Improving Documentation in Chiropractic Care

Laura M. Cascella, MA, CPHRM

Accurate and thorough documentation is a crucial element of high-quality patient care, and it’s a critical component of a sound risk management approach. Documentation provides essential patient information, historical details about the course of care, and a record of services. It also facilitates communication among caregivers, 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.

Yet in busy healthcare settings, documentation can create a burden and may take a backseat to other important administrative and patient care activities. Unfortunately, oversights in documentation can later resurface as liability risk factors. Even if practitioners meet the standard of care, failure to thoroughly document that care can increase liability exposure.

For chiropractors, documentation issues represent a discernable risk. MedPro malpractice case data show that documentation is a contributing factor in about 1 in 4 cases in which chiropractors are named as the responsible service.¹ In these cases, issues associated with insufficient documentation or lack of documentation dominate. Examples of insufficient/lack of documentation include:

• Missing documentation in patients’ health records (e.g., imaging results, symptoms, patient history, diagnosis, treatment plans, etc.)
• Failure to document attempts to follow up with patients about their care and treatment
• Inadequate details about patient encounters
• Lack of documentation about adverse events or unanticipated outcomes
• Insufficient documentation related to informed consent processes

Addressing documentation risks requires a practice-level commitment to implementing comprehensive documentation policies, training the workforce, auditing for compliance with organizational standards, and monitoring for quality assurance.

The following strategies can help chiropractors implement a more robust and conscientious approach to documentation. Please note that some variations in approach will occur based on the nature of the practice (solo practitioner, small practice, or group practice); however, the underlying principles are broadly applicable across practice settings.

• Adopt a uniform system for patient records to ensure consistency regardless of who is documenting. Define the specific formats for documentation as well as the requirements for entries, completion, review, and signoff.
• Develop a practice-wide documentation policy that includes detailed guidance related to:
  • Accountability and responsibility for various types of documentation.
  • Documentation requirements for clinical encounters (e.g., patient history, family history, medications, allergies, problem list, diagnoses, treatment plans, patient response to treatment, patient education, and referrals).
  • Appropriate steps for amending health records, and situations in which altering or modifying records is prohibited.
  • Acceptable timeframes for various documentation tasks.
  • Best practices for language and wording (e.g., using patient-centered language and objective statements as well as avoiding editorializing).
  • Appropriate and required use of standardized checklists and forms.
  • Methods and expectations for reviewing transcribed documentation.
  • Rules and standards for electronic documentation (e.g., in relation to copy/paste, data fields, check boxes, and alerts).
• Carefully consider whether documentation supports clinical judgment and decision-making and provides a rationale for the patient’s treatment approach.
• Implement a tracking mechanism to ensure prompt review of all imaging results, documentation of the results in patients’ records, and communication of results to patients. Failure to document and follow up on imaging results is a known area of risk for many specialties, including chiropractic.
• Record the use of interpreters, auxiliary aids, and/or chaperones during patient encounters (including names, if applicable). If patients are offered a chaperone and refuse, document the refusal in the record.
• Devise a protocol for consistently documenting the informed consent process in patients’ health records, including discussions related to risks and benefits, treatment alternatives, self-care regimens, and patient education. Any forms used as part of informed consent also should be included in patients’ records.
• Keep consistent records of patient nonadherence with treatment recommendations and appointments, including any methods used to resolve these issues and any attempts to follow up with the patient.
• Periodically audit paper and electronic records to ensure they are logical, accurate, complete, and comply with organizational policies. Provide feedback to staff members as needed (individually or as a group) to address documentation gaps and identify quality improvement opportunities.
• Educate employees (if applicable) about organizational documentation policies during orientation and periodically as refresher training. Make sure staff receive adequate training if policies or systems related to documentation change.

Creating quality documentation requires time and resources, but its value cannot be disputed. Thorough and accurate documentation can help chiropractors ensure they are making informed treatment recommendations, facilitating continuity of care, communicating important information with patients, and protecting themselves from liability exposure. For more information and a helpful documentation tool, see MedPro’s Checklist: Documentation Essentials.

¹ MedPro closed malpractice cases, 2015–2025, chiropractic as the responsible service.

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