AI Scribe for Chiropractic
Transcribe Health drafts your exam, daily visit, and re-evaluation notes while you work, so the spinal findings and the reason for the adjustment are on the page before the patient leaves.
Photo: Sincerely Media / Unsplash
Chiropractic documentation, from initial exam to daily adjustment
A chiropractic chart usually starts with a full initial exam. You take the history, run orthopedic and neurologic tests, check range of motion and posture, palpate for segmental dysfunction, and land on the involved spinal regions. From that you build a plan of care: which regions you will adjust, how often, for how long, and what functional goals tell you the patient is improving. This note sets the baseline everything else is measured against.
Then come the daily visits. A patient with low back pain may be in three times a week, and each of those notes has to stand on its own. It needs the change since the last visit, the regions you adjusted (spinal chiropractic manipulative treatment is coded by how many regions you touch), any modalities, and the patient's response. When those notes are copied forward with the same words every time, they read as cloned, and cloned notes are one of the first things a reviewer flags.
Chiropractic is audited hard on medical necessity, and Medicare only covers manual manipulation to correct a subluxation. The record has to show an active problem, a functional deficit, and care aimed at improvement rather than open-ended maintenance. Transcribe Health listens to the encounter and drafts a note that keeps the regions, the findings, and your reasoning where they belong. You read it and sign. Nothing is filed without you.
Documentation Challenges in Chiropractic
- 1
Documenting medical necessity for spinal manipulation on every date of service, with the exam findings and functional deficits that justify the care
- 2
Writing daily visit notes that stay distinct when a patient comes in three times a week for the same complaint, instead of cloned notes that trigger denials
- 3
Recording the spinal regions treated, the subluxation or segmental findings, range of motion, and the treatment plan in a way that ties back to the initial exam
How Transcribe Health Helps Chiropractic
Initial Exam and Plan of Care
Drafts the history, orthopedic and neurologic exam, spinal findings, and a plan of care with frequency and measurable goals from what you say during the visit.
Daily Visit Notes That Read Differently
Captures what changed since the last visit, the regions adjusted, and the patient's response, so each daily note reflects that specific encounter.
Medical Necessity on the Page
Puts the functional deficits, the exam findings, and your reasoning into the note, which is the detail a payer looks for when a manipulation claim is reviewed.
A chiropractic note, captured in real time
An abridged re-evaluation for a patient in active care for low back pain, drafted the way you would see it before signing.
44-year-old woman returns for re-evaluation of mechanical low back pain that began after moving boxes about five weeks ago. Reports her pain is down to 3 out of 10 from 7 out of 10 at intake. She can now sit through a full workday and has returned to light gardening. Still has morning stiffness that eases after 20 minutes. No radiation below the knee, no numbness, no bowel or bladder changes.
Lumbar range of motion improved: flexion 55 degrees (was 35), extension 20 degrees, lateral bending near equal bilaterally, with mild end-range discomfort on extension. Palpable segmental restriction and tenderness at L4-L5 and L5-S1 with associated paraspinal hypertonicity. Straight leg raise negative bilaterally. Deep tendon reflexes 2+ and symmetric at the patella and Achilles. Gait normal.
1) Segmental and somatic dysfunction of the lumbar region, improving with care. 2) Low back pain, mechanical, moderate at intake and now mild. 3) Functional gains: range of motion and tolerance for sitting and daily activity both improved from the initial exam. Care remains medically necessary; patient has not yet reached the pre-injury baseline.
Chiropractic manipulative treatment performed today to the lumbar and sacral regions (2 regions), diversified technique, with good tolerance and no immediate adverse response. Manual therapy to the lumbar paraspinals. Step frequency down from 3 to 2 visits per week for the next 2 weeks, then reassess. Continue home program: McKenzie extension exercises and walking 20 minutes daily. Goal is full pain-free lumbar range of motion and return to unrestricted gardening within 3 to 4 weeks. Re-evaluate at that point; if progress plateaus, discuss discharge to self-management.
Illustrative example. Not a real patient encounter.
Built for chiropractic coding and your EHR
Notes capture the spinal regions you treated, the exam findings, and the functional deficits that back up the medical necessity of a manipulation. That is the detail a payer looks for on review, and the first thing to slip when you are documenting between patients.
- 98940Chiropractic manipulative treatment, spinal, 1 to 2 regions
- 98941Chiropractic manipulative treatment, spinal, 3 to 4 regions
- 98942Chiropractic manipulative treatment, spinal, 5 regions
- 99202 / 99203New-patient exam, straightforward to low complexity
- 99213Established-patient re-evaluation, low to moderate complexity
- 97140 / 97110Manual therapy or therapeutic exercise, per 15-minute unit
- M54.5Low back pain
- M54.2Cervicalgia (neck pain)
- M99.01Segmental and somatic dysfunction of cervical region
- M99.03Segmental and somatic dysfunction of lumbar region
- M54.6Pain in thoracic spine
Fits the workflow you already have
Drafts drop into the systems chiropractic offices actually run on: ChiroTouch, Genesis Chiropractic Software, and general platforms like Jane. You get the note type you are working in, an initial exam, a daily visit note, or a re-evaluation, with the SOAP structure and the regions filled in. It writes up the findings and the plan you dictate. It does not set your fee schedule or submit the claim; you make the call and it records it.
Chiropractic AI scribe questions
Does it understand chiropractic terminology?
How does it keep daily visit notes distinct and support medical necessity?
Can it handle both the initial exam and the short follow-up?
How is patient information protected?
Does it connect to our EHR?
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