Recordkeeping, Informed Consent, and Patient Rights
Records that satisfy the board
Each patient record should identify the patient, date of service, history, examination findings, diagnosis, treatment rendered, patient response, and informed consent. Entries should be timely, legible, authenticated, and specific enough for another chiropractor to understand the care. Michigan rules require retention for at least seven years from the last treatment; minors’ records should be kept longer under board guidance. Electronic records must be secure and backed up.
Informed consent
Consent must cover the diagnosis, nature of the proposed adjustment or adjunctive procedure, material risks and benefits, reasonable alternatives, and the consequences of declining care. It must be documented. A signed form alone is not sufficient if the discussion did not occur; a documented verbal discussion can support consent.
Patient rights
Patients have rights to confidentiality, access to their records, copies, privacy, dignified treatment, and refusal of care. The provider owns the physical record, but the patient has a legal right to access and obtain copies under applicable law and HIPAA. Minors generally require parent or guardian consent, except emancipated minors or emergency situations.
Worked example
A 16-year-old athlete requests an adjustment while a parent waits in the car. The chiropractor treats and writes “patient consented.” A minor generally cannot consent to chiropractic treatment; treatment without guardian consent may be treated as unprofessional conduct or battery unless an exception applies. The record should identify the guardian, the consent discussion, and the risks explained.
Traps that cost marks
A chart note does not prove informed consent by itself. HIPAA does not eliminate state access rules. Records cannot be destroyed on a short arbitrary schedule. “The patient owns the record” is imprecise; the patient has access rights, not ownership of the original.