In celebration of our 80th anniversary, we're flipping through the case study archives. While documentation methods may have changed (you're probably not using correction fluid anymore), one thing remains constant: thorough documentation makes all the difference in winning a claim.
Posted in Case Studies on Monday, January 12, 2026
The patient, a 29-year-old male, sought treatment from the insureds for injuries sustained in an on-the-job motor vehicle accident in 1988. He complained of pain in the neck, and upper and mid-back regions, with some numbness and tingling in the left upper extremity.
The patient was treated for more than two years with manipulation, physical therapy, and a TENS unit. During this time period, he received a referral to a neurosurgeon for further evaluation. He also had cervical and thoracic MRIs done (Both were within normal limits).
The summons and complaint received by the insured alleged failure to diagnose and treat some of the patient’s injuries, failure to document and apply for worker’s compensation benefits for some of the patient’s injuries, and failure to properly administer activator treatments. In addition, the patient alleged that the defendants were negligent and callous in their professional treatment and care and failed to meet the standards of chiropractic care. He stated that he suffered severe bodily injury and pain and suffering, along with physical disability, mental anguish, loss of capacity for life enjoyment, and lost benefits from worker’s compensation, as a direct result of the “negligence and carelessness” of the insureds.
The insureds performed and documented a thorough examination and had the patient document his symptomatology in writing at every visit. Overall, the documentation of physical findings, patient complaints, and treatment rendered was excellent.
Experts for the defense could find absolutely no deviation from standard of care, and no basis for the complaint. The defense attorney filed a motion for summary judgement, which was successful.
Implications for Risk Management in Your Office Practice
This case demonstrates how helpful thorough documentation can be if you are served with a lawsuit. In the above case, the excellent documentation allowed the judge to rule that no negligence occurred. Documentation can make or break a case! Following are some tips to help you to document defensibly.
Report Progress in Writing
Many doctors have heard a patient’s disgruntled account of treatment that “never did any good.” Such characterizations frequently are inaccurate. Doctors hear complaints like this from patients who have been helped, and who acknowledged during treatment that they were feeling better. A statement in the doctor’s records may even note that the “patient reported feeling better today.” Unfortunately, such entries are seldom persuasive when weighted against the vivid testimony of a patient weaving a story of months of unremitting agony.
One way to protect yourself in this area is to have patients report their progress in writing. DCs should consider incorporating into their clerical records a patient progress form to be filled in, dated, and signed by the patient at reasonable intervals.
Make Proper Corrections
Preserve the credibility of your records by making corrections in the following manner: Draw a single line through the erroneous information, insert the corrections, and initial and date it. Never use correction fluid.
Don’t Skip Lines
Records which contain one or more blank lines between entries may leave the impression that space was left in which to make additions later. Conversely, don’t squeeze notations into the records. Entries which are routinely scribbled in the margins, inserted with arrows, or written between entries may leave the impression that space was left to put in additions later. Chiropractors who utilize bar-code scanning noting systems should, at the very least, initial and date their printed copies. Complete handwritten back-up notes are strongly recommended.
Following guidelines can help you to provide better patient care, as well as protect you in the event of a malpractice lawsuit.