Chart Review Checklist Form Page 2
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49. Adverse reactions, history of adverse reactions and / or contraindications to care must be prominently noted in
the file, i.e. pregnancy, strokes, history of clots, use of blood thinners, etc.:
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Pass
Fail (noted in summary)
N/A
Notice Given: ____________________
10. Description by the chiropractor or written description by the patient each time an incident occurs that results in
an aggravation of the patient’s condition or a new developing condition:
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Pass
Fail (noted in summary)
N/A
Notice Given: _____________________
11. X-rays taken by the chiropractor / resultant findings
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Pass
Fail (noted in summary)
N/A
Notice Given: ____________________
12. Consultant reports must be in the file and initialed by the treating chiropractor to signify review:
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Pass
Fail (noted in summary)
N/A
Notice Given: ____________________
13. Patient file must be organized and legible. If symbols or abbreviations are used, a key must accompany the file:
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Pass
Fail (noted in summary)
Notice Given: __________________________________
14. The patient record is kept in chronological order and written in permanent ink:
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Pass
Fail (noted in summary)
Notice Given: __________________________________
15. Amended / corrected record entries should be crossed out yet readable, contain a date and a signature:
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Pass
Fail (noted in summary)
N/A
Notice Given: ____________________
16. Daily notes documenting current subjective complaints as described by the patient, any change in objective
findings if noted during that visit, a listing of all procedures provided during that visit and information that is
exchanged and will affect that patient’s treatment must be recorded in the patient file. The daily notes should
be SOAP type format and shall contain date for return visits or a follow-up plan. An expected time for a return
visit or a follow-up plan for each encounter should be in the record. This can be noted by a return visit date
following each entry in the daily record or a treatment plan initiated with the onset of care. No-show and recall
efforts should be documented in the file.
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Pass
Fail (noted in summary)
Notice Given: __________________________________
17. Contains a discharge record that includes the reason for discharge with the patient health status noted:
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Pass
Fail (noted in summary)
N/A
Notice Given: _____________________
18. Contains documentation that family history has been evaluated:
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Pass
Fail (noted in summary)
Notice Given: _________________________________
19. External Documentation Requirement – Documentation to and from external sources is maintained in the
patient’s record (i.e. correspondence to another physician, general correspondence to payers, attorneys, etc.)
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Pass
Fail (noted in summary)
N/A
Notice Given: _____________________
Page 2 of 4
CRM014_Chart Review Checklist
9.1.2011_LN
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