In this guide 6 sections
A chiropractic record needs four linked parts: case history, spinal assessment, a plan with a visit count, and a note for each adjustment. GullySystem’s Chiropractic Clinic Management Software keeps them on one profile, so the note, the count and the bill agree.
What a case history should hold
The case history is the first record in a patient’s file. It notes where the pain is, when it began, what makes it worse and what the patient has already tried.
Past falls, road accidents, sports injuries and spinal operations are listed with dates. Medical conditions and regular medicines are recorded where they matter to treatment. The doctor decides what matters.
The referring doctor or the source of the patient is kept for the clinic’s own records. It is a short field, filled once, and it helps the clinic see where new patients come from.
Assessment findings and visit notes
Assessment findings go in by spinal region. Tenderness, restriction, muscle tone, posture and range of movement each have a field. The tests your doctors use are listed with a positive or negative result.
A visit note is shorter. It names the region treated, the technique, the patient’s response and the advice given. Choices replace typing wherever possible, so a note takes under a minute on a busy day.
A patient who reports soreness is flagged to the doctor at the next visit. The flag is plain.
- Region treated at this visit
- Technique from the clinic’s own list
- Response since the last visit
- Advice and home care given
Treatment plans with a visit count
A plan states the number of visits, the regions treated, the goal and the gap between visits. It also names a review point, set at a visit number or a date.
Each saved visit note counts one visit against the plan. Visits used and visits left show to the doctor and at the desk. Billing reads the same plan.
A doctor may lengthen or shorten a course once the patient responds. The change is made with a reason typed in, and earlier visits stay as recorded.
Scores, scans and consent
Pain scores, range of movement and short functional questionnaires are recorded at the visits the doctor chooses. A review then shows the first assessment beside the latest one. Small groups prove little, so owners read group trends with care.
X-ray images, MRI reports and outside prescriptions are attached with a date and a source. Consent to treatment and a separate tick for photographs are saved against the patient with the date.
For a child, the guardian’s name and relationship are recorded with the signature. Consent is easy to find.
Decide who writes what before you start
Reception enters registration details and collects consent. Chiropractors write the history, the findings, the visit notes and the plan. Assistants may be given the posture section if the clinic wants that.
Agree the technique list, the plan templates and the review rule first. The consent wording is supplied by the clinic. GullySystem records the signature and the date.
A doctor with a handful of patients a week can keep a paper card. The case for software begins with courses, scans or a second doctor.
Case note field checklist
A one-page checklist of every field your doctors fill today, grouped as history, assessment, visit note, plan and review. Mark who writes each field and who reads it. Fields nobody reads can be dropped before the forms are set up.
Open a blank worksheet to printQuestions owners ask
Who writes which part of a chiropractic record?
Reception enters registration details and consent. The chiropractor writes the history, assessment, visit notes and plan. The clinic sets who else may see each section, such as an assistant seeing posture only.
Can a treatment plan be changed after it is saved?
Yes. A doctor may lengthen or shorten a course once the patient responds. The change is saved with a typed reason, and the visits already recorded stay as they were.
Where do X-rays and reports go?
They are attached to the patient’s record with a date and a source. Which file types are stored is reviewed during scoping with the clinic.