As a general guideline, documentation of the patient’s first visit should include, but is not limited to:

• Date of visit;

• History and physical including a chronological description of the development of the patient’s present problem from onset to present;

• Chief complaint or purpose for the visit;

• Allergies;

• Objective findings, including physical examination and current clinical condition;

• Patient’s expectations and goals for chiropractic treatment;

• Functional limitations;• Diagnosis or impression;

• Treatment plan, including diagnostic and radiologic tests and results;

• The patient’s informed consent;

• Treatment administered and anticipated frequency and duration of treatment;

• Treatment results, including complications;

• Prognosis;• Medication therapy, or other therapies;

• Special procedures anticipated;

• Education provided;

• Follow-up instructions and appointments; and

• Signature of practitioner and professional designation.

As a general guideline, documentation of each subsequent visit should include,

but is not limited to:

• Date of visit;

• Reason for the encounter and relevant history;

• Area and/or condition for which treatment was provided;

• Treatment provided, including positioning and padding of the patient during treatment;

• All formal or informal education;

• Review instructions about home-care programs, including a statement of the patient’s safe demonstration and understanding of the covered aspects of the programs;

• Subjective comments or complaints made by the patient;

• Physical examination findings;

• Pertinent prior diagnostic test results;

• Appropriate health risk factors;

• Patient’s response to treatment;

• Incidents or lack thereof;

• Patient’s progress or lack thereof;

• Changes in treatment and the patient’s response;

• Assessment, clinical impression or diagnosis/revision of diagnosis;

• Current or continuing prognosis;

• Rationale for any deviations in the plan of care;

• Plan for continuation or discontinuance of care/treatment; and

• Signature of practitioner and professional designation.