« Back to Guides

Australian Chiropractic Board Notes Compliance

Instinctive Notes aims to help you meet your compliance requirements with the Chiropractic Board of Australia Guidelines for clinical record keeping. Here is a detailed outline of the support you receive.

The sections follow the board guidelines. You can download a copy of these guidelines at the Codes and Guidelines page of the Chiropractic Board Web Site.

1. Responsibilities

This section discussed general professional and legal responsibilities for Chiropractors. It involves the need to record clinical records for each patient and to keep information confidential and secure.

Instinctive Notes is designed to securely store all clinical records for your patients confidentially and securely. Encryption is used across all components of the application and access to customer information is restricted. You can see full details of our approach to security in our security guide.

2. General principles to be applied

a. Clinical records can be kept in either paper or electronic format. Any electronic format should be the equivalent of any paper format and should be able to be printed.

>> Instinctive Notes stores all patient records electronically, either as treatment notes or as attachments you provide. Treatment notes and attachments can be viewed and downloaded by you and printed at any time.

b. Each patient should have an individual health record containing all the health information ( radiographs excepted) held about them.

>> Every patient has a separate health record and all information is stored against this record.

c. A chiropractic clinical record should be made at the time of the consultation or as soon thereafter as practicable or as soon as information (such as test results) becomes available. It must be an accurate and contemporary reflection of all consultations or interactions. If the date the record is made is different to the date of the consultation, the date the record is made and the time and date of the consultation must be noted.

>> This is largely your responsibility to be timely and accurate in your note taking. Instinctive Notes records both an appointment time and the time the note is recorded automatically. Instinctive Notes provides a listing of appointments that are missing notes to help you keep on top of your note taking responsibilities and never miss a note.

d. Entries on a clinical record must be made in chronological order.

>> Notes are recorded with both the appointment time and the time recorded. All note listings are in order of appointment times, unless an appointment was not registered in Instinctive Notes in which case the note recorded time is used. Even if some notes are delayed, or taken out of order, they will be presented in chronological order of when each patient was seen.

e. Chiropractic clinical records must be legible and understandable and of such a quality that another chiropractor could read and reasonably understand the terminology and abbreviations used and, from the information provided, be equipped to manage the care of the patient. The Australian Dictionary of Clinical Abbreviations, Acronyms and Symbols is a useful resource for practitioners regarding abbreviations. It may be helpful for individual practitioners to maintain a readily accessible glossary of common abbreviations that they use to assist subsequent practitioners.

>> As an electronic record Instinctive Notes is always legible. Standard codes are used to describe many chiropractic techniques which makes them unambiguous. Custom codes are always standardised within a practice so an abbreviation is unambiguous and always means the same thing for all practitioners in the practice. Other lists, for muscles, cranials, limbs and organs, are standardised and unambiguous. The descriptions of all standard codes used in Instinctive Notes is available if required, just contact us for more details.

f. If documents are scanned to the record, such as external reports, the scanning needs to be undertaken in a way that retained the legibility of the original document.

>> Instinctive Notes allows attachments of reasonable size to be attached to the patient record. It is your responsibility to ensure legibility before an attachment is uploaded. Attachments taken directly with the Instinctive Notes App will be legible.

g. Chiropractic clinical records must be able to be retrieved promptly when required.

>> Instinctive Notes provides a quickly searchable list of all clients, available at all times, with their complete treatment record, attachments and schedule history available.

h. Chiropractic clinical records must be stored securely and safeguarded against loss or damage, including a process for secure transmission and a backup of electronic records.

>> All information, including client records, are stored in Australia and securely encrypted at all times. All access to data is by secure connection. Data is stored in multiple redundant databases at separate locations to guard against data loss. Data is backed up daily and restore operations are in place to rebuild lost data if necessary.

i. All comments in the clinical record should be clinically relevant, respectful of the patient and be couched in appropriate clinical, objective language.

>> This is your responsibility during note taking.

j. Chiropractors should be familiar with, and adhere to the requirements in the Board’s Code of Conduct for Chiropractors that relate to record keeping.

>> This is your responsibility during note taking.

k. Corrections can be made to a clinical record either at or after the time of original entry. The correction must be initialed, dated and tracked by the practitioner and the original entry must still be visible or digitally traceable.

>> Corrections can be made to any treatment note. Instinctive Notes records the change, who made it and the reason for the change. The original entry and every correction are stored in case the information is required in the future.

l. A treating chiropractor must not delegate responsibility for the accuracy of information in the chiropractic clinical record to another person.

>> This is your responsibility during note taking.

m. A treating chiropractor must recognise and facilitate a patient’s right to access information contained in their clinical records. If a patient disputes the information then it should be removed, unless the practitioner disagrees. In the latter situation, the record should be maintained with a note stating the patient’s beliefs about the accuracy of the record.

>> Corrections to information can be made. Explanatory notes can be added to the patient record, or to individual clinical notes, in the case where further detail regarding corrections and client requests are needed.

n. The transfer of health information must be done promptly and securely when formally requested by the patient (preferably in writing), and patients advised of the location of records upon request. Practitioners should keep a record of any such requests.

>> This is largely your responsibility when responding to your patients. Please use a secure mechanism to send patient information (email is not secure unless the information is in an encrypted attachments). All Instinctive Notes data is held in Australia, in data centers in Sydney.

