What specific information must a chiropractor include in patient records according to Ohio law?

The inclusion of patient history, exam findings, treatment plan, and progress notes in patient records is mandated by Ohio law to ensure comprehensive documentation of a chiropractor's care and treatment process.

Patient history provides essential context regarding the individual's past medical conditions and treatments, which allows chiropractors to make informed decisions about care. Exam findings outline specific physical assessments and observations made during the evaluation, establishing a basis for diagnosis.

The treatment plan details the intended therapeutic approach and expected outcomes specific to the patient, while progress notes track the patient's improvement or any adjustments needed in the treatment strategy. This thorough documentation supports continuity of care, legal protection, and adherence to regulatory standards.

In contrast, focusing solely on patient history and medical history fails to capture essential elements like treatment plans and ongoing progress, which are critical for effective chiropractic care. Limiting documentation to only treatment plans and progress notes would overlook important patient context and examination details. Lastly, personal contact information and insurance details, while important for practical administration, do not encompass the clinical information necessary for proper patient care records.