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.

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

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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

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Since 8-08-2003