chiropractic, Watertown, SD for the use of this document!


   Medical Shorthand I      AND      Medical Shorthand II
          Thanks to Dr. Boileve for these 2 documents. These Adobe PDF files spell out accepted medical and chiropractic "shorthand" for files.


   Documenting Physical Therapy – The Reviewer Perspective
           This text book (available in our Book Shelf Page) is a comprehensive overview of documentation for physical therapy, for the purpose of justifying treatment strategies and avoiding claim denials. Case studies illustrate acceptable and unacceptable documentation practices. It also provides suggestions to improve documentation


   Best Practices in Clinical Chiropractic
           This collection of articles (also available in our Book Shelf Page) from five years of the journal Topics in Clinical Chiropractic. These articles cover topics such as record keeping, history taking, evaluating soft tissue pain, and deciding how much care is needed. Chapters are grouped in sections on primary care, optimizing practice, and special issues, with material on areas including boundary issues, headache management, and differentiating mechanical pain from visceral pain.

Return to the Documentation Section

Since 2-18-2001

Updated 11-14-2007