Chart Review Checklist Form
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4Chiropractic Care of Minnesota, Inc.
Chart Review Checklist
Patient Name: ______________________________
Provider Name:
_______________________________
Clinic Address: ______________________________
Clinic Name:
_______________________________
______________________________
Clinic Phone:
_______________________________
____________________________
_____________________
Reviewer:
Date of Review:
____
Required Documentation in Patient Record
1. Contains date of birth, marital status, occupation, employer name, home / cell / work phone numbers:
□
□
□
Pass
Fail (noted in summary)
Notice Given: __________________________________
2. Each page of record contains either the patient name or assigned ID number:
□
□
□
Pass
Fail (noted in summary)
Notice Given: __________________________________
3. Entries are dated and contain author identification (can be stamped, electronically added or hand written):
□
□
□
Pass
Fail (noted in summary)
Notice Given: __________________________________
4. Description of past conditions and trauma, past treatment received, current treatment being received from other
health care providers, description of the patient’s current conditions including onset and description of trauma (if
trauma occurred), vital signs including blood pressure, height, weight, and/or BMI.
□
□
□
Pass
Fail (noted in summary)
Notice Given: _________________________________
5. Must contain examination(s) performed – a preliminary diagnosis based on indicated diagnostic tests, with an
indication of all findings of each test performed:
□
□
□
Pass
Fail (noted in summary)
Notice Given: __________________________________
6. Results of re-examinations that are performed to evaluate significant changes in a patient’s condition, including
tests that were positive or deviated from results used to indicate normal findings:
□
□
□
Pass
Fail (noted in summary)
Notice Given: _______________________________
7. A diagnosis supported by documented subjective and objective findings or clearly qualified as an opinion must be
recorded in the patient file:
□
□
□
Pass
Fail (noted in summary)
Notice Given: __________________________________
8. Contains a treatment plan that meets minimum standards:
□
□
□
Pass
Fail (noted in summary)
Notice Given: __________________________________
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CRM014_Chart Review Checklist
9.1.2011_LN
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