TBCE Reports: Documentation Rule Updated
Wednesday, May 07, 2014 10:16 PM

You may have heard by now that the TBCE has updated Board Rule 80.5 to more specifically outline what documentation is required to be done by a Doctor of Chiropractic. The amendment to this rule is effective April 24, 2014.

See below for the text of the rule change. Underlined portions are new language, while text struck through has been deleted.

§80.5 Maintenance of Chiropractic Records

(a) An adequate chiropractic record, as described in this section, for each patient shall be maintained for a minimum of six years from [the anniversary date of] the date of last treatment.

(b) If a patient was younger than 18 years of age when last treated by a licensee, the chiropractic records of the patient shall be maintained until the patient reaches age 21 or for six years from the date of last treatment, whichever is longer.

(c) Chiropractic records that relate to any civil, criminal or administrative proceeding shall not be destroyed until the proceeding has been finally resolved.

(d) Chiropractic records shall be maintained for such longer length of time than that imposed by this section when mandated by other federal or state statute or regulation.

(e) Each licensee practicing at a facility and each facility is equally responsible for compliance with this section.

(f) Licensees shall maintain patient and billing records in a manner consistent with the protection and welfare of the patient. A licensee’s patient records shall support all diagnoses, treatments, and billing. Records shall be timely, dated, accurate, legible, and signed or initialed by the licensee or the person providing treatment[, and legible]. Electronic signatures are acceptable.

(g) Licensees are required to perform an appropriate history and exam based on the nature of the presenting problem described by the patient and in accordance with accepted documentation guidelines. Accepted guidelines include, but are not limited to, the latest edition of the American Chiropractic Association Clinical Documentation Manual, American Medical Association CPT Code Book, 1997 DG and/ or Chiropractic Service Manual Guidelines set forth by CMS.

(h) All patient records for an initial visit shall include:

(1) Patient History;
(2) Description of symptomatology or wellness care;
(3) Examination findings, including imaging and laboratory records when clinically indicated;
(4) Diagnosis;

(5) Prognosis;
(6) Assessment(s);
(7) Treatment Plan;
(8) Treatment provided or
recommended; and
(9) Periodic reassessment(s) when
appropriate, with a minimum of once per calendar year.

(i) Each patient visit after the initial visit is considered a subsequent visit unless there is a new illness or injury. The following information must be reported in each patient's file on each subsequent visit:

(1) Updated History

(A) Review of the chief complaint(s);

(B) Changes, if any, since the last visit;

(2) Physical Exam

(A) Examination of the area involved in the diagnosis;

(B) Assessment of any change in the patient's condition since last visit; 

(3) Treatment

(A) Documentation of treatment given;
(B) Documentation of patient’s response to the treatment rendered on that visit

(C) Change in treatment plan or planned referrals if indicated.

(j) All licensed chiropractors shall observe and comply with all documentation laws pertaining to health care providers under state and federal law. Nothing within this section should be construed to constrain or limit the obligation of chiropractors to meet duly authorized law, rules and regulations.