Chapter Chir 11

Chapter Chir 11

PATIENT RECORDS

Chir 11.01   Definitions.

Chir 11.02   Patient record contents.

Chir 11.03   Initial patient presentation.

Chir 11.04   Daily notes.

Chir 11.01 Chir 11.01 Definitions. In this chapter:

Chir 11.01(1) (1) “New patient” means an individual who has not been examined or treated by the chiropractor or another chiropractor in the same group practice within the last 3 years.

Chir 11.01(2) (2) “Patient record” has the meaning given for “patient health care records” in s. 146.81 (4), Stats.

Chir 11.01 History History: Cr. Register, May, 1997, No. 497, eff. 6-1-97; CR 17-057: r. and recr. Register August 2018 No. 752, eff. 9-1-18; correction in (2) made under s. 35.17, Stats., Register August 2018 No. 752.

Chir 11.02 Chir 11.02 Patient record contents.

Chir 11.02(1) (1) Complete and comprehensive patient records shall be created and maintained by a chiropractor for every patient with whom the chiropractor consults, examines or treats.

Chir 11.02(2) (2) Patient records shall be maintained for a minimum period of 7 years as specified in s. Chir 6.02 (27).

Chir 11.02(3) (3) Patient records shall be prepared in substantial compliance with the requirements of this chapter.

Chir 11.02(4) (4) Patient records shall be complete and sufficiently legible to be understandable to healthcare providers generally familiar with chiropractic practice, procedures, and nomenclature.

Chir 11.02(5) (5) 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.

Chir 11.02(6) (6) Rationale for diagnostic testing, treatment or other ancillary services shall be documented in or readily inferred from the patient record.

Chir 11.02(7) (7) Significant, relevant patient health risk factors shall be identified and documented in the patient record.

Chir 11.02(8) (8) Each entry in the patient record shall be dated and shall identify the chiropractor, chiropractic assistant or other person making the entry.

Chir 11.02 Note Note: Chiropractors should be aware that federal requirements, especially in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), may have an impact on record-keeping requirements.

Chir 11.02 History History: Cr. Register, May, 1997, No. 497, eff. 6-1-97; CR 18-105: am. (4) Register May 2020 No. 773, eff. 6-1-20.

Chir 11.03 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:

Chir 11.03(1) (1) History of the present illness or complaints, and significant past health, medical and social history.

Chir 11.03(2) (2) Significant family medical history and health factors which may be congenital or familial in nature.

Chir 11.03(3) (3) Review of patient systems, including cardiovascular, respiratory, musculoskeletal, integumentary and neurologic.

Chir 11.03(4) (4) Results of physical examination and diagnostic testing focusing on areas pertinent to the patient’s chief complaints.

Chir 11.03(5) (5) Assessment or diagnostic impression of the patient’s condition.

Chir 11.03(6) (6) Treatment plan for the patient, including all treatments rendered, and all other ancillary procedures or services rendered or recommended.

Chir 11.03 History History: Cr. Register, May, 1997, No. 497, eff. 6-1-97.

Chir 11.04 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.

Chir 11.04 History History: Cr. Register, May, 1997, No. 497, eff. 6-1-97.