Mechanics of Documenting Examination

Steps to Document Chiropractic Examination

After establishing the patient’s history as the basis to prove the medical necessity of care, chiropractors must perform and appropriately document a complete chiropractic examination. This documentation includes:

• Tests performed – typically chosen from your most commonly-used orthopedic and neurological tests performed in your chiropractic office. You may include the indications found in the history that resulted in your ordering these tests.
• Documenting process – make sure to define how you will enter examination data into your chiropractic documentation, including how, when, and by whom your chiropractic documentation will be completed as a part of your Policies and Procedures in your chiropractic practice.

The goal of proper chiropractic documentation is always the utmost care for your chiropractic patient, continuing to tell the story of your patient’s ongoing complaints and their current condition, while proving medical necessity, where appropriate.