Clinical Documentation and Record Keeping for Chiropractors
Good records underpin safe chiropractic care and protect you if your practice is questioned. This guide sets out what a good chiropractic record contains — including the reasoning, consent and imaging justification that matter most — and the privacy, retention and access rules to follow.
Key takeaways
- The shared Code of conduct requires accurate, up-to-date, factual, objective and legible records.
- Record your clinical reasoning and the rationale for the care plan, not just the treatment given.
- Document consent, material risks, and the justification for any imaging.
- Make entries contemporaneously and never alter a record after a concern is raised.
- Records are health information — store securely and retain per state and territory law.
Why documentation matters in chiropractic
Clear records underpin safe chiropractic care and protect you if your practice is questioned. The shared Code of conduct requires accurate, up-to-date, factual, objective and legible records held securely. Given that consent, claims and the justification for care are recurring themes in chiropractic concerns, your record is where you demonstrate that your management was reasoned and consented.
What a good chiropractic record contains
- Presenting complaint, history, medications and red-flag screening.
- Examination findings, including pertinent negatives, and the indications for any imaging.
- Working diagnosis and clinical reasoning — and the rationale for the care plan.
- Consent to assessment and treatment, and any material risks discussed.
- Treatment provided, techniques used and the patient’s response.
- Review plan, advice and any referral or safety-netting.
Imaging, necessity and consent
Document the clinical justification for any imaging you order or recommend, and the consent discussion around it. Records that show a clear, evidence-based rationale for care are the best answer to any suggestion of unnecessary or indiscriminate treatment.
Contemporaneous, unaltered, secure
Make entries at or near the time of care and never alter a record once a concern arises — corrections should be transparent, dated and never obscure the original. Chiropractic records are health information and must be stored securely under the Australian Privacy Principles. Retention is set by state and territory law — generally at least seven years from the last entry for adults, and for children until a specified age — and patients have a right to access their records.
Records and complaints
If a concern arises, your records let you demonstrate reasoned, consented, necessary care. See our guides to advertising compliance and Chiropractic Board complaints.
Related CPD courses
Build the documentation habits this article describes with CPD for Australian practitioners:
CPD courseDocumentation for Healthcare Professionals CPD courseConfidentiality in Healthcare Practice CPD courseProfessionalism and Professional Standards for ChiropractorsContinue the Chiropractic Board series
Complaints Explained Advertising Compliance for ChiropractorsFrequently asked questions
What should a chiropractic record include?
The presenting complaint and history, red-flag screening, examination findings including pertinent negatives, working diagnosis and reasoning, consent and material risks, treatment and response, and the review plan.
Why record the rationale for care?
Recording why a treatment or investigation was indicated demonstrates evidence-based, necessary care and answers concerns about unnecessary or indiscriminate treatment.
Do I need to document imaging decisions?
Yes. Record the clinical justification for any imaging and the consent discussion around it.
How long must chiropractic records be kept?
Retention is set by state and territory law — generally at least seven years from the last entry for adults, and for children until a specified age.
Can I amend a record after a complaint?
Only transparently — date the correction and never obscure the original. Altering notes undermines their credibility.
This article is general information for education and CPD purposes. It is not legal advice and does not create a practitioner–adviser relationship. If you have received a notification, seek advice from your professional indemnity insurer, your union or professional association, or an independent lawyer experienced in health practitioner regulation. Healthcare Ethics Courses is an independent education provider and is not affiliated with, endorsed by, or acting on behalf of Ahpra or any National Board; regulator names are used for reference only.