Wisconsin Chiropractic Association

Recommendations for Chiropractic Documentation (1996)

Introduction:

Over the past decade, chiropractic has occupied a constantly growing position in today’s complex health care delivery system. Chiropractors in Wisconsin now work routinely with a myriad of parties who are interested in assessing the quality of clinical work performed by the chiropractor.

The principal method through which other parties attempt to assess the quality and necessity of a chiropractor’s work is through submitted clinical documentation. The clinical records of Wisconsin chiropractors are now examined with an increased amount of scrutiny. Many different payors and agencies have the right to access a chiropractor’s clinical records, including:

• insurers who wish to determine whether a claim is a covered benefit under the terms of their contract with the patient
• managed care organizations who conduct reviews of clinical record keeping as part of their quality assurance and utilization review programs
• attorneys who utilize clinical documentation as evidence in personal injury litigation
• attorneys who represent patients in malpractice suits against chiropractors
• other health care providers who may request records in order to coordinate interprofessional patient care
• other chiropractors who assist with treatment for a patient
• state regulatory agencies, who investigate consumer complaints, review payment for government programs, etc.

Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Because chiropractic practice patterns vary from medical practice patterns, recommendations for chiropractic documentation necessitate additional modifications when compared to generally accepted medical record keeping formats.

 

General Disclaimer

This document contains recommendations for the clinical documentation of chiropractic care. These recommendations are intended for educational and instructional purposes only and do not constitute a standard of care for any specific clinical situation. These recommendations, which may need to be updated, are intended to be flexible.

In is not the purpose of this document, which is advisory in nature, to take precedence over any federal, state or local statute, rule, regulation or ordinance which may affect chiropractic practice.

This document may provide some assistance to third parties in the evaluation of chiropractic care, but it is not by itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity.

Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Further, these recommendations will require constant re-evaluation as additional scientific and clinical information becomes available.

 

Acknowledgments:

The Wisconsin Chiropractic Association is indebted to chiropractic colleges and insurers who provided valuable background information for the work of the Committee, and also to the Committee members for their diligent effort on this project.

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Since 8-08-2003