Documentation, Consent, Communication and Referral

The best examination and the soundest plan are worth little if they are not written down clearly, agreed to by an informed patient, explained in words the patient understands, and passed accurately to the next clinician. Case management stations score these communication tasks as heavily as the clinical ones, and in practice they are where most complaints and legal claims begin. This chapter gives you the scripts, structures and documentation habits that let you do all of it well inside a timed station.

Section 1The patient note

Why the note matters in a station

Some case stations are followed by a written task: a patient note, a set of short answers, or both. Others score documentation indirectly by asking you to state what you would record. Either way, the note is judged on the same standard used in practice: could another clinician pick it up, understand what you found and why you decided what you did, and continue care safely? In practice the record is also a legal document, the basis for billing and the evidence that consent was obtained and red flags were considered. If it is not documented, for legal and audit purposes it was not done. Check the current official candidate materials for the format and length of any written component; the structure below works for any of them.

SOAP structure

The SOAP format divides the note into Subjective, Objective, Assessment and Plan. Its strength is that each part feeds the next: subjective and objective findings support the assessment, and the assessment justifies the plan. A reader should be able to trace every plan item back to a finding.

Writing findings so they can be read

Good findings are specific, measurable and lateralized. Write "Cervical rotation R 50° with R neck pain, L 75° pain free" rather than "decreased ROM." Write "Spurling's R: reproduced R arm pain to the thumb" rather than "Spurling's +." For neurologic findings use standard grades: muscle strength 0 to 5 (5 normal, 4 movement against some resistance, 3 against gravity only) and deep tendon reflexes 0 to 4+ (2+ normal). Record pertinent negatives explicitly, for example "Denies saddle anesthesia, bladder or bowel change; no fever or weight loss." These lines carry your safety screen into the record and are often what an examiner reads first.

Use only accepted abbreviations. Avoid abbreviations on safety "do not use" lists (such as "QD," "U" for units, trailing zeros) and ambiguous shorthand. Common accepted ones in musculoskeletal notes: CC, HPI, ROS, PMH, ROM, SLR, DTR, NRS, ODI, NDI, WNL (use carefully: "within normal limits" must mean you tested it), R and L, bilat, Dx, DDx, Tx, Rx, HEP (home exercise program), f/u, w/o.

Documentation rules

• Timeliness. Write the note at the visit or as soon as possible. Entries made later are labeled as late entries with the current date and time and the date of the visit they describe.
• Corrections. Draw a single line through the error so it remains legible, write the correction, and date and initial it. Never erase, use correction fluid, overwrite or remove pages. In electronic records, use the amendment function, which keeps the original visible in the audit trail.
• Objectivity. Record facts and quotations, not judgments of the patient ("patient is difficult" is a judgment; "patient declined lumbar radiographs after the risks of not imaging were explained" is a fact).
• Identification. Every page carries the patient's name and a second identifier (date of birth or record number), the date, and your signature or electronic authentication.
• Confidentiality. Disclose only the minimum necessary for the purpose, except to other treating providers for treatment, and follow privacy law for release of records.
• Adverse events and refusals. Record what happened, the time, what you did, who you notified and what you told the patient. Record refusals with the risks explained.

Section 2Informed consent in practice

Elements of valid consent

Informed consent is a process of shared decision making, of which the signed form is only the record. Valid consent requires five things. The patient must have capacity; must receive adequate disclosure; must understand what was disclosed; must decide voluntarily, free from coercion or undue pressure; and the process must be documented. Consent is specific to the procedures and regions discussed, and it is renewed when the plan, technique or risk profile changes.

Capacity is decision specific and is presumed in adults unless there is reason to doubt it. A patient has capacity for a decision when they can understand the relevant information, appreciate how it applies to them, reason about the options, and communicate a choice. Intoxication, acute confusion, severe pain or distress, and some cognitive impairments may reduce capacity temporarily. Minors generally need consent from a parent or legal guardian, with the child's assent sought in age appropriate language; local law governs exceptions (emancipated minors, specific statutes). For adults lacking capacity, a legally authorized representative decides. In a true emergency, care needed to prevent serious harm may proceed under implied consent, which does not extend to elective manipulation.

The disclosure standard in most jurisdictions is the material risk or reasonable patient standard: disclose what a reasonable person in this patient's position would want to know to make the decision, including rare but serious risks. The older professional standard asked what a reasonable practitioner would disclose. Treating without consent can constitute battery even if the care was skillful; failing to disclose a material risk that then occurs can support a negligence claim.

