The Initial Exam

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

This page is devoted to a full description of what is considered “complete” patient file documentation, as described by National Associations and Third party Payors. It is the intention of this page to inform our profession of the most efficient means of communicating patient information, as well as outlining what is considered adequate documentation.

Association Recommendations

	Initial Clinical Examination Clinical Guidelines for Chiropractic Practice in Canada
	Consultation, History and Examination in Adobe Acrobat PDF (33 KB) OR as a Word document (72 KB) ICA's Clinical Protocols and Guidelines for the Practice of Chiropractic.
	Chiropractic Examination Vertebral Subluxation in Chiropractic Practice (2008) This is an Adobe Acrobat file (1.34 MB). Chiropractic Examination starts on page 55 of 318.
	Patient Examination Guidelines for Chiropractic Quality Assurance and Practice Parameters a.k.a. The Mercy Conference   Refer to Section I
	Chapter 1: Objective: Initial New Patient Physical Examination Wisconsin Chiropractic Association This section forms the objective area of clinical documentation. The complexity of the patient’s health problems will determine which of these elements a chiropractor will choose to use in the patient’s record. A chiropractor’s records detailing problems of greater severity will generally include more of these elements. It may not be necessary to include many of these elements in the records of patients with less severe problems.

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Since 2–18–2001

Updated 12-25-2023