The Cervical Adjustment and the Missing Adverse Event
Mrs. Grant, 58, receives a cervical manipulation for neck pain. She has osteoporosis and takes warfarin; she did not tell Dr. Kim, and the intake form asks about blood thinners but the box is blank. The form was completed at the front desk and Dr. Kim did not review it before treatment. During the adjustment she feels dizzy and has visual blurring. Dr. Kim tells her to sit for 10 minutes, documents tolerated well, no adverse reaction, and does not record the dizziness. Two days later she goes to the emergency room with a vertebral artery dissection. Her daughter files a Board complaint. Dr. Kim's chart has no informed consent form and no record of the risks discussed; the visit note is two lines.
1. Identify the documentation and informed-consent failures in Dr. Kim's record.
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The record fails to document review of the intake form: the blood-thinner question was blank despite warfarin and osteoporosis, both relevant to manipulation risk. There is no informed consent covering the risks of cervical manipulation, including dizziness, visual changes, and rare vascular events. The note says tolerated well, no adverse reaction even though the patient became dizzy with visual blurring; that is inaccurate. It omits the 10-minute observation, vital signs, and any referral. A two-line note is insufficient for a high-risk cervical visit. Accurate, contemporaneous documentation should record the history, consent discussion, technique, patient response, adverse event, and follow-up plan.
2. How should Dr. Kim respond to the Board complaint filed by the patient's daughter?
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He should cooperate, preserve the original record, and not alter or backdate it. He may write a clear, factual response describing the visit, the consent discussion, the symptoms, and the referral or advice given. If the record is incomplete, he may add a dated addendum stating what he recalls, but he must not make it appear contemporaneous. He should notify his malpractice carrier and obtain legal advice. He should avoid contacting the family to discourage the complaint. Remediation such as consent forms, red-flag screening, and documentation training can be presented, but the Board will focus on whether he met the standard of care and whether the record is truthful.
3. What risk-management steps should the practice adopt for cervical manipulation after this event?
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Screen for red flags and contraindications, including anticoagulation, osteoporosis, recent trauma, and vascular symptoms. Use a procedure-specific consent that lists material risks and alternatives. Document the pre-manipulation examination and the patient's response. Observe patients with new dizziness or visual symptoms and refer urgently for medical evaluation. Train staff to complete intake forms and flag blank answers. Audit records for accuracy. Do not use preprinted tolerated well language. These steps address both patient safety and the evidentiary record the Board will review.