PARQ: the disclosure script

Discussing cervical artery dissection

For cervical manipulation, the material rare risk patients most need to hear about is stroke associated with cervical artery dissection. The evidence is debated: dissection is rare, estimates of manipulation associated cases vary widely between studies, and population studies show that people with an early dissection often seek care for neck pain and headache from both chiropractors and primary care physicians before the stroke occurs, which makes a causal relationship difficult to establish. A balanced disclosure states that the risk is rare, that it cannot be reduced to zero, that you screen for warning signs, and that alternatives without cervical thrust exist. Avoid both minimizing ("it never happens") and alarming exaggeration.

A station ready script: "With neck adjustments there is a very rare risk of a stroke related to a tear in an artery in the neck. Research has not settled whether the adjustment causes these tears or whether people with an early tear come in because of the neck pain and headache it produces, but I take it seriously. I have asked you about warning signs, and I will check in with you during treatment. If you prefer, I can treat your neck without the quick thrust, using mobilization, soft tissue work and exercise. If you ever notice dizziness, double vision, trouble speaking or swallowing, or sudden severe headache, call 911."

Documenting consent

Record that consent was obtained, what was discussed (each PARQ element, including the specific rare risks named), that questions were invited and answered, the patient's decision, the use of an interpreter (name or identification number) when applicable, and the presence of a chaperone where relevant. A signed form supplements this note but does not replace it. For sensitive procedures (contacts near the breast, groin or coccyx, internal coccyx work where permitted) obtain specific consent, explain draping and offer a chaperone, and document both. Consent can be withdrawn at any time, including mid procedure; stop and record it.

Section 3Report of findings and patient education

What a report of findings contains

The report of findings (ROF) is the conversation in which you tell the patient what you found, what it means, what you recommend and what they can do. In practice it often happens at a second visit after results are back; in a station it is usually compressed into the last part of the encounter, immediately before consent. A good ROF follows a predictable order so nothing is lost: findings, diagnosis, prognosis, recommendation, risks and alternatives (leading into consent), the patient's role, and warning signs.

Plain language

Explain at roughly a sixth to eighth grade reading level, whatever the patient's education, because people under stress and in pain retain little. Replace jargon with everyday words, use analogies and models, show the area on a spine model or the patient's own body, and give numbers in natural frequencies ("about 1 in 3 people") rather than percentages or relative risk. Avoid language that creates fear or dependence (the nocebo effect): phrases such as "your spine is out of place," "degeneration," "crumbling disc" or "bone on bone" can increase pain, fear avoidance and disability even when the imaging finding is a normal age related change.

Checking understanding

Teach-back asks the patient to explain in their own words what you said. It tests your explanation, not the patient: "I want to make sure I explained this clearly. Can you tell me what you will do if the numbness spreads?" If the answer is incomplete, re-explain differently and check again. Ask-tell-ask frames each chunk: ask what the patient already knows or believes, tell the new information, ask how it lands. Chunk and check means giving two or three pieces of information at a time. Close with an open invitation ("What questions do you have?") rather than a closed one ("Any questions?"), and support the conversation with written home care instructions.

Patient education extends beyond the diagnosis: explain the expected course (including the likelihood of a flare up and how to handle it), how activity helps, the home exercise (demonstrated and then performed by the patient), and the specific warning signs that warrant urgent contact. Reassurance must be honest; never promise a cure or a fixed number of visits.

Section 4Referral letters and co-management communication

Match the channel to the urgency

Referral communication must reach the right person in time. For emergencies, the first communication is a telephone call (to emergency services or the receiving department), and the written summary follows with the patient or immediately after. For urgent problems, call the receiving clinician or office and send the letter the same day. Routine referrals and co-management updates go by letter or secure electronic message. Whatever the urgency, tell the patient what you are doing, why, and what to do if they cannot get the appointment in the stated time.

What a referral letter contains

A good letter is short (often one page), professional and specific. Lead with the purpose and urgency: "I am referring Mr. Ortiz, 67, for same day evaluation of suspected giant cell arteritis." Then summarize the relevant history, examination findings (pertinent positives and negatives with numbers), any results, your impression and differentials, the care you have provided and how the patient responded, and the specific question or request ("Please evaluate for temporal arteritis, including ESR and CRP, and advise whether chiropractic care for his neck may continue"). Close with your availability for discussion, a direct phone number, and a statement of whether you will continue to see the patient. Attach or offer relevant records with the patient's authorization where required. Use the same professional tone with every discipline: no jargon unique to chiropractic, no criticism of previous care, and no request beyond what you need.

SBAR for the phone call

SBAR structures a telephone handoff so the receiver hears the most important facts first. Situation: who you are, who the patient is, and the problem in one sentence. Background: brief relevant history. Assessment: your findings and what you think is happening. Recommendation: what you want and how fast. Read back the receiver's instructions and record the call (time, person, content) in the note.

