By clearly capturing clinical decisions, tailoring treatment plans to each patient and maintaining compliance with legal and ethical standards, strong documentation safeguards patient safety, strengthens professional accountability and ultimately leads to better outcomes.
By clearly capturing clinical decisions, tailoring treatment plans to each patient and maintaining compliance with legal and ethical standards, strong documentation safeguards patient safety, strengthens professional accountability and ultimately leads to better outcomes.In speaking with chiropractors, chiropractic assistants, and support staff, one topic often discussed is the need for and requirements of documentation. In the past, patients often turned to chiropractors only as a last resort; however, we are now frequently their first choice. This shift means medical professionals no longer screen our patients for conditions beyond subluxations, increasing both our clinical and legal responsibilities. The primary defense for any practitioner continues to be documentation. We have a greater responsibility to document services in a way that is within acceptable standards of care.
There are many new technologies and treatments that did not exist just a short time ago. One of the most prominent changes is the rise of light-based products such as lasers, light therapy pads and LED beds. These modalities will be used as examples throughout the article.
Why is documentation important?
Memorializes care: Documentation serves as both a shield and a lens, protecting you from liability while allowing you to clearly track a patient’s clinical journey. Proper notes guide you through complex clinical scenarios and ensure that, should questions arise, you can confidently demonstrate the soundness of your decisions and actions.
Provides continuity: Documentation captures the nuances of clinical judgment, validates your choices and interventions. Adequate records ensure continuity of care from provider to provider. Robust records foster trust among colleagues, regulatory bodies and most importantly, your patients. By investing in acceptable documentation practices, we preserve the integrity of chiropractic as well as those who entrust us with their health.
Complies with standards of care, laws and regulations: Documentation is the cornerstone of professional accountability. Maintaining compliance with established standards of care is not merely a bureaucratic exercise; it is a demonstration of your dedication to excellence. This vigilant attention to detail provides a foundation for quality assurance initiatives and ensures your practices withstand the scrutiny of audits or peer review.
Avoids billing issues: Clear, comprehensive documentation also streamlines the often-complex interface between providers and payers. By aligning your clinical records with best-practice benchmarks, you minimize the risk of misunderstandings, reduce administrative burdens and create a defensible trail of care that anticipates the questions of insurers and regulatory agencies alike. Medical review policies often deem light-based therapies “experimental, unproven and investigational,” and regardless of what the provider may know to be true, the service is commonly not covered. Non-coverage does not remove the requirement for adequate documentation.
Helps manage risk: Detailed records serve as your strongest ally. They provide a chronological account of clinical decision-making, demonstrating each step rests on sound judgment and established protocols. Such documentation substantiates the appropriateness of care and ensures providers are prepared to respond to any queries that may arise from patients, payers or legal bodies.
Two formats
There are technically two formats: 1. Evaluation and management (E&M) and 2. daily notes (Medicare distinction).
Elements of E&M services are where the narrative transitions from general principles to patient-specific action. It is here providers synthesize the collected history (Hx), examination (Ex) and diagnoses (Dx) to generate a specified plan of care (POC) that would justify their course of treatment. E&Ms provide the first opportunity to report the clinical rationale for any and all potential services such as laser and light therapy. Additionally, it is in the E&M the “laundry list” of possible treatments and recommendations over the course of care can be described. E&Ms report changes from exam to exam.
Required elements for E&M services:
• Medical necessity/rationale for possible services correlating history and examination
• Possible locations(s) of service(s)
• Type(s) of device(s)
• Constant attendance or supervised
• Probable time of treatment
• Likely settings of device
• Short- and long-term goals for the treatment
• Informed consent
Elements of daily notes are described as subjective (S), objective (O), assessment (A) and plan (P), which form the acronym SOAP. Daily notes are specific to that date of service. Daily SOAP notes report changes from visit to visit.
Required elements for daily SOAP notes:
• Oral informed consent
• Rationale for service linked to the subjective and objective findings for the day
• Actual locations(s) of service(s)
• Type of device
• Constant attendance or supervised
• Application technique to include any necessary safety concerns, e.g., goggles
• Time of treatment
• Settings of device
• Staff ID if not DC
• Coding
• Response at completion of treatment
Additional elements unique to light such as a laser:
The information above is designed to work with many approaches and techniques. In keeping with our example of laser therapy, you would make sure to document:
• Laser penetration
• Technique you are applying
• Effective dosage
• Physiological treatment goals
• Health/safety precautions
• Results of treatment
What if I am a cash-only or mostly-cash practice?
There are no simplified versions of either the E&M or daily SOAP notes based on financial category. Some practitioners believe if they are not billing insurance, thorough documentation is unnecessary. This is unequivocally wrong. A note is a note. The volume of information in a wellness note would certainly differ from that of a note in a personal injury or worker’s compensation case, but both must have the same elements. Do not fall into the trap of doing less because the patient is paying cash. State regulatory boards and malpractice cases do not have a different standard and neither should you.
EHR/EMR templates
Templates found in most electronic health/medical records systems make documentation easier. Once the initial E&M and daily SOAP notes are created, there is generally little day-to-day change. With caution, carrying over recurring information is acceptable as long as changes are made within the note.
Enter artificial intelligence
Artificial intelligence (AI) is a game-changer. Although the technology is in place, the legality lags behind. There are many questions still open, including:
• Who owns the full transcript?
• Is the full transcript considered the actual record?
• Is the treatment state a dual consent state for recording along with HIPAA confidentiality, records retention, state regulations and more?
What to do
• Everything mentioned to this point.
• Document unusual events such as noncompliance with care.
• Record all patient contacts including telephone calls, date and time of call.
• If handwritten, records must be legible and in ink (black or blue).
• If you make a mistake, just put one line through it and initial the correction.
• Identify the patient’s name, date and date of birth.
• Use standard medical abbreviations only.
• If billed to a carrier, point on the claim form to connect ICD-10 code to CPT/HCPCS.
What to avoid
• Don’t erase.
• Don’t create notes in batches; complete notes contemporaneously.
• Don’t use white-out.
• Don’t treat relatives, friends or staff differently than any other patient.
• Don’t ignore changes in laws, regulations, policies, etc.
• Don’t backdate or alter records.
• Don’t say anything disparaging about the patient.
• Don’t criticize other providers.
• Again, don’t create notes in batches.
Final thoughts
Thorough documentation forms the backbone of effective chiropractic practice. It ensures care is accurately tailored to each patient’s needs, supports sound clinical decision-making and guides personalized treatment planning. Maintaining clear, compliant records also upholds legal and ethical standards, reinforcing professional accountability and safeguarding patients. Ultimately, strong documentation practices enhance the quality of care delivered, leading to better patient outcomes and greater overall satisfaction.
Mark Davini, DC, DABCN, CPCO, is a 1981 graduate of Palmer College of Chiropractic and has more than 24 years in active practice. Davini has served as chairman of the Massachusetts Board of Registration of Chiropractors, vice president of Public Information and Education and chairman of the Ethics Committee for the Massachusetts Chiropractic Society. He can be reached at 508-612-9087,
mark@toolsofpractice.com or toolsofpractice.com.
Rob Berman, MBA, is a partner at Berman Partners LLC, a medical device sales and marketing company. Berman Partners specializes in new and pre-owned therapeutic lasers. He also is partner at Energia Medical LLC, which specializes in light therapy and vibration products. He helps doctors improve patient outcomes while increasing their income. He can be contacted at 860-707-4220, rob@bermanpartners.com or bermanpartners.com.
