CA 104: Documentation & Recordkeeping | Certified Chiropractic Assistant Program

CA 104: Documentation & Recordkeeping is Chapter 4 of the CCEDseminars Certified Chiropractic Clinical Assistant program and focuses on daily notes and clinical records. Accurate documentation protects patients, doctors, and the practice—and the chiropractic assistant plays a key role in keeping charts clear, complete, and compliant.

This two-hour online chiropractic assistant course explains SOAP-style daily notes, documentation workflows, and recordkeeping habits that align with modern chiropractic standards. You will see how assistants support note-taking, EHR use, and paper chart organization so that records are defensible and easy to follow during audits, referrals, and patient care transitions.

Estimated Completion Time

Approximately 2 hours (Online Format: Video, text & downloadable study guide)

Course Topics

• Purpose of documentation and recordkeeping in chiropractic practice
• SOAP-based daily notes and core elements of each section
• Chiropractic assistant roles in documentation and chart support
• Documentation workflows and EHR best practices for CAs
• Risk management, privacy, and compliance themes in recordkeeping

Learning Objectives

• Explain why accurate documentation and recordkeeping are critical to patient safety and practice protection
• Describe the structure and purpose of SOAP-style daily notes
• Identify appropriate chiropractic assistant tasks in documentation and chart management
• Apply practical strategies for supporting consistent, organized records in paper and electronic systems
• Recognize documentation habits that reduce risk and support regulatory compliance

Course Structure

• Concise video modules with text and downloadable study guide
• Examples of SOAP notes, chart entries, and documentation checklists
• Discussion of real-world workflows in chiropractic EHR and paper charts
• Knowledge checks reinforcing documentation and recordkeeping concepts

Quick Course Details

• Course Type: Online
• Credit Hours: 2
• Instructor: Monte Horne, DC
• Format: Recorded online presentation with self-paced access
• Access: Log in and out as needed; resume where you left off
• Certificate: Instant certificate available upon successful completion
• Program: Chapter 4 in the Certified Chiropractic Clinical Assistant (CCCA) curriculum
• Bundle & Save: Eligible for multi-course CCCA bundles and assistant training packages

About the Instructor

Monte Horne, DC is Founder and Lead Educator at CCEDseminars and postgraduate faculty at Texas Chiropractic College. He has taught documentation, functional assessment, and clinical reasoning to chiropractors and assistants for decades and created the FCLB-recognized Certified Chiropractic Clinical Assistant pathway.

Dr. Horne’s instruction emphasizes practical, compliance-focused documentation strategies that teams can implement immediately. His goal is to help chiropractic assistants become indispensable in recordkeeping and daily note support while aligning with board and payer expectations.