What if You Fail to Keep Proper Documentation as a Chiropractor?

As a chiropractor, keeping documentation of patient visits may feel like a normal part of the job. Still, its importance is critical when it comes to keeping your professional license in good standing. Unfortunately, many chiropractors keep shoddy or brief records, only to face a patient complaint and realize that they don’t have evidence they need to defend themselves against the accusations. Below you can read more about what to keep in mind when maintaining records and when you may need a licensing attorney for your case. 

The Benefits of Documentation

Licensing boards and federal and state laws require that chiropractors keep sufficient documentation for all patient treatments. While documenting every patient visit can be tedious, it has enormous benefits to you as a chiropractor. 

First and foremost, if you’ve done your job well, documentation can show that you adhered to the accepted standards of care you are expected to extend to your patients. Whether a patient requests their records for review or submit files as part of a complaint hearing, having detailed documentation of treatments can show that you did everything by the book. If a complaint against you goes to court, you can use this evidence to defend yourself. 

In a different scenario, if a patient is referred to another chiropractor or health professional, your records will help ensure that the patient receives proper treatment. Good documentation can also protect you if a patient takes a break from treatment, as you can quickly review your records when they return and refresh yourself on how to proceed with proper treatment.

Documentation can also be immensely useful when you are facing alleged charting or billing errors. If you encounter a medicare or insurance company audit or suffer a catastrophic loss like theft, earthquake, or fire, these records are indispensable. 

Documentation is also vital for the patient, especially if they sought treatment from you after an accident. Submitting detailed records to the insurance company will help ensure that the patient is fairly compensated. 

Common Documentation Errors

By far, the most common documentation error we see among chiropractors is a failure to keep complete records. Some chiropractors argue that they don’t have enough time between appointments to document visits in detail, while others believe they are immune to disciplinary action. Still, others think that they don’t need documentation in some instances, such as simple wellness visits, a patient whose condition has not changed during recent appointments, or when a patient pays cash. In reality, this could not be further from the truth, especially if a patient files a complaint against you. 

While it’s tempting to believe that you could quickly recreate patient records if a complaint is brought against you, chiropractors who skimp on records often find themselves in hot water when a claim is investigated. It is because it’s really not possible to remember all of the details of a patient’s treatment weeks or months after the fact. If a case is severe enough to go to court, any records created long after treatment occurred will almost certainly be contested. 

When to Seek Legal Help

If you are a chiropractor facing disciplinary action or an investigation, getting a professional license defense is likely in your best interest. An experienced licensing attorney will understand the legal complexities that chiropractors face and can build a case that will help you get the best possible outcome in court. 

Scott J Harris has successfully defended many chiropractors over the years, and he may be able to help you. Get in touch with us today for a free consultation at 323-794-0701.

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This blog is meant to be informational. It is not meant to be all-encompassing legal advice. If you are facing a situation involving your professional license, seek counsel from a licensed attorney.