Making Documentation Simple Yet Effective

By: Gerald T. Lalla, DC and Diane Lalla, CW, CA

Plan Your Work—Work Your Plan

Regardless of the type of practice you pursue, every practitioner should be well aware of the need for proper documentation of all aspects of patient care. Not only do regulatory licensing boards and agencies require proper record keeping, but other third parties do so as well. Records are the method by which we inform third parties of what we know about the patient and our care of them. By and large most doctors do not enjoy the paperwork aspect of practice which has led to the development of countless forms, voice activated and other computer generated records. The more legible and comprehensive the documentation, the more a practitioner reduces the likelihood of problems with third parties.

At minimum the patient should be required to complete and sign the following forms: Informed Consent, Cervical Adjustment/Consent/Authorization, and Waiver of Liability. If the patient is a minor, aged, or not capable of understanding or authorizing care, his/her parent or guardian should complete and sign said forms.

Initial and Subsequent Records

Initial and subsequent records should include: claim number, name of the insurance company, date of injury, date of previous examination, examination number, HPI (history of present illness), chief complaint/present symptoms, past surgical history, preexisting conditions, PFSH (past family and social history), medications, date of birth, height, weight, marital status, occupation, ROS (review of systems) and examination findings.

Examination Findings

Examination findings should include the results and patient responses to physical, orthopedic, neurological, and postural examinations. In particular, records should indicate if the patient is expressing spinal locomotion discomfort and if you did or did not note defects, areas of inductions, effusions, masses, lipomas, or nodules in the cervical, thoracic, dorsal, or lumbar spinal muscles. Record should be made of any palpable spinal or other articular subluxations, tenderness, fixations, spasm, or rigidity in the cervical, thoracic and lumbar paraspinal muscles, or other areas of the body. Any signs of skin indurations, subcutaneous nodules, rashes, lesions, ulcers; any cervical abnormalities, masses, lymphatic, or thyroid enlargements, symmetry, and tracheal position should be noted. Results of palpation of the axillae, inspection of the patient’s digits and finger and toe nails, presence or absence of clubbing, dermatitis, xanthomas, scars, cyanosis, inflammation, petechiae, ischemia, infections, Osler’s nodes, vertical or horizontal lines, concavities or convexities, and nail thickness, cracking, chipping, or brittleness, etc. should also be recorded.

Postural Findings

Postural evaluation should include: Any noted postural antalgia, head tilt (right/left), Rust’s Test, mandible movements, shoulder level, anterior posterior cervical curve, Dowagers Hump (present/not present), anterior posterior dorsal curve, anterior posterior lumbar curve, lateral cervical curve, lateral dorsal curve, lateral lumbar curve, leg length measurement, Derifield (lumbar and cervical spine), heel wear: (none/right/left/outside/inside), hip level, were the feet sore, pronated, supinated, measurement of arches, record of palpable subluxations, ranges of motion of the cervical, thoracic and lumbar spine (on a one- or two-inclinometer basis), as well all other appropriate findings.

We make photographs of the patient standing inside the Posture Check® and give the photographs to the patient.

Automobile Accidents

When the patient has been involved in an automobile accident, incurred a workers compensation or other injury where the feet may have been involved, not only should they be examined, but the following and/or similar appropriate statement should be included when appropriate:

“The patient reports that since the accident her/his feet have been sore and notes that they have been turning (out/in). The patient may have jammed her/his feet or foot into the brake pedal/floor board predisposing her/him to foot injury.”

This is of particular importance, because the driver of an automobile involved in an automobile accident will commonly jam her/his left foot into the brake pedal or floorboard, and the reflex of passengers in the automobile will be to jam both feet into the floorboard—the result often being injury to the feet/ankles. This type of injury often goes undetected or is not evaluated during the initial examination. Again documentation is essential and important. If one recommends custom-made functional orthotics and expects third-party reimbursement, it is essential that documentation exists which justifies the recommendation of custom-made orthotics.

Substantiation and Justification

Remember, not only are we held responsible to perform due diligence in examinations, but the history and examination findings give us justification to recommend further diagnostic tests and the treatment plan. As stated in a previous article in Success Express, we recommend that the patient’s written permission be obtained to make digital or Polaroid pictures of the patient’s posture, feet and/or any other areas of objective abnormality or injury. Copies of those postural alterations should be given to the patient as well as included in the copy of records forwarded to third parties.

Treatment Plan

All treatment plans should include the following: any further diagnostic recommendations, referrals, Chiropractic care (including type, number of visits dispensed, over what period of time), therapies, cervical collar, back supports, cervical pillow (Pillo-Pedic®, Ultra®, Pillo-Pedic® Plus, etc.), rehabilitation program and re-evaluation date. Any time any adjunctive devices and/or services are recommended, it behooves the practitioner to include a “statement of necessity” that explains its recommendation and use.


