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Chiro=
practic
Record Keeping
=
A
Summary of the Lecture
Pres=
ented
by N. Edwin Weathersby, D.C.
=
Upda=
ted
May 2011
Patient Records
<=
span
style=3D'mso-special-format:bullet;position:absolute;left:-4.43%'>•<=
/span>Must
meet the legal requirements set in
A.R.S. § 12-2291 (=
5)
and A.A.C. R4-7-902 (5)(6);
•Must allow other healthcare providers to quickly
read and understand the patient’s past and current health
concerns and treatment;
Patient Records
•Should provide a key that explains any acronyms;
•Should provide detailed documentation of any
test or diagnostic procedures, specific methods of treatment,
specific areas of treated and the length of therapies;
=
•Should clearly document subjective complaints
and objective findings.
Organizing and Maintaining Charts
<=
span
style=3D'font-size:88%'>•All patient
related documentation must be dated.
•Every patient encounter must be documented, =
dated and signed or initialed.
<=
/div>
•You should initial and date when you receive =
outside patient records.
•File reports chronologically in the chart to show =
the course of treatment.
•Corrections to the patient record should only be in the form of additions. They should be clearly =
indicated, dated and initialed.
Patient Record Self Evaluation
• Auditing your patient records may help you identify
strengths and weakne=
sses
in your record keeping. The
following check list may help you
to evaluate your records.
ü<=
/span>My record keeping system allows for ready retrieva=
l of
an individual patient
file.
<=
span
style=3D'font-size:63%'>üThe patient’s identity is clearly evident on each component of =
the
file.
ü<=
/span>Each patient file clearly shows the patient’=
s full
name address, date of birth =
and
gender.
ü<=
/span>The family history, functional inquiry and past hi=
story
are recorded and
maintained.
ü<=
/span>The chief complaint is clearly stated and an adequ=
ate
description of sympto=
ms and
their duration is present.
<=
span
style=3D'font-size:63%;mso-special-format:lastCR;display:none'>
Self-Evaluation Continued
ü<=
/span>The treatment plan and/or treatment is recorded and
detailed as to the metho=
d of
treatment, the areas treated, the time components and the need for continued treatment.
<=
/div>
ü Operations and surgeries are noted.
ü Reports are initialed.
ü<=
/span>The record includes progress notes relating to the
management of the patie=
nt’s
condition through both subjective and objective findings.
ü<=
/span>There is documented evidence that appropriate foll=
ow-up
has taken place following the
receipt of abnormal test results.
üIn the event that more than one physician is making
entries in the patient
file, each physician is identifiable.
To receive a copy of the record keeping presentation in
its entirety, please send a written request and a $12.50
check or money order to:
=
;
State=
of
Arizona, Board of Chiropractic Examiners
5060
North 19th Avenue, Suite
416
Phoe=
nix,
Arizona 85015
' + ENDSHOW_MESG + '
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