What the statutes mean

This is the section of Wisconsin law that primarily addresses a chiropractor’s clinical obligations to a patient. Instead of defining a standard of care, the Chiropractic Examining Board has approached the issue indirectly by requiring specific items in a chiropractor’s clinical records.

The board’s requirements are an absolute minimum. Their requirements do not specify the number or type of clinical services that a chiropractor should provide to his/her patients. Fulfilling these minimum requirements for record keeping does not mean that a chiropractor has met the “medical necessity” requirements of an insurance company.

Most importantly, the state’s requirement that a chiropractor keep complete and comprehensive patient records applies to every patient with whom the chiropractor consults, examines or treats. The record requirement is the same for all patients, even those that pay for care out of their own pocket.

BASIC CHIROPRACTOR’S CLINICAL RECORD REQUIREMENTS AT A GLANCE

 

Basic Requirement	Practical Advice
Patient records shall be maintained for a minimum period of 7 years as specified in s. Chir 6.02 (27).	This rule applies to clinical records and x-rays. You may destroy administrative records such insurance EOBs and patient sign-in logs whenever you have the information you need for financial purposes.
Patient records shall be prepared in substantial compliance with the requirements of this chapter.	The state requires so little in the way of record keeping that it should not be difficult to prove that you have all of the elements they require. Remember that these rules apply to all patients – even those that pay for their services out of their own pocket.
Patient records shall be complete and sufficiently legible to be understandable to health care professionals generally familiar with chiropractic practice, procedures and nomenclature.	Initial use of your own personal abbreviations is acceptable, however; the records must be transcribed to meet the requirements of this rule every time the record is given to a party outside your practice. The fact that you and your staff can read your handwriting is not enough to satisfy the requirements of the rule. If there is any doubt as to the legibility of your records, they must be transcribed every time the record is given to a party outside your practice.
Patient records shall include documentation of informed consent of the patient, or the parent or guardian of any patient under the age of 18, for examination, diagnostic testing and treatment.	The WCA does not publish an informed consent form because attorneys tell us that no form could possibly cover all of the potential clinical scenarios faced by a patient. A patient is not required to sign an informed consent “form” to meet the requirements of this rule. Alternative documentation is allowed. The best source for advice in this area is your malpractice carrier.
Rationale for diagnostic testing, treatment or other ancillary services shall be documented in or readily inferred from the patient record.	You cannot take x-rays or treat a patient unless your records indicate there is a clinical need for the service. With this portion of the rule, the examining board is clearly indicating the importance of exams and re-exams.
Significant, relevant, patient health risk factors shall be identified and documented in the patient record.	With this portion of the rule, the examining board is highlighting the importance of obtaining the patient’s full and complete health history.
Each entry in the patient record shall be dated and shall identify the chiropractor, chiropractic assistant or other person making the entry.	Since Medicare, Medical Assistance and many insurance companies require the chiropractor to sign or personally stamp each clinical note, it is advisable that you apply this standard to all patient records.

New patient records

Upon presentation of a new patient, patient records must contain the following elements:

• History of the present illness or complaints
This must include significant past health, medical and social history.

• Significant family medical history
This must include health factors which may be congenital or familial in nature.

• Review of patient systems
This must include a review of the cardiovascular, respiratory, musculoskeletal, integumentary and neurologic systems.

• Results of physical examination and diagnostic testing
This must focus on areas pertinent to the patient’s chief complaints.

• Assessment or diagnostic impression of the patient’s condition.

• Treatment plan for the patient. This must include all treatments rendered, and all other ancillary procedures or services rendered or recommended.

Daily notes

For patient visits in which you are carrying out a previously devised treatment plan your daily notes must be made and maintained documenting all of the following:

• All treatments rendered
• All services rendered

• Any significant changes in the subjective presentation, objective findings, assessment or treatment plan for the patient.

Statute excerpts

11.01 Definition
11.02 Patient record contents
Chir 11.01 Definition.

As used in this chapter “patient record” means patient health care records as defined under s. 146.81 (4), Stats.

Chir 11.02 Patient record contents.

(1) Complete and comprehensive patient records shall be created and maintained by a chiropractor for every patient with

11.03 Initial patient presentation
11.04 Daily notes
whom the chiropractor consults, examines or treats.

(1) Patient records shall be maintained for a minimum period of 7 years as specified in s. Chir 6.02 (27).
(2) Patient records shall be prepared in substantial compliance with the requirements of this chapter.
(3) Patient records shall be complete and sufficiently legible to be understandable to health care professionals generally familiar with chiropractic practice, procedures and nomenclature.
(4) Patient records shall include documentation of informed consent of the patient, or the parent or guardian of any patient under the age of 18, for examination, diagnostic testing and treatment.
(5) Rationale for diagnostic testing, treatment or other ancillary services shall be documented in or readily inferred from the patient record.
(6) Significant, relevant, patient health risk factors shall be identified and documented in the patient record.
(7) Each entry in the patient record shall be dated and shall identify the chiropractor, chiropractic assistant or other person making the entry.

Chir 11.03 Initial patient presentation.

Upon presentation of a new patient, patient records shall contain the following essential elements as relevant or applicable to the evaluation and treatment of the patient:

(1) History of the present illness or complaints, and significant past health, medical and social history.
(2) Significant family medical history and health factors which may be congenital or familial in nature.
(3) Review of patient systems, including cardiovascular, respiratory, musculoskeletal, integumentary and neurologic.
(4) Results of physical examination and diagnostic testing focusing on areas pertinent to the patient’s chief complaints.
(5) Assessment or diagnostic impression of the patient’s condition.
(6) Treatment plan for the patient, including all treatments rendered, and all other ancillary procedures or services rendered or recommended.

Chir 11.04 Daily notes.

For patient visits in which the chiropractor carries out a previously devised treatment plan, daily notes shall be made and maintained documenting all treatments and services rendered, and any significant changes in the subjective presentation, objective findings, assessment or treatment plan for the patient.