Each patient's health care record must include documentation of all services performed in a chiropractic physician's office. All diagnostic studies performed or ordered must be recorded in the patient's file and a report shall accompany the procedure.

The Board's laws and rules require release of patient records upon written request of the patient or patient's representative.

The Board has approved the following documents and courses to improve documentation and record keeping:

OAC § 4734-8-04 Documentation and Record Keeping

(A) Chiropractic physicians shall maintain proper, accurate, and legible records in the English language documenting each patient's care. If non-standard codes or abbreviations are used, a key for interpreting this information shall be included in the file.

(B) Each patient's health care record shall include documentation of all services performed in the chiropractic physician's office.

(C) All diagnostic studies performed or ordered by a chiropractic physician shall be documented in the patient's health care record. A report shall accompany each diagnostic procedure performed by the chiropractic physician.

(D) Records, including x-ray films shall be maintained on site for current patients and may be stored off-site for former patients. Records shall be maintained in a safe, confidential, and secure location. Patient records shall be destroyed in a confidential manner, such as shredding or burning, and the records retention schedule is as follows:

(1) Five years beyond when a patient either terminates care or is discharged from care by the chiropractic physician;

(2) Records pertaining to minors shall be maintained for two years beyond the minor's 18th birthday, or five years from the termination of care, whichever is longer;

(3) Records which contain information pertinent to contemplated or ongoing legal proceedings which the chiropractic physician has knowledge or notice of shall be kept for two years beyond the conclusion of the legal proceedings, or five years from the termination of care, whichever is longer;

(4) Radiographs (x-rays) over five years old may be destroyed, or in the case of minors, shall be maintained for two years beyond the minor's 18th birthday, or for five years after taken, whichever is longer.

(E) Patient records are the responsibility of the treating chiropractic physician. If the chiropractic physician was the employee of another chiropractic physician, then the records belong to the employer. However, if a corporation or another entity employed the chiropractic physician, the Ohio licensed chiropractic physician who is the majority owner of the corporation or entity owns the records and is responsible for their custody and disposition.

(F) Chiropractic physicians shall release patient records pursuant to Section 3701.74 et. seq. of the Ohio Revised Code.

(G) A chiropractic physician who wishes to close his or her practice shall make provisions for the housing of his or her patient records with another chiropractic physician and shall attempt to notify his or her patients in writing of the location of their files. If a chiropractic physician dies, becomes incapacitated or otherwise unable to practice, his or her executor, guardian, administrator, conservator, next of kin, or other legal representative shall endeavor to either return the patient files to the affected patients, or to transfer the records to another chiropractic physician. In either case, the chiropractic physician, executor, guardian, administrator, conservator, next of kin, or other legal representative, or probate court shall notify the board of the location of the patient files. Any person who takes custody of chiropractic patient records is bound to protect the safety, security, and confidentiality of those records.
Effective: 8-1-07
R.C. 119.032 review date: 8/1/2012

OAC § 4734-8-05 Examination and Prescription Protocols

(A) A chiropractic physician shall conduct an appropriate evaluation of a patient prior to initiating treatment. Such evaluation shall include at least the following elements:

(1) History;
(2) Examination;
(3) Clinical impression(s);

(B) The history, examination, findings, and clinical impression(s) shall be documented in the patient file or in another readily accessible medium. Further evaluation and management shall be conducted as needed, based on each patient's condition in accordance with prevailing standards of care.

(C) Once a chiropractic physician prescribes care for the management of any condition, the chiropractic physician shall record the treatment plan prescribed for management of the diagnosed condition(s).
Effective: 8-1-07