CA 104: Documentation & Recordkeeping

This chapter is designed for current and aspiring chiropractic assistants who want structured, practical training in documentation and daily notes. It also supports Doctor of Chiropractic who want their staff training to align with online chiropractic CE and modern documentation standards discussed in professional resources such as the American Chiropractic Association.

If you have ever wondered, “What is a chiropractic assistant, and how can I become indispensable in the practice?” this chapter answers that question from a documentation and records perspective, with a focus on SOAP-style daily notes and clinical workflows.

• New team members exploring careers in chiropractic assisting who need a clear, step-by-step introduction to documentation.
• Experienced CAs seeking affordable continuing education to update their skills and support board-compliant records.
• Doctors of chiropractic who want staff trained in the same principles emphasized in PACE-approved documentation and risk management courses.
• Office managers building a structured CA training program for onboarding and annual review.

Chapter 4 is delivered as an online chiropractic assistant course with on-demand streaming and, when scheduled, live webinar options. Your progress is tracked inside the CCEDseminars learning platform so you can pause, resume, and review key concepts in documentation and daily note-taking.

• Approximate contact time: 2 hours of focused instruction in documentation and clinical records.
• Access duration: A generous replay window so you can revisit complex topics like SOAP, POMR, and SORE note formats.
• Certificate: Printable certificate of completion for office files and staff training records.

Many boards emphasize documentation, ethics, and patient privacy as core elements of safe and effective care. While regulations differ by state or province, the themes in this chiropractic assistant class align with what doctors encounter in chiropractic ethics and law CE, risk management courses, and documentation-focused continuing education.

• Legal and ethical rationale for maintaining clear, complete, and timely health records.
• How accurate daily notes support evidence-based chiropractic education, continuity of care, and defensible documentation.
• Documentation practices that reduce risk by clarifying what care was delivered, why it was provided, and how patients responded.
• Boundaries between the chiropractic assistant role and the doctor’s role in diagnosis and clinical decision-making.

Chapter 4 gives chiropractic assistants a structured blueprint for daily note-taking and chart support. Use the outline below as study notes or as a quick guide for team meetings and in-service training.

• Legal & Ethical Foundations of Records — Why every CA must understand the purpose of documentation, medical-legal risk, and third-party payer expectations, including how records are used in audits and reviews.
• S.O.A.P., P.O.M.R. & S.O.R.E. Note Formats — How different daily note systems organize subjective findings, objective data, assessments, and plans, with side-by-side examples of when each format is most appropriate.
• Legibility, Completeness & EHR Best Practices — Strategies for entering information, supporting the doctor, and avoiding documentation gaps that create audit or liability risk.
• Common Chiropractic Abbreviations — A practical reference list of everyday abbreviations and terminology so CAs can read and support clinical notes accurately.
• Workflow & Communication — How to move information from phone calls, front desk, treatment rooms, and follow-up into a clear, complete record.
• Case-Based Examples — Sample documentation scenarios to help chiropractic assistants apply concepts to real patients and busy clinics.

This CA training program is available in flexible formats so you can learn in the way that works best for your schedule and practice.

• On-Demand Module — Complete Chapter 4 at your own pace with pause, rewind, and replay for complex documentation topics.
• Team Access — Enroll multiple CAs so everyone learns the same documentation language and standards.

Many offices bundle this chapter with other chiropractic assistant courses and chiropractic certification programs for a more complete staff curriculum.

Discount bundling: CCEDseminars offers bundle options so you can package multiple CA classes (for example, Chapters 1–4 or a full assistant training sequence) at a reduced per-hour investment. This makes it easier to provide affordable continuing education for chiropractic assistants while also supporting the doctor’s online chiropractic CE plan. Contact us for current bundle options and group access.

Dr. Monte Horne, DC, is the founder of CCEDseminars and has practiced chiropractic for more than 35 years. He has served in the postgraduate education division at Texas Chiropractic College and, through CCEDseminars, has trained more than 10,000 chiropractors since 2012.

Dr. Horne’s expertise in documentation standards draws from his years as a Designated Doctor for the Texas Department of Insurance (1996–2010) and his ongoing work as an expert witness in chiropractic malpractice defense—experience that informs every module in this program. His teaching style is practical, clear, and focused on real-world application in active practice settings.

Under his leadership, CCEDseminars has grown into a PACE-recognized provider serving chiropractors in more than 40 states, Canada and internationally, with PACE-approved courses spanning documentation, sports certification, pediatrics certification, neurology, and comprehensive assistant training.

• Access: Course access, replay windows, and handout availability are published in your CCEDseminars account at registration.
• Technology: A reliable internet connection, audio, and an updated browser are recommended for the best experience.
• Refunds & transfers: See the CCEDseminars policy page for details on cancellations, transfers, and substitutions.
• Board recognition: Each licensing board defines how chiropractic assistant training and online CE activities are recognized. Always confirm acceptance and topic applicability before relying on any course for license renewal.
• No legal advice: This course is educational and does not provide legal, billing, or coding advice. Specific cases should be reviewed with your compliance advisor, malpractice carrier, or legal counsel.

↑ Back to top