Practice More Safely // Risk Tips // Documentation Essentials

Documentation Essentials

November 2022

Reading time: 4 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. This checklist can help chiropractic practices review important risk management strategies for documentation and identify potential areas for improvement.

Documentation Policies	Yes	No
Does your practice have written policies that delineate documentation expectations for chiropractors and staff members?
Do documentation policies:
Specify requirements related to documentation format, content, review, and signoff?
Include information about accountability and responsibility for various types of documentation?
Contain detailed guidance about alteration of chiropractic records, including how to appropriately amend a record and guidance for when alteration is prohibited?
Strictly prohibit negative, judgmental, or subjective comments about patients, their families, and other healthcare providers in health records and other forms of documentation?
Establish proper notation methods to prevent misunderstandings about the level of care or the timing of care?
Include guidance and requirements related to using scribes to document clinical care?
Stipulate that appropriate and qualified chiropractors must review and approve dictated and transcribed documentation?
Define and encourage appropriate use of checklists and forms?
Establish appropriate terminology and abbreviations to help prevent confusion and errors?
Establish appropriate timeframes for completion of documentation-related tasks, such as chiropractic record entries, review of transcribed information, and signoff of consultative reports?
Account for unique risks related to electronic documentation?

Clinical Encounters	Yes	No
Is thorough information documented for patients during initial chiropractic encounters and at each follow-up visit, including:
Health history and family history?
Medications, including prescription and over-the-counter medications, vitamins, supplements, and herbal remedies?
Physical exam findings?
Recommended screenings and tests as well as results?
Referrals and consultations?
Differential diagnosis and final diagnosis?
Treatment recommendations (including the clinical rationale) and the provision of care?
Patient education, including techniques used to improve comprehension or address health literacy barriers (e.g., the teach-back technique)?
Follow-up for persistent problems?
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?

Administrative/Systems	Yes	No
Is a reliable system in place to document:
All tests and consults ordered?
All test results and consultative reports received?
Review of all test results and consultative reports by an appropriate and qualified chiropractor?
Any decisions (and corresponding rationale) based on test results or consults?
Patient notification of test results and consultative reports?
Are hospital records and information from other healthcare providers incorporated into chiropractic records?
Are telephone calls to pharmacies documented, including the name of the pharmacy, phone number, medication prescribed, dose, schedule, volume dispensed, and number of refills authorized?
Are any limitations or requirements related to automatic medication refills documented in patient records (e.g., the patient must be seen prior to a refill)?

Auditing	Yes	No
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?

Staff Education	Yes	No
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:
Including incident reports or lawsuit-related correspondence in chiropractic records?
Using legal terms such as ”negligence,” ”duty,” or ”liability,” in chiropractic records?
Speculating about, or criticizing, the actions of other chiropractors or professionals in chiropractic records?
Editorializing or including subjective information in chiropractic records?
Altering or revising chiropractic records?
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?

Resources

For more information about various aspects of documentation, see the following MedPro resources:

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This document should not be construed as legal or medical 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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