If you are recommending any physiotherapy, you might consider a modification of the following statement (we advise practitioners to attend the seminars sponsored by Foot Levelers, as their instructors provide the latest diagnostic and treatment protocols):

  1. One unit of Neuro/Muscle/Skeletal Re-education and 
  2. Two units of Myofascial Release on average of ___ times per week for ___ weeks.

I told the patient that I would be happy to discuss my specific rehabilitative therapy recommendations with a therapist of mutual choice and/or she/he could utilize the therapy services of one of the professional therapists that work in our clinic. The professionally administered therapies are designed to promote healing of the accident caused traumatized soft tissues and minimize spasm, fixation, and rigidity of musculoligamentous tissues.”

The same holds true if you are recommending cryotherapy, heat, Electro/Muscle Stimulation, Ultrasound, or any other therapies.

Cervical Support Pillow (Pillo-Pedic):

If a cervical support pillow is indicated, you might use a modification of the following statement:

“Based on the history given by the patient, the current symptoms (injuries) and the patient’s responses to examinations performed, it appears reasonable and necessary that the patient begin using a cervical support pillow with the purpose of attempting to afford the patient’s neck better support while sleeping and to promote healing. I have recommended the (Pillo-Pedic, Ultra, Pillo-Pedic Plus, etc.) because it is most suitable to fitting and supporting the patient’ skull and cervical spine as well as promote healing of the soft tissues.”


When in the clinic we use the TRI-FLEX®. For follow-up home rehabilitation we dispense the NECKSYS®, BACKSYS®, and/or THERA-CISER®. Depending on what rehabilitation equipment you dispense for home use, you might want to use an appropriate modification of the following statement in the patient’s treatment plan:

“The isokinetic rehabilitative exercise devices and program are recommended to assist in maximizing the potential value of the patient’s in-clinic and self-help home portion of the rehabilitative exercise program. These recommendations are based on the patient’s history, responses to examinations, as well as documented evidence that this form of rehabilitation is indicated in similar conditions. I am recommending (number of visits ) in-clinic supervised visits which will include training and use of the (Cervical Trauma Care Pack, NECKSYS, BACKSYS, and/or THERA-CISER). This Phase (1,2, 3) will be pursued on each visit through (reevaluation date). See attached illustrations of the rehabilitation device and prescribed program. The BACKSYS and THERA-CISER rehabilitative equipment involves supervised training with the use of specialized elastic bands which promote musculoligamentous and articular joint stretching, increased flexibility, circulation, and functionality to the area(s) noted in the patient’s examinations. (We list the muscles/joints that showed weakness and need for rehabilitation in our reports.) These self-help, home-use rehabilitation activities hopefully will assist healing, pain management, prevent and/or loosen any adhesions, improve circulation and the return to more normal health.”

Insurance Code (Therapeutic Activities)

  • Supervised In-Clinic Rehabilitation Training – each fifteen minutes – 97530
  • Rehabilitations Visits – one unit (15 minutes) for each device utilized – 97530

Insurance Code (Product Supplies/Materials)

  • NECKSYS – 99070
  • BACKSYS – 99070
  • THERA-CISER – 99070

We have scanned the Foot Levelers booklets regarding the NECKSYS, BACKSYS, and THERA-CISER into our computers and print out the appropriate exercises, but the booklets themselves can be used as well. Just sure that the patient is given copies of the appropriate instructions, the instructions are referred to in your treatment plan, copies of the instructions are included in their records, and copies are included in billings to the patient’s insurance company.

Good Record Keepers Are Record Breakers

The major complaint of attorneys and insurance companies regarding Doctors of Chiropractic is poor record keeping. When establishing and/or updating record keeping procedures, the patient and doctor are well served if a system is established and maintained which documents all aspects of the doctor/patient relationship. The more clear and extensive those records are, the greater the likelihood of avoiding problems with third parties.

No Lack of Patients:

There is no lack of patients, but rather, a lack of practitioners who are offering appropriate services to their present patients. Very often those practitioners who contend that there is a lack of patients are—as often as not—not being thorough in taking case histories, performing comprehensive examinations, preparing a whole person treatment plan, or utilizing services that are appropriate to the whole person nature of their present patient. Those who will succeed in the future are going to look at their patients from the feet up and utilize a full and appropriate range of services.

About the Authors

or. Gerald and Diane Lalla practice in Roseville MN. They are the authors of numerous articles and license-renewal seminars on Risk Management and Professional Boundaries.