Record Keeping

This section was 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.

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 (2008) This is an Adobe Acrobat file (1.34 MB). Record Keeping starts on page 148 of 318.
	Record Keeping Guidelines for Chiropractic Quality Assurance and Practice Parameters a.k.a. The Mercy Conference   Refer to Section V
	Recommendations for Chiropractic Documentation Wisconsin Chiropractic Association This 45 page document from the includes a section on chiropractic “listings”, indicators of chronicity, and an extensive list of commonly used abbreviations.

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.

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Since 2–18–2001

Updated 12-25-2023