Documentation Requirements

Documentation Requirements The chiropractor must maintain auditable records that substantiate the services provided. At a minimum, the records must contain the following on each patient: A. The dates of services provided. B. The patient’s presenting complaint. C. Date of the x-ray which must be within twelve (12) months of the date of service. D. Expected date of delivery if the patient is pregnant. E. Date of last menstrual period if a pregnancy is suspected but not confirmed. F. Child’s date of birth when the child is twelve (12) years of age or less. (The x-ray is at the discretion of the chiropractor). G. The results/findings of all diagnostic studies. H. The patient’s history and physical findings. I. The treatment rendered, including: 1. Frequency, 2. Proposed length, 3. Progress, and 4. Prognosis. J. The chiropractor’s signature.