Code of Colorado Regulations
700 - Department of Regulatory Agencies
707 - Division of Professions and Occupations - Board of Chiropractic Examiners
3 CCR 707-1 - CHIROPRACTIC EXAMINERS RULES AND REGULATIONS
Section 3 CCR 707-1.21 - RECORD KEEPING REQUIREMENTS

Universal Citation: 3 CO Code Regs 707-1 ยง 21

Current through Register Vol. 47, No. 17, September 10, 2024

This Rule is promulgated pursuant to sections 12-20-204 and 12-215-105(1)(a), C.R.S.

Documentation of the patient's current and past health, medical, surgical, and medication history, presenting complaint(s)/the reason for the clinical encounter, progression of care, diagnosis, prognosis and treatment plan must be reflected in the record keeping and written reports of the patient file. Records are required to be contemporaneous, legible, utilize standard medical terminology or abbreviations, contain adequate identification of the patient, contain adequate identification of the provider of service and indicate the date the service was performed. All professional services rendered during each patient encounter should be documented. Any addition or correction to the patient file after the final form shall be signed and dated by the person making the addition or correction. The following minimum components must be documented within the patient file:

A. The following minimum components must be documented within the patient file:

1. The patient's identifying information, and identity of the treating Chiropractor and all health care providers;

2. The reason for the clinical encounter, including any subjective complaints and pertinent history;

3. The current vitals as clinically indicated;

4. The current objective findings and results of diagnostic studies;

5. The diagnosis and/or assessment of the patient's condition;

6. A management and/or care plan, including the recommendations, intended goals, prognosis, modifications to the plan, and the procedures provided; and

7. Evidence that the patient was informed of any material risk relative to a proposed treatment/procedure and consented to receive this treatment/procedure.

B. Ancillary Documentation:

1. Correspondence sent and received.

2. Specialty reports (diagnostic imaging, laboratory results, nerve conduction studies, etc.).

3. Communications (telephone conversations, dialogue with patient guardian or other healthcare providers).

C. Patient clinical records shall be maintained for a minimum of seven years after the last date of treatment or examination, or at least two years after the patient reaches the age of eighteen, whichever occurs later.

D. When the destruction cycle is imminent, written notice to the patient's last known address, or notice by publication, must be made sixty days prior to destruction allowing a thirty (30) day period wherein the patient may claim his/her records. When a patient claims such records, the records must be provided to the patient, or legal guardian, at no charge; however, recovery of appropriate postage and handling costs is permitted.

E. Records shall be destroyed in a manner that totally obliterates all information contained in the record such as by incinerating, shredding, or permanently deleting.

F. Records may not be withheld for outstanding/past due professional fees. A reasonable fee for copying records may be assessed to the requesting party.

G. If patient records are maintained electronically, then an off-site, secure back-up and data recovery system must be in place. Contemporaneous documentation is required regardless of whether electronic record keeping is accessible.

Disclaimer: These regulations may not be the most recent version. Colorado may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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