Cervical Manipulation After Dizziness and Blurred Vision
A 42-year-old woman sees an Indiana chiropractor for three days of neck pain and a new headache. She also reports dizziness, blurred vision, and nausea that began after a minor traffic collision. The chiropractor does not take a full history, does not check vital signs, and does not document a neurologic examination. He performs a high-velocity, low-amplitude cervical manipulation. The clinic uses a one-page 'consent' that says only 'I agree to chiropractic treatment.' No risks, benefits, alternatives, or questions are discussed. Two days later the patient goes to an emergency department and is diagnosed with a vertebral artery dissection. The chiropractor's note, written after the patient calls to report the diagnosis, states: 'Patient tolerated adjustment well; no complications; consent obtained.'
1. Evaluate the informed consent and red-flag management in this case.
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Informed consent in Indiana requires more than a signed line. The chiropractor should have explained the nature of the condition, the proposed cervical manipulation, its material risks-including the rare but serious risk of vertebral artery dissection-the expected benefits, reasonable alternatives, and the consequences of declining care. He should have invited questions and documented the discussion. A form saying only 'I agree to chiropractic treatment' does not show that the patient understood the risk. The red flags make the consent problem worse. New headache after trauma with dizziness, blurred vision, and nausea can suggest a vascular or neurologic problem; high-velocity cervical manipulation should be deferred until the patient is medically evaluated. The correct response would have been to take a full history, check vital signs, perform and document a neurologic examination, and refer urgently. If the patient had been cleared and manipulation was still appropriate, consent should have been obtained and charted before the adjustment, not after the emergency diagnosis.
2. What recordkeeping deficiencies exist, and how should the chiropractor handle the note written after the adverse event?
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The record has several deficiencies: no full history, no vital signs, no neurologic examination, no diagnosis or clinical rationale, no consent discussion, and no contemporaneous note. The note written after the patient called is also a serious problem because it appears to be an attempt to create consent after the fact. A late entry is permissible only if it is clearly labeled as late, dated and timed, and explains why it is being added; it must not change or backdate the original record. The chart should contain the patient's presenting complaint, trauma history, red flags, examination findings, vital signs, neurologic screen, diagnosis, treatment options, informed consent discussion, the treatment given, the patient's response, and any referral. Because this patient developed a dissection, the chiropractor should not alter the original note, should preserve all records, should cooperate with any Board or insurer inquiry, and should notify his malpractice carrier. The Board can discipline for inadequate records and for failing to obtain informed consent even if the patient cannot prove causation.