CAC Documentation & Record Management 2 — Questions and Answers
Question 1: When documenting a chiropractic adjustment for a horse, which anatomical descriptor best captures the direction of the corrective force applied?
- Listing notation indicating the direction of misalignment relative to the segment above (Correct answer)
- Body weight distribution noted as percentage across all four limbs
- Heart rate measured immediately before and after adjustment
- Coat condition score on a 1–5 scale
Correct answer: Listing notation indicating the direction of misalignment relative to the segment above
Listing notation records the direction of vertebral misalignment and the vector of the corrective thrust, making it the standard descriptor for chiropractic adjustments.
Question 2: A veterinary chiropractor's SOAP note section labeled 'O' should contain which of the following for a canine patient?
- Owner's description of lameness onset
- Static and motion palpation findings at each vertebral segment (Correct answer)
- Recommended home exercise protocol
- Follow-up appointment scheduling notes
Correct answer: Static and motion palpation findings at each vertebral segment
The Objective section of a SOAP note records measurable, observable clinical findings such as palpation results, gait analysis, and range-of-motion measurements.
Question 3: Which document must accompany an animal to legally authorize a certified veterinary chiropractor (non-DVM) to perform treatment in most US states?
- A signed owner liability waiver only
- A valid veterinary referral or prescription from a licensed veterinarian (Correct answer)
- An AVCA membership card
- A breed registration certificate
Correct answer: A valid veterinary referral or prescription from a licensed veterinarian
Most US states require a veterinary referral or prescription because non-DVM animal chiropractors must work under veterinary supervision or referral.
Question 4: How long should chiropractic records for an equine patient typically be retained according to standard professional guidelines?
- 1 year after the last visit
- 3 years after the last visit
- A minimum of 5–7 years after the last visit (Correct answer)
- Until the animal is sold to a new owner
Correct answer: A minimum of 5–7 years after the last visit
Professional and legal standards generally require animal health records to be retained for a minimum of 5–7 years after the final entry to support continuity of care and liability protection.
Question 5: Which of the following best describes a 'problem-oriented' chiropractic record for a multi-visit canine patient?
- A single intake form completed only at the first visit
- A record organized by numbered clinical problems that are tracked across all visits (Correct answer)
- A billing ledger sorted by date of service
- A log of medications administered during each session
Correct answer: A record organized by numbered clinical problems that are tracked across all visits
Problem-oriented records organize findings around specific, numbered clinical issues that are monitored and updated throughout the course of care.
Question 6: When a veterinary chiropractor transfers care to a colleague, which record elements are most critical to include in the transfer summary?
- Owner's insurance policy number and payment history
- Diagnosis, treatment history, responses to adjustments, and current listing findings (Correct answer)
- Staff notes about owner communication style
- Appointment no-show history
Correct answer: Diagnosis, treatment history, responses to adjustments, and current listing findings
A transfer summary must convey the clinical picture—diagnosis, treatments performed, patient responses, and current spinal findings—so the receiving clinician can continue care safely.
Question 7: In chiropractic recordkeeping, what is the purpose of recording pre- and post-adjustment gait analysis findings?
- To satisfy insurance billing requirements only
- To objectively document treatment efficacy and track patient progress over time (Correct answer)
- To determine breed-specific adjustment protocols
- To comply with kennel club registration standards
Correct answer: To objectively document treatment efficacy and track patient progress over time
Pre- and post-adjustment gait analysis provides objective, comparative data that demonstrates the immediate effect of treatment and supports longitudinal outcome tracking.
CAC Documentation & Record Management 2
When documenting a chiropractic adjustment for a horse, which anatomical descriptor best captures the direction of the corrective force applied?