The steps to keep everything in focus are not difficult. They are routine in health care and deserve our attention. We suggest you consider the following “Top-Ten” procedures: 1. Complete a pertinent history at the time the patient presents for care. The history should reflect the patient presentation as well as your clinical judgment. 2. Complete a pertinent physical examination, don’t see the patient as low back pain or headaches, see them as a whole. Check their vital signs and provide an examination that correlates with the patient presentation and concerns developed from the history and other elements of the physical examination. 3. Seek additional studies to rule out any contraindications to chiropractic care and a more thorough understanding of the structure of the spine or areas to which care is being provided. 4. Don’t hesitate to refer a patient to another chiropractor or other provider type if you are concerned about the presentation of the patient or any of your examination findings 5. Develop a care plan for each patient, provide them with a complete explanation of the care you propose to provide, do all you can to make certain they understand your recommendations 6. Provide the patient with an “informed consent to care.” Ideally this should include what you are proposing to do, why you feel it is needed, alternative to your care recommendations and the impact of patients doing nothing in response to their circumstances. Document the informed consent in writing, preferably signed by the patient after providing them with an opportunity to ask you any questions about the plan. 7. Document your care, what you did-what was adjusted, how it was adjusted etc., the response to your care, feedback of the patient and any change in circumstances. Always relate their care back to their presenting circumstances and the findings you developed in your evaluation of the patient. If a patient complicates for any reason be as thorough as possible in documenting the events before, during and following the complication. 8. Re-evaluate the patient whenever there has been a change in their circumstances or after a given interval of time or number of adjustments. 9. Maintain and store your records appropriately, remember the demands of HIPAA! 10. Provide the kind of care to each patient that you would like to see your mother, father, brother, sister, husband, wife or child receive. June 22, 2015 On June 16, 2015 the online journal Chiropractic and Manual Therapies published an article entitled “Chiropractic care and the risk of vertebrobasilar stroke; results of a case-control study in U.S. commercial and Medicare Advantage populations” by Kosloff et al. The article concluded in part “We found no significant association between exposure to chiropractic care and the risk of VBA stroke.”
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