3. Information to be recorded at an initial or new presentation

Instinctive Notes currently only captures limited information for initial consultations. Please ensure your initial consultation notes captures all the required information. You may attach any initial consultation notes and medical history to the patient record in Instinctive Notes to have complete documentation for a patient in one place.

Our recommendations for information capture are as follows:

a. identifying details of the patient, including name, preferred name, contact details, date of birth and occupation

>> This information should be held in your practice management system. The patients name will be held in Instinctive Notes, and date of birth can be stored.

b. contact details of the person the patient wishes to be contacted in an emergency (not necessarily the next of kin)

>> This information should be held in your practice management system.

c. presenting complaint

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record. For ease of recall it could also be added to the "general notes" field of the clinical note.

d. examinations and investigations conducted and relevant clinical findings

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record.

e. relevant diagnosis(es)/clinical impressions/ working diagnosis(es), therapeutic trials or management/care plan(s)

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record.

f. current health history including a relevant medical history, systems review, work history, ‘red flags’, current medications/supplements, allergies, referrals

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record.

g. any contraindications or health alerts

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record.

h. relevant family history

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record.

i. relevant social and lifestyle history including cultural background (where clinically relevant)

>> This information should be captured in your own initial consultation forms and attached to the Instinctive Notes patient record.

j. name of the consulting practitioner

>> Instinctive Notes hold all appointments transferred from integration sources, including initial consultations. This information includes the patient name and the name of the consulting practitioner.

4. Information to be recorded at a subsequent consultation or any consultation where care or advice is provided

Instinctive Notes treatment notes capture most of the information required in this section.

a. date of the consultation

>> Automatically captured by Instinctive Notes when appointment details are transferred from integration sources. If a note is recorded without an appointment the date of record is used so we recommend recording the note as closely to the appointment as possible.

b. any change in consulting practitioner

>> The consulting practitioner is stored with each note. For each appointment the practitioner is determined from your Practice Management System's integration with Instinctive Notes. To record a change in practitioner simply change a client's appointment to the new practitioner in your Practice Management System before they arrive and make sure the new practitioner is set up for Instinctive Notes. The appointment will appear in the new practitioners list and the note taken will include the new practitioners details.

c. name of the person providing information if not the patient, e.g. parent, guardian

>> This information should be added to the "general notes" field on the treatment note.

d. reason for care/consultation

>> This information can be inferred from the plan a patient is placed on. If on a schedule then the patient is seeking remedy of a specific complaint outlined in an initial consultation. If on a wellness schedule then the patient is seeking general wellness. If there are more specific reasons for care the information should be added to the "general notes" field on the treatment note.

e. relevant subjective information including response to any treatment, including that provided by other practitioners

>> This information should be added to the "general notes" field on the treatment note.

f. relevant objective information about any examination or investigation conducted and relevant clinical findings

>> This information should be added to the "general notes" field on the treatment note.

g. the documentation of any offer of a chaperone to patients or when any such request is made by a patient

>> This information should be added to the "general notes" field on the treatment note.

h. details of any informed consent (see Code of Conduct or Chiropractors section 3.5)

>> This information should be added to the "general notes" field on the treatment note.

i. when there are changes to any previous consent i.e. withdrawn, extended, modified, along with
notes on the parameters of the change

>> This information should be added to the "general notes" field on the treatment note.

j. changes to a documented working diagnosis or therapeutic trial

>> This information should be added to the "general notes" field on the treatment note.

k. changes to a documented management/care plan

>> Instinctive Notes allows easy updating of the plan for each patient. Schedules and wellness plans can be set and changed as required. Original plan elements are stored and available for review if necessary.

l. procedures conducted, techniques used and advice/instructions given

>> Instinctive Notes adjustment codes, along with the adjustment method, and the muscle, organ, limbs and cranial lists allow quick selection of the procedures conducted and techniques used. Custom codes can be set up for each practitioner to capture details not covered by the standard templates. Add any additional advice to the "general notes" field on the treatment note.

m. items prescribed, administered or supplied for the patient

>> This information should be added to the "general notes" field on the treatment note.

n. any referrals, letters, correspondence, clinical records, reports, or any relevant communications regarding the patient

>> This information should be added to the patient record as a file attachment, which can then be viewed in alongside patient treatment notes.

o. any unusual sequelae of treatment or changes in contra-indications or health alerts

>> Red flags and general notes can be recorded against the patient record, with clear indications of red flags during note taking. Any other information should be added to the "general notes" field on the treatment note.

p. any relevant diagnostic data, including accompanying reports

>> This information should be added to the patient record as a file attachment, which can then be viewed in alongside patient treatment notes.

q. setting and context (e.g. after hours, home visit or at a sporting event)

>> Instinctive Notes can configure appointment types, either transferred from an integration, or directly. Appointment types should be set to allow easy understanding of the setting and context of an appointment. An appointment type description is stored with the treatment note when it is recorded.

r. details of anyone contributing to the chiropractic care and record

>> This information should be added to the "general notes" field on the treatment note.

5. Summary

Instinctive Notes provides an easy method of capturing all the information required to meet the Chiropractic Board guidelines on clinical record keeping.

Many of the most time consuming elements of record keeping are quickly or automatically recorded by Instinctive Notes. Much of the less common and ancillary information can be added to the free text notes available on every treatment note.

Instinctive Notes will continue to develop more effective recording and automation for as many different record keeping requirements as possible to ensure that your record keeping responsibilities are met with the minimum of effort.

« Back to Guides