As a chiropractor treating personal injury patients, you know the importance of documenting care. But when attorneys and insurance adjusters enter the picture, the quality and detail of your notes take on a whole new level of significance. In many cases, your treatment notes can make or break a patient’s claim. They are not just clinical records—they are legal evidence.
Why Detail Matters
Insurance companies look for any reason to downplay an injury. If treatment notes are vague or incomplete, adjusters may argue that the injury wasn’t serious or that care wasn’t medically necessary. On the other hand, well-documented notes provide objective proof of both the injury and the patient’s progress.
Attorneys, too, depend on your records. When we present a case, your notes help us prove three things:
- The patient was actually injured.
- The accident caused the injury.
- The recommended treatment was reasonable and necessary.
The more clearly your notes address these points, the stronger the case becomes.
What Attorneys and Adjusters Look For in Treatment Notes
When reviewing chiropractic treatment records, here are the details that matter most:
Objective Findings
Document measurable, observable data such as range of motion limitations, muscle spasms, tenderness on palpation, or positive orthopedic tests. These objective markers carry more weight than subjective complaints alone.
Subjective Complaints (with Context)
Patient-reported pain levels and descriptions are valuable, but they are most persuasive when paired with objective findings. For example: “Patient reports 7/10 low back pain, aggravated by sitting more than 20 minutes. Examination revealed reduced lumbar flexion and palpable spasm in the paraspinals.”
Treatment Rationale
Explain why each treatment is being performed. Was spinal manipulation needed to improve alignment and relieve nerve pressure? Was physiotherapy prescribed to restore mobility? Connecting the treatment plan to the injury is key.
Progress Over Time
Show how the patient’s condition changes—whether they are improving, plateauing, or experiencing setbacks. This timeline paints a picture of recovery and helps justify continued care.
Consistency
Attorneys and adjusters notice gaps or inconsistencies in records. Missed visits, abrupt stops in care, or unexplained changes in treatment can raise red flags.
Striking the Right Balance
You don’t need to write lengthy essays for every SOAP note. The goal is clarity and completeness, not verbosity. Think of it this way: if someone unfamiliar with the patient read your notes six months from now, would they clearly understand what the injury was, why treatment was necessary, and how the patient responded?
Notes should be factual, specific, and consistent. Avoid vague language like “patient is better.” Instead, write “patient reports pain decreased from 7/10 to 4/10, lumbar flexion improved by 15 degrees.” This level of detail is manageable in daily practice and invaluable in the legal arena.
Detailed treatment notes not only strengthen your patient’s personal injury claim, they also protect you as a provider. Should your records ever be scrutinized in court, clear documentation demonstrates your professionalism, medical reasoning, and commitment to patient care.
