Committee recommends updates to patient record and billing rules; removes gender requirement

The Enforcement Committee on Dec. 19 recommended that the full board consider amendments to California Code of Regulations, Title 16, section 318 to clarify patient-record and billing requirements for chiropractors.

Miss Pitto, staff, summarized proposed changes made after board feedback earlier in 2024. The draft removes a requirement to record a patient's gender in the initial visit note, replaces the word “estimated” with “approximate” for height and weight to allow provider discretion, and adds orthopedic and neurological testing to the examination elements. The draft also removes the requirement that procedure codes be recorded in the clinical file (recognizing that codes are often retained in billing records) and adds explicit language that providers must maintain billing records and document treatments and patient responses.

“We looked at other programs, and they didn't have any gender requirements. So we struck the gender, and then we replaced, estimated with approximate height and weight because that will allow the provider discretion,” Miss Pitto said. The committee discussed how the language applies to initial exams, subsequent visits and periodic reexaminations, and staff agreed to add guidance that commonly used documentation formats such as SOAP notes are acceptable.

Committee members discussed tailoring documentation expectations so follow‑up and wellness visits are not subject to the same level of detail as initial evaluations while retaining requirements to document changes in history, complaints and any reexaminations when clinically indicated. Dr. Perez and others said the draft language appears to strike a balance between clarity and flexibility for practice variation.

The committee voted 3–0 to recommend the conceptual changes to the full board, with staff to finalize regulatory text for the board’s consideration.