College of Chiropractic Intern’s Clinic Handbook

8.0 Patient Care Records

It is the policy of the clinics of Northwestern College of Chiropractic that routine access to records is restricted to those faculty and interns having a direct responsibility for the care of the patient, business office personnel, clinic administrators, and research faculty and staff when data is being acquired for an institutionally approved project. Patient records are also considered the property of the Northwestern Chiropractic Clinics and are not released or reviewed by individuals not included in this policy without patient authorization.

8.1 Necessary Standards for Record-keeping

Clinical Education has established the following necessary standards for record-keeping. These standards must be met and maintained by all clinicians and clinics in the Community Based Internship (CBI) program. Health records must justify the need for chiropractic care. In order to accomplish this, the following information must be completed and documented:

  • A description of past conditions and trauma, past treatment received, current treatment being received from other providers, and a description of the patient’s current condition including onset and description of trauma, if trauma occurred.
  • Documentation that family history has been evaluated.
  • Examinations performed to determine a preliminary diagnosis based on indicated diagnostic tests, with an indication of all findings of each test performed.
  • A diagnosis supported by documented subjective and objective findings or clearly qualified as an opinion.
  • Daily notes documenting current subjective complaints as described by the patient, any change in objective findings if noted during that visit, a listing of all procedures provided during that visit, and all information that is exchanged and will affect that patient’s treatment.
  • Results of reexaminations that are performed to evaluate significant changes in a patient’s condition, including tests that were positive or deviated from results used to indicate normal findings.
  • A treatment plan that describes the procedures and treatment used for the conditions identified, including approximate frequency of care.
  • A description by the clinician, or written by the patient, each time an incident occurs that results in an aggravation of the patient’s condition or a new developing condition.
  • A key that explains the meaning of symbols or abbreviations used in the patient record. This key must accompany each file when requested in writing by the patient or a third party.

Records are to be written in ink or computerized, legible, organized and complete. Entries must not be erased or altered, and should be dated and signed by the person making the entry.

8.2 Documenting Valid Adjustments

Definition of a Valid Adjustment

In order to graduate with a Doctor of Chiropractic degree, each intern must satisfy quantitative requirements in a number of different categories. This includes the physical performance of a minimum of 250 adjustments in 250 different patient encounters during the intern’s outpatient, clinical experience. A minimum of 75 of the 250 adjustments must be directly observed by the faculty clinician to whom the student is assigned. All T7 interns must be observed and assessed for each adjustment. T8-T10 interns may adjust if the faculty clinician is not in the room, but the clinician must be in the clinic at all times.

The required 250 adjustments are broken down as follows:

  • At least 80% (200) must be some form of spinal adjustment/manipulation;
  • No more than 20% (50) may be adjustments of extremities.

The faculty clinician is responsible for ensuring that the adjustment an intern claims on their monthly adjustment record truly meets these criteria. This will require some discretion on the part of the clinician, and the following guidelines should be used to determine what is and what is not a valid adjustment:

To be considered a valid adjustment, the following considerations must be present:

. . . A Doctor - Patient relationship must be established, in which the intern is perceived by the patient as a significant participant in the provision of their care for at least this particular interaction.

. . . The intern must be involved ACTIVELY with the patient's care, through assessment/diagnosis, treatment planning, and/or treatment delivery.

Examples of Valid Spinal and Non-Spinal Adjustments. . .

. . . The intern handles the entire patient visit, which includes an adjustment;

. . . The intern performs one or more of the adjustments on the patient, as directed by the faculty clinician. It is left to the faculty clinician’s discretion to determine whether to grant an adjustment credit for an intern's attempt, regardless of whether "it took", or not (this is allowable if the faculty clinician feels the intern's set-up and attempt was technically good and the lack of success is due more to the difficulty the patient/situation presents);

. . . The intern adjusts the faculty clinician, or adjusts a staff member while being directly supervised by the faculty clinician . To get credit, the intern must receive constructive feedback and document the interaction via S.O.A.P. notes just as they would with any other patient.

It is NOT a Valid Adjustment when:

  • an intern is simply applying a therapy, X-ray, or lab function as directed by the faculty clinician;
  • the intern's function is not directly involved with delivery of patient care (i.e. only documenting the DC's treatment and not actively sharing in the patient's care);
  • the intern is strictly observing;
  • an intern is adjusting his or her significant other, parent or child;