ECC Documentation & Record Keeping 2 — Questions and Answers
Question 1: When documenting a horse's response to equine chiropractic treatment, which outcome measure is most clinically relevant to record?
- Owner's subjective satisfaction score
- Changes in range of motion at treated vertebral motion units (Correct answer)
- The ambient temperature during the session
- The brand of adjusting instrument used
Correct answer: Changes in range of motion at treated vertebral motion units
Objective changes in range of motion at treated spinal segments provide clinically meaningful outcome data for reassessment and continuity of care.
Question 2: Which section of an equine chiropractic SOAP note is most appropriate for recording static and motion palpation findings?
- Subjective
- Objective (Correct answer)
- Assessment
- Plan
Correct answer: Objective
Palpation findings are physical examination data and belong in the Objective section of the SOAP note.
Question 3: A referral letter from a veterinarian authorizing chiropractic care should be retained in the patient file for at least how long according to standard professional guidelines?
- 6 months
- 1 year
- The duration of active treatment only
- A minimum of 3–7 years or per state law (Correct answer)
Correct answer: A minimum of 3–7 years or per state law
Medical and professional records, including veterinary referral letters, should be kept a minimum of 3–7 years or per the applicable state statute.
Question 4: Which of the following best describes the purpose of recording a horse's performance history at the initial intake?
- To determine the owner's financial ability to pay for treatment
- To establish a baseline for correlating musculoskeletal findings with functional demands (Correct answer)
- To comply with insurance reimbursement formatting requirements
- To document the farrier's contact information
Correct answer: To establish a baseline for correlating musculoskeletal findings with functional demands
Performance history provides context linking the horse's workload and discipline to the musculoskeletal complaints being evaluated.
Question 5: In equine chiropractic records, 'CSM' typically refers to what finding?
- Cervical subluxation at the mandible
- Chiropractic subluxation mechanism (Correct answer)
- Caudal sacral mobility
- Complete skeletal mapping
Correct answer: Chiropractic subluxation mechanism
CSM (Chiropractic Subluxation/Spinal Manipulative lesion) is the standard term for a vertebral motion unit with altered position, motion, or function noted in chiropractic documentation.
Question 6: When a horse receives both veterinary and chiropractic care concurrently, documentation should include:
- Only the chiropractic findings, to avoid confusion with veterinary notes
- Notation of concurrent treatments, providers, and any reported interactions (Correct answer)
- A separate file entirely unrelated to the veterinary record
- Only the dates of veterinary visits without clinical details
Correct answer: Notation of concurrent treatments, providers, and any reported interactions
Documenting concurrent care and providers ensures coordinated treatment, avoids contraindicated therapies, and supports a complete clinical picture.
Question 7: Which notation system uses symbols such as arrows and triangles to map vertebral misalignment direction in equine chiropractic records?
- ICD-10 coding
- Anatomical listing system (Correct answer)
- SOAP narrative format
- AVMA progress note standard
Correct answer: Anatomical listing system
The anatomical listing system uses directional symbols and abbreviations to record the position and direction of vertebral misalignment in chiropractic records.
ECC Documentation & Record Keeping 2
When documenting a horse's response to equine chiropractic treatment, which outcome measure is most clinically relevant to record?