Co-management communication

When you share care, send an initial letter that explains your diagnosis and plan, what you will and will not do, and what you need from the other clinician; send updates at re-examination or when something changes; and ask a direct question when you need a decision, such as whether an anticoagulated patient's dose is stable, whether a postoperative patient may begin spinal manipulation above the fusion, or whether a pregnant patient has any obstetric contraindication. Respect the other provider's role, and keep the patient informed of what is shared, within privacy law.

Section 5Difficult conversations and professionalism

Delivering unwelcome news

Stations sometimes require you to tell a patient something they do not want to hear: you suspect a serious disease, you will not adjust them today, they need surgery referral, or chiropractic care is not the answer. The SPIKES protocol gives a reliable structure, and it works in a few minutes.

A warning shot ("I am afraid the findings are more concerning than a simple back strain") gives the patient a moment to prepare. After giving the news, stop talking. Silence lets the patient react; information given during strong emotion is not retained. Respond to emotion with NURSE statements: Name ("You seem worried"), Understand ("It makes sense that this is frightening"), Respect ("You have been dealing with a lot of pain"), Support ("I will help you get this looked at quickly"), Explore ("Tell me more about what worries you most"). Never give false reassurance ("I am sure it is nothing") when you are referring because it might be something.

Refusals and informed refusal

A competent adult may refuse any recommended test, referral or treatment, even when you think the choice is unwise. Your duty is to make the refusal informed: explain the reason for your recommendation, the risks of declining in specific terms, the alternatives, and that the patient can change their mind. Explore the reason (cost, fear, past experience, transport, beliefs), because the barrier is often solvable. Then document the informed refusal: what you recommended, the risks explained, the patient's stated reason, alternatives offered, and that the patient understood. Refusal of an emergency referral is the hardest version: stay calm, restate the danger in plain words, involve a family member if the patient agrees, offer to call emergency services yourself, and never proceed with treatment that the red flag contraindicates simply because the patient refuses referral.

The reverse situation, a patient demanding something inappropriate, is handled the same way. A patient who insists on lumbar radiographs without indication gets an explanation of why imaging will not change care and could cause harm (radiation, incidental findings), plus the conditions under which you would order it. A patient who demands a neck adjustment despite a contraindication gets a clear refusal with the reason and a safe alternative: "I understand you feel better after adjustments, but with the dizziness you described, a neck adjustment is not safe until you have been checked. Here is what I can do today."

Boundaries, chaperones and draping

• Draping and gowns. Explain why an area must be exposed, expose only what is needed, provide a gown, leave the room or turn away while the patient changes, and knock before re-entering.
• Chaperones. Offer a chaperone for sensitive examinations and procedures and whenever the patient or you would prefer one; record the offer and the response.
• Narrate touch. Say where you are going to touch before you do it ("I am going to press along the muscles beside your spine now"), and stop immediately if the patient asks.
• Romantic or sexual advances. Decline clearly and kindly, redirect to the clinical task, and if the behavior persists end the encounter, document it and arrange transfer of care as appropriate. A relationship with a current patient is never acceptable.
• Gifts, social media and dual relationships. Follow professional codes; avoid relationships that compromise objectivity.
• Angry patients. Stay calm, listen without interrupting, acknowledge the emotion, apologize for the experience where appropriate ("I am sorry you have waited so long"), focus on what you can do, and keep yourself and staff safe; leave the room if there is a threat of violence.

Cultural humility and interpreters

Cultural humility is a stance of curiosity and self reflection rather than a list of facts about groups. Ask rather than assume: "Is there anything about your beliefs or background that would help me care for you?" Some patients prefer a same gender clinician or chaperone, may wish to involve family in decisions, may have specific modesty needs during examination, or may hold explanatory models of pain that differ from yours. Respect these preferences where possible and negotiate the plan around them. Address the patient by the name and pronouns they prefer.

For patients with limited English proficiency, use a qualified professional interpreter (in person, video or telephone). Do not use family members, and never children, for clinical interpreting except in an emergency until a professional is available, because they may filter information, lack medical vocabulary and compromise confidentiality, especially for sensitive questions and consent. When working with an interpreter: brief them first, face and speak to the patient in the first person ("Where does it hurt?" not "Ask her where it hurts"), use short sentences and pause for interpretation, avoid idioms, use teach-back through the interpreter, and record the interpreter's name or identification number. Patients who are deaf may need a qualified sign language interpreter; lip reading alone is insufficient for consent.

Words worth knowing