9.1 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.