Simply noting that the patient should return as needed (PRN) should be considered acceptable depending on the nature of the case.
Other note taking formats should be considered acceptable such as DAP notes.
D = DATA A= ASSESSMENT P= PLAN
In this system, the subjective and objective portions of the note are combined and might be more amenable to chiropractic note taking where the practitioner’s goals revolve more around wellness care. Other similar methods of note taking should be considered acceptable as long as pertinent information is provided. The use of abbreviated notations, examination checklists, and computerized notation systems should be encouraged and considered acceptable as long as patient care is not compromised.
The construction of detailed narrative reports or progress reports may be advantageous in a situation involving litigation or reporting to a third party for various reasons. If this is necessary for the third party to make a decision regarding payment or some other need, then the requesting party should expect to compensate the attending chiropractor for his or her time, effort and energy expended to compile such a detailed report. Administrative costs and time associated with the recording, storage, copying and retrieval of patient records, if overly burdensome, can interfere with what is best for the patient, may distract the doctor from the task at hand, and use up valuable resources.
The performance and/or recording of extraneous examination procedures that are not germane to the evaluation of a particular patient should be discouraged as this wastes time, money and energy and adds nothing to the patient's health benefit. This would include any mandate that an attending chiropractor perform some predetermined procedure(s) such as provocative orthopedic maneuvers or extensive neurological examination procedures, especially if these procedures have been shown to be unreliable or invalid.
_________________________________________________________ Council on Chiropractic Practice Clinical Practice Guideline Number 1 Vertebral Subluxation in Chiropractic Practice – 2003 Update & Revision