TBCE Proposes Amendments to Chiropractic Record Keeping
Written by Editor   
Thursday, December 05, 2013 12:00 AM

The TBCE has proposed an amendment to Rule 80.5 to require that "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."  The proposed rule (law) will require: 

"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."

"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."
"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."
"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."

Read the full proposal here