Which elements are typically documented to indicate subluxation in a chiropractic note?

Which elements are typically documented to indicate subluxation in a chiropractic note?

• A. Radiographic findings only
• B. Patient's dietary history
• C. Physical examination, orthopedic testing, palpation of pain/tenderness, asymmetry, ROM abnormality, tissue tone changes
• D. Therapy session notes only

Answer: (C)

In chiropractic notes, subluxation is indicated by objective findings from a thorough exam. The best documentation includes physical examination results, orthopedic testing, palpation notes of pain or tenderness, evidence of asymmetry, abnormalities or restrictions in range of motion, and changes in tissue tone. These signs together show a dysfunction in a segment and justify documenting a subluxation and guiding the treatment plan. Radiographic findings can support the picture, but relying on imaging alone isn’t sufficient to establish subluxation; dietary history isn’t relevant to subluxation documentation, and therapy session notes describe what was treated rather than the diagnostic signs themselves.

In chiropractic notes, subluxation is indicated by objective findings from a thorough exam. The best documentation includes physical examination results, orthopedic testing, palpation notes of pain or tenderness, evidence of asymmetry, abnormalities or restrictions in range of motion, and changes in tissue tone. These signs together show a dysfunction in a segment and justify documenting a subluxation and guiding the treatment plan. Radiographic findings can support the picture, but relying on imaging alone isn’t sufficient to establish subluxation; dietary history isn’t relevant to subluxation documentation, and therapy session notes describe what was treated rather than the diagnostic signs themselves.