Documentation Standards Flashcards
7 cards from real CBP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation Standards flashcards as text
In CBP, what should a re-examination document to justify continuing corrective care?
Answer: Objective comparisons with baseline: posture, radiographic measures, and outcome scores
Re-exams compare objective data with baseline to show progress and need for more care.
Which piece of information belongs in the 'O' (Objective) part of a SOAP note?
Answer: Measured range of motion and radiographic mensuration values
Objective holds measurable, observed data such as ROM, posture readings, and x-ray measurements.
What is the documented CBP ideal lumbar lordosis value (ARA L1–L5) from the Harrison model?
Answer: Approximately -40°
The Harrison lumbar model gives an L1–L5 ideal ARA of about -40°.
Which statement about electronic health record (EHR) templates in chiropractic is correct?
Answer: Cloned or identical notes across visits can be judged insufficient to show medical necessity
Payers flag cloned documentation because it fails to show visit-specific findings and progress.
When documenting a 'mirror image' adjustment, what should the note include?
Answer: The displacement being corrected, the opposite position used, and the patient's response
Notes should link the specific displacement to the mirror-image setup and record the response.
Which item is essential in a valid informed consent record for spinal traction?
Answer: Material risks, benefits, alternatives, and the patient's agreement
Valid informed consent covers risks, benefits, and alternatives and is documented with the patient's agreement.
What date is required in the documentation for Medicare when subluxation is shown by x-ray?
Answer: The x-ray must be dated within a set window around the start of the treatment episode
Medicare requires supporting x-rays to be taken within a defined time frame of starting care.