Chiropractic malpractice and the clinic around it.

Written consent before the first adjustment

In California, under 16 CCR 319.1, a licensed chiropractor must inform each patient of the material risks of proposed care both verbally and in writing. "Material" means a procedure that inherently involves a known risk of serious bodily harm. The chiropractor must obtain the patient's written informed consent before initiating clinical care, and the signed consent becomes part of the patient's record. A violation is unprofessional conduct and may lead to discipline.

The regulation defines what makes a risk material, but it does not list specific risks. For Medicare patients, the CMS Medicare Benefit Policy Manual (chapter 15, section 240.1.3) adds a separate charting point: when a patient has a relative contraindication to dynamic thrust, such as a bleeding disorder or anticoagulant therapy, the doctor should discuss that risk with the patient and record it in the chart.

What I look for when I review a clinic's file:

• Consent comes before care. That includes patients an associate sees first.
• The form tracks the care you propose. 319.1 ties the disclosure to the proposed care, so a form written before you added a service may not mention it.

Other states set their own consent rules, so the requirements vary by state. For how California limits malpractice damages and filing deadlines, see medical malpractice insurance.

Where the chiropractic license stops

I ask every clinic for its services list, because care outside chiropractic scope is a different risk. In California, 16 CCR 302 draws the line.

• Allowed. Manipulating and adjusting the spinal column and other joints, and the related muscle and connective tissue. As part of a course of chiropractic treatment, measures such as air, cold, diet, exercise, heat, light, massage, rest, ultrasound, water and physical therapy techniques.
• Diagnosis only. X-ray and thermography equipment may be used for diagnosis but not treatment. Diagnostic ultrasound is limited to neuromuscular skeletal diagnosis.
• Not authorized. Surgery, or severing or penetrating tissue. Delivering a child or practicing obstetrics, dentistry or optometry. Any drug or medicine included in materia medica. A lithotripter, ultrasound on a fetus, or mammography.
• Titles. A chiropractor may not hold out as licensed as anything other than a chiropractor, or use the term "physical therapy" in advertising, without holding that license.

Two Board rules reach past your own hands. Under 16 CCR 317(w), it is unprofessional conduct not to refer a patient to a physician and surgeon or other licensed health care provider when your diagnostic evaluation detects a condition that chiropractic methods cannot appropriately manage, unless the patient says another provider is already managing it. Under 16 CCR 316(a), you are responsible for the conduct of employees and others you supervise in your place of practice, and must ensure it conforms to the law and the regulations.

If your clinic includes massage, rehab or aesthetic services, tell me who performs each one and under what credential, so we can confirm whether each person is named on your policy or carries their own. Related pages: massage therapist insurance, physical therapy clinic insurance and med spa insurance.

Advertising and referral rules the Board enforces

Several Board rules have nothing to do with an adjustment. Under 16 CCR 311, constructive educational publicity is encouraged, but advertising that contains misstatements, falsehoods, misrepresentations, or distorted, sensational or fabulous statements, or that is intended or tends to deceive the public, is grounds for discipline. Penalties include suspension for up to one year, probation, or other action short of revoking the license. 16 CCR 317 adds these to its list of unprofessional conduct:

• Cappers or steerers employed or used to obtain business.
• Compensation for referrals, whether offered, delivered, received or accepted.
• Waiving deductibles or copayments as an advertising or marketing procedure, unless the insurer is notified in writing in each instance.
• Unauthorized disclosure of patient information revealed during examination or treatment, except as required by law.
• Clearly excessive treatment or diagnostic procedures, measured by the customary practice of the local community of licensees.
• Offering, advertising or substituting spinal manipulation for vaccination.

I'll ask how new patients reach you: online ads, attorney referrals or a marketing company. Ask me whether your malpractice policy includes defense of a Board complaint, and up to what amount. For slip-and-fall and other premises claims against the clinic, see general liability insurance.

Official sources

• Cal. Code Regs. tit. 16, § 319.1 — Informed consent (Cornell LII)
• Cal. Code Regs. tit. 16, § 318 — Chiropractic patient records/accountable billing (Cornell LII)
• Cal. Code Regs. tit. 16, § 302 — Scope of practice (Cornell LII)
• Cal. Code Regs. tit. 16, § 316 — Responsibility for conduct on premises (Cornell LII)
• Cal. Code Regs. tit. 16, § 317 — Unprofessional conduct (Cornell LII)
• Cal. Code Regs. tit. 16, § 311 — Advertisements (Cornell LII)
• 42 CFR § 410.21 — Limitations on services of a chiropractor (Cornell LII)
• CMS Medicare Benefit Policy Manual, Chapter 15, §240 Chiropractic Services