California chiropractors must keep detailed patient records or risk violating their professional licenses.
Consider the following vignette:
1) Ima Chiro is a licensed chiropractor in California who has been in practice for 10 years. Today she is seeing her long-term patient, Ura Patient, for her ongoing lower back pain. Ura has been Ima’s client for several years, over which time Ima and Ura have become friends. While they have never seen each other outside of the office, they often discuss details of their lives during their office visits. Today during their appointment, Ima tells Ura that she is getting a divorce. Ima becomes emotional while sharing the details. Ima then adjusts Ura’s thoracic spine, after which Ura briefly loses consciousness on the table. When Ura wakes less than one minute later, she complains of pain in the thoracic area. Ima performs a few tests on Ura’s spine, but all appears okay. The next morning, Ura calls Ima saying that she cannot walk correctly and that her right leg is dragging. Ima tells Ura to come to the office immediately and arranges to have a neurologist on site to examine Ura. Ura refuses and says that she will find her own neurologist and will not be returning to Ima’s office. Ima does not see Ura as a patient again. Ima is later notified that Ura is suing Ima for medical malpractice. Shortly thereafter, Ima receives notice from the California Board of Chiropractic Examiners (BCE) that Ura has filed a complaint against her. Ura’s patient file is requested, and Ima’s career and reputation are threatened.
The above example underlines the importance of establishing proper documentation as a chiropractor. Keeping detailed patient charts protects both patient and practitioner, yet some practitioners still choose either not to chart or to chart very briefly.
Documentation benefits the chiropractor by providing:
• Proof of the standard of care in the event that patient records are requested, such as by a patient or by a representative of the BCE upon presentation of a patient’s written consent or a valid legal order.
• Protection against insurance company or Medicare audits.
• Protection in the event of catastrophic loss such as theft, fire, earthquake.
• Proof of continuity of care to the patient when a patient is referred to another professional, when a considerable period of time elapses between patient appointments, or if a patient is transferred to a different chiropractor in the event of the unanticipated death/illness of the original chiropractor.
• Protection in the event of legal proceedings between chiropractor and patient.
• Protection against charting or billing errors.
Documentation benefits the patient by providing:
• Treatment details for third-party reimbursement.
• Reminders to the practitioner of a patient’s medical history and treatment plan.
• Continuity of care to the patient when a patient is referred to another professional, when a considerable period of time elapses between patient appointments, or if a patient is transferred to a different chiropractor in the event of the unanticipated death/illness of the original chiropractor.
The duty to maintain complete patient files is regulated by federal and state laws in addition to professional licensing boards and benefits both chiropractor and patient.
So why do some chiropractors choose either not to chart or to keep minimal documentation?
Some chiropractors believe that a cash-paying patient or a wellness visit does not require documentation. Others reason that there is not enough time between patient appointments to chart in addition to tending one’s personal needs such as grabbing a quick bite or returning patient calls. Some may believe that keeping records could violate a client’s confidentiality if records are sought by third parties, such as insurers. Others feel there is nothing new to add to a patient’s chart after every appointment. Some erroneously assume that disciplinary action will never occur to them and, if it ever did, mistakenly believe that patient records could be cobbled together at that time. Many also believe that they will accurately remember relevant case details if ever needed, but it is important to note that a complaint may take several months to review and/or resolve.
It is important to remember that the details within a patient’s file are of critical importance when a licensing board decides whether to pursue disciplinary action after receiving a patient’s complaint. If it’s not in the record, it didn’t happen. Chiropractors must understand the laws, standards, and state licensing board requirements pertaining to patient documentation. If you have a patient visit, visit your notes.
If you are a chiropractor facing disciplinary action, it is imperative to enlist the assistance of an experienced licensing attorney at the earliest stage of the disciplinary process. The Law Offices of Lucy S. McAllister are here to help. We understand the unique legal complexities facing chiropractors. We have the knowledge and experience to craft a comprehensive strategy and are dedicated to navigating your specific case through the disciplinary process to best defend your professional interests.
The Law Offices of Lucy S. McAllister have successfully represented a wide range of California licensed professionals including chiropractors, mental health practitioners, accountants, engineers, and medical professionals such as nurses, physicians, and dentists. We are experienced in handling all types of licensing issues. Let us help you protect your professional license, your reputation, and your livelihood.
For additional information or to schedule a consultation on a professional licensing issue, please contact us today at (877) 280-9944.
For Additional Information
Board of Chiropractic Examiners – File a Complaint
State of California Board of Chiropractic Examiners – Rules and Regulations