Proper record keeping for chiropractors -- Part 1

Every chiropractic licensing jurisdiction in the world has its own regulations and scope of practice laws that can differ widely, yet every one of them addresses the need for comprehensive and accurate patient records. The importance of recordkeeping for the chiropractic office cannot be overestimated: it is one of the most common causes for malpractice lawsuits and board complaints and good records can be a key to the successful defense in any situation.

Despite the recognized significance of record keeping, many doctors still do not take the steps to ensure their records are complete and properly maintained. Over the next several issues of The Chiropractic Journal, I'll review some of the most critical "rules" all DCs should observe to protect themselves in the case of litigation or board review.

Record only the facts. When making notes on your patients, record your observations and actions. Do not record your opinions or speculations about any aspect of your patient or his or her situation.

Let's take a look at an example: A 46‑year old male patient comes to you complaining of headaches after a recent work‑related accident, and you suspect he may be "faking" to get time off from work. You provide him with information regarding the purpose of chiropractic, have him read and sign the Terms of Acceptance form, examine him and determine he has subluxations at C5 and L2. Finally, you discuss your plan for a series of adjustments to correct the vertebral subluxations.

Your records should include:

---  Detailed chiropractic case history form (completed);

---  The patient's statements to you about his symptoms and health situation (use quotation marks, for example: patient stated, "I hit my head at work");

---  Your observation and assessment;

---  Your findings regarding the subluxations;

---  X‑rays and results of any other diagnostic tests for vertebral subluxation; and,

---  Signed Terms of Acceptance

Do not include any notes about your speculation that the patient may be guilty of malingering. Should he later sue you, it could be argued that you were wrong to "treat" a patient you felt was uninjured. In addition, should the patient indeed have a significant injury, any indication that you thought he was "faking it" will be used as evidence of your negligence.

You make your practice decisions based on the observable facts of each case ‑‑ and you should record only those facts in your records.

Tailor forms to your practice. Chiropractors obtain forms from a wide variety of sources. Forms can be purchased from practice consultants, published by insurance companies, copied from articles like this one and downloaded from the internet. Many of these forms are very useful, but invariably they contain items or entire sections that do not apply to every practice.

Chiropractors should carefully review every form they use in their practice. Make sure they do not contain grammatical errors, are difficult to read, appear shoddy or can be used in court to portray a general lack of professionalism in the practice.

If part of a form does not apply to your practice, the section should be deleted and the form reprinted. For example, if the form you use to document your initial assessment lists a review of systems that you typically do not perform, you may be subjected to allegations that you should have reviewed those systems but did not.

Take and document a comprehensive chiropractic history. It may seem obvious that an adequate history is critical to patient care, however, the requirement to document it thoroughly may be less apparent. Be aware that a skilled plaintiff's attorney will focus on your failure to note an apparently important aspect of the patient's past history, even if it is unrelated to the alleged malpractice in an effort to destroy your credibility.

Also keep in mind that you should:

• Implement a form or other mechanism to ensure that a comprehensive case history is recorded on every patient;
   
• If you use a form to document the case history, do not leave any items blank. If the items are not reviewed with the patient because they do not apply, write "N/A" in the space;
   
• Staff members who are assigned to take initial histories should be trained to elicit important information from the patient;
   
• Don't delegate the case history to staff without following up. Even if a staff member records the case history, you should review the information with the patient directly and note that he or she has done so;
   
• Have patients update their progress on every visit. A simple form, completed, dated and signed by the patient, can help defend against a patient's contention that their vertebral subluxations never improved or that they did not receive any benefit from care.