Chiropractor Documentation of Care in Washington State

Accurate patient records are an essential part of responsible chiropractic care. In Washington State, chiropractors are required to document patient history, examination findings, diagnoses, treatment, and changes in a patient's condition.

The Washington State Chiropractic Quality Assurance Commission establishes these requirements in WAC 246-808-560 — Documentation of Care.

This regulation explains what must be included in patient records and how chiropractors must document care throughout the patient relationship.

1. Complete and Accurate Patient Records

Washington State requires chiropractors to maintain complete and accurate documentation for every patient and patient encounter.

Patient records must describe the patient's clinical history, the reasons for examinations, diagnostic or analytical procedures, and treatment services provided. The diagnosis or clinical impression must appear in the patient record itself—not only on a billing form or statement.

A patient's subjective health status must also be documented at every encounter, whether or not the patient is experiencing symptoms.

2. What Must Be Included in the Initial Patient Record?

Under WAC 246-808-560(2), the initial record must include, at a minimum:

• Patient history: Relevant health and clinical history.

• Subjective presentation: The patient's reported symptoms and condition.

• Examination findings: Objective findings related to the presenting condition.

• Diagnostic testing: Any diagnostic tests performed.

• Diagnosis or clinical impression: The chiropractor's assessment.

• Treatment provided: Any care or services delivered.

• Plan of care: The proposed course of care.

These elements help establish the patient's initial clinical status and provide a basis for evaluating progress.

3. Reexaminations and Monitoring Progress

Reexaminations are necessary to monitor a patient's progress and update their clinical status.

Washington's rule requires reexaminations at reasonable intervals sufficient to reflect treatment effectiveness. A reexamination must also be documented when there is an unexpected change in the patient's subjective or objective condition.

Reexamination records must include subjective presentation and objective findings. They must also reflect changes in the patient's care, progress, and treatment plan.

4. Documentation at Every Patient Visit

Documentation is required for every patient encounter, including visits between formal examinations.

The record must sufficiently describe:

• Services and treatment provided.

• Changes in the patient's symptoms or condition.

• The body region or regions treated.

• When applicable, the specific spinal level or levels adjusted.

This documentation helps maintain a clear record of the care delivered at each visit.

5. Timely Records and Corrections

Patient records must be legible, permanent, and recorded in a timely manner.

If a chart note is not entered on the date of service, the record must identify both the date of service and the date the note was entered.

The regulation also specifies how corrections and additions must be handled. For written records, the original entry must remain legible, with a single line drawn through the text and the correction initialed.

For computer-organized records, unintended entries may be identified and corrected, but must not be deleted. Spelling and grammar errors may be corrected and deleted.

6. Referral Correspondence and Provider Identification

Correspondence relating to referrals concerning a patient's diagnosis or treatment must be retained in the patient record.

Patient records should also clearly identify the provider of services by name, initials, or signature. If a chiropractor uses codes in the documentation, a code legend must be made available upon request.

Why Accurate Documentation Matters

Good clinical documentation serves several important purposes:

• It creates a record of the patient's reported condition and clinical findings.

• It documents the care and services provided.

• It helps monitor changes in symptoms and clinical status.

• It supports communication and coordination when referrals are needed.

• It provides a record of the clinical reasoning and treatment plan.

For patients, documentation is an important part of continuity, accountability, and responsible healthcare.

Official Washington State Regulation

For the complete and current regulatory language, refer to the Washington State Legislature:

WAC 246-808-560 — Documentation of Care

This article is intended for general educational purposes. The official regulation is the controlling source for Washington State chiropractic documentation requirements.

About the Doctor

Dr. Shao-Hao Cheng, D.C. has provided chiropractic care in Bellevue, Washington, since 2010. His approach includes chiropractic adjustments, manual therapy, and exercise therapy.

Learn more about Dr. Shao-Hao Cheng.

Schedule an Appointment

Active Spines Chiropractic serves patients in Bellevue and the surrounding Eastside communities.

• Online scheduling: Book an appointment through Zocdoc

• Phone: (425) 818-0086

• Email: frontdesk@activespines.com

Active Spines Chiropractic
1530 Bellevue Way SE, Suite C
Bellevue, WA 98004