August 9, 2022
Reading time: 3 minutes
Documentation in patient chiropractic records and other systems fulfills many purposes. It memorializes patient care, facilitates communication among chiropractors, forms the basis for coding and billing, provides data pertinent to quality improvement, and may provide information that is critical to the defense of a legal action.
Chiropractic practices should have written policies and procedures to ensure thorough and consistent documentation and mitigate liability exposure. Use this checklist to review important risk management strategies for documentation and identify potential areas for improvement.
|Does your practice have written policies that delineate documentation expectations for chiropractors and staff members?|
|Do documentation policies:|
|Is thorough information documented for patients during initial chiropractic encounters and at each follow-up visit, including:|
|Are informed consent and informed refusal discussions documented, including risks and benefits, treatment alternatives, self-care regimens, and patient education?|
|Are issues related to patient nonadherence documented, including methods used to address the problem (e.g., additional education, patient agreements, etc.)?|
|Does documentation about patient encounters use language that is specific and objective? Are direct patient quotes included to clarify context?|
|Is a reliable system in place to document:|
|Are hospital records and information from other healthcare providers incorporated into chiropractic records?|
|Are documentation policies periodically audited to identify gaps and information that requires updating?|
|Are hardcopy records periodically reviewed to ensure text is legible, information is chronological, and all entries are dated and signed?|
|Is the tracking documentation for consultative reports periodically reviewed to ensure entries have appropriate dates, times, and reviewer signatures?|
|Is disclosure of chiropractic records and protected health information (PHI) periodically reviewed for compliance with organizational policies on release of chiropractic records?|
|Are chiropractors and personnel educated about organizational documentation policies during orientation and as part of in-service training?|
|Are chiropractors and personnel educated about the risks of:|
|Are chiropractors and personnel educated about the practice’s policy guiding the release of chiropractic records and the confidentiality of PHI?|
|Are chiropractors and personnel educated about the practice’s record retention policy?|
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This document should not be construed as medical or legal advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.
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