Wisconsin Administrative Code
Chiropractic Examining Board
Chapter Chir 11 - Patient Records
Section Chir 11.02 - Patient record contents
Current through August 26, 2024
(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.
(2) Patient records shall be maintained for a minimum period of 7 years as specified in s. Chir 6.02(27).
(3) Patient records shall be prepared in substantial compliance with the requirements of this chapter.
(4) Patient records shall be complete and sufficiently legible to be understandable to healthcare providers generally familiar with chiropractic practice, procedures, and nomenclature.
(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.
(6) Rationale for diagnostic testing, treatment or other ancillary services shall be documented in or readily inferred from the patient record.
(7) Significant, relevant patient health risk factors shall be identified and documented in the patient record.
(8) Each entry in the patient record shall be dated and shall identify the chiropractor, chiropractic assistant or other person making the entry.
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.
