Documentation, recordkeeping, and patient confidentiality
The clinical record
New Jersey requires chiropractors to maintain legible, contemporaneous records sufficient for another practitioner to understand the care. At minimum, record the history, examination findings, diagnosis, treatment plan, informed consent, dates and types of treatment, patient response, and X-ray findings. Entries must be authenticated and corrected only by dated addenda, never by obliteration.
Retention and confidentiality
- Retain records for the period the Board requires; when in doubt, keep adult records at least seven years after the last visit and minor records until majority plus the same period.
- Release records only with valid written authorization from the patient or legal representative, or as required by law, subpoena, or court order.
- HIPAA privacy rules apply in addition to state law; the stricter rule controls.
- Electronic records need access controls, audit trails, and backup.
Worked example
An attorney sends a subpoena for a patient's entire chart in a personal-injury case. Correct handling: verify the subpoena is valid, confirm patient authorization or a court order, and release only the records requested. Do not release the whole file to the patient's employer or the opposing insurer without authorization. A subpoena is not a blank check, and unauthorized disclosure is a privacy violation.
Traps
- Altering a record after a complaint, converting a documentation problem into a credibility problem.
- Destroying records while an investigation or litigation is pending.
- Releasing records to a spouse or parent of an adult patient without authorization.
- Failing to document a missed appointment, referral, or refusal.