Wisconsin Chiropractic Association

Recommendations for Chiropractic Documentation (1996)

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

Thanks to Steven G. Yeomans, DC, FACO and the Wisconsin Chiropractic Association for sharing these guidelines with Chiro.Org, and to Dr. Jeff Wilder, DC, FACO, co-author of the document.

Chiro.Org is proud to support CMCC, FCER, and the ICPA for their continuous research into the health benefits of chiropractic care.   Please offer them your financial support.

Table of Contents:

Introduction ~ General Disclaimer ~ Acknowledgments

Chapter 1:   Documentation Recommendations

• Format



• Legibility



• Patient Consent



• Initial New Patient History: Subjective



• Initial New Patient Physical Examination: Objective



• Initial New Patient Assessment



• Initial New Patient Treatment Plan



• Daily Notes



• Progress Notes



• Documentation of X-ray Findings



• References

Chapter 2:   Commonly Used Mechanisms of Record Keeping

Chapter 3:   Commonly Used Outcome Assessment Measurements

Chapter 4:   A Primer on Chiropractic Listings

Chapter 5:   Glossary

Chapter 6:   Commonly Used Abbreviations


Appendix A:   HCFA Guidelines for Patient History Level Selection (E&Ms)

Appendix B:   Physical Medicine and Rehabilitation Services

Appendix C:   Risk Factors of Chronicity

Appendix D:   Chart Audit Checklist

Appendix E:   Bibliography AND Suggested Reading List


Thanks to Steven G. Yeomans, DC, FACO
for sharing these guidelines with Chiro.Org!

Return to the DOCUMENTATION Section

Since 8-08-2003