Discipline for Recordkeeping and Informed Consent Violations
Dr. Maria Gonzalez, a chiropractor in Birmingham, treated a 35-year-old female patient for neck pain over six visits. During the initial visit, Dr. Gonzalez performed a cervical manipulation without obtaining a written informed consent. The patient later developed a vertebral artery dissection and suffered a stroke. The patient's medical records, obtained by the Board, contain only brief notes: 'Neck pain. Adjusted C1-C2. No complications.' There is no documentation of the risks of cervical manipulation, no record of the patient's chief complaint, history, or physical exam findings, and no treatment plan. The patient files a complaint with the Board, alleging that Dr. Gonzalez failed to obtain informed consent and kept inadequate records. The Board investigates and charges Dr. Gonzalez with violations of the chiropractic practice act and board rules.
1. What recordkeeping requirements apply to chiropractors in Alabama, and did Dr. Gonzalez's records comply?
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Alabama Board of Chiropractic Examiners Rule 190-X-5-.01 requires chiropractors to maintain accurate and complete patient records. At a minimum, records must include: patient identification, date of service, chief complaint, history, physical examination findings, diagnosis, treatment plan, informed consent, and a description of the treatment provided. Dr. Gonzalez's records are grossly deficient. She failed to document the patient's history, exam findings, diagnosis, and treatment plan. The note 'Adjusted C1-C2. No complications' is insufficient. The lack of informed consent documentation is also a violation. Under Alabama law, informed consent is required for procedures with material risks; cervical manipulation carries a known risk of vertebral artery dissection. The Board's rules likely require documentation of informed consent discussions. Therefore, Dr. Gonzalez violated both recordkeeping and informed consent requirements.
2. What disciplinary actions could the Board impose, and what factors would be considered in determining the sanction?
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The Board may impose sanctions including reprimand, probation, suspension, revocation, or a civil penalty. Under Ala. Code § 34-24-160, grounds for discipline include gross negligence, incompetence, and violation of board rules. The Board would consider: (1) the severity of harm-the patient suffered a stroke, a catastrophic injury; (2) whether Dr. Gonzalez's failure to obtain informed consent was a proximate cause; (3) the pattern of inadequate recordkeeping; (4) any prior disciplinary history; (5) evidence of remediation; and (6) aggravating factors such as failure to recognize and document risks. Given the severe harm and the fundamental nature of the violations, the Board might impose a suspension, require additional education on recordkeeping and informed consent, and impose probation. Revocation might be considered if there is a pattern of negligence, but the Board may consider mitigating factors such as cooperation and lack of prior violations.