CERTIFIED CHIROPRACTIC CLINICAL ASSISTANT
Introduction
NOTE: This manual is intended as a refresher summary and study aid
for experienced chiropractic assistants. It is not a comprehensive
text, and chiropractic assistants who lack practical experience should
not consider it authoritative or the equivalent of formal, in-depth
coursework.
A statute was passed by the North Carolina General Assembly mandating that an employee
of a chiropractic physician who performs clinical duties must be certified. The law
defines who must be certified as follows:
(a) "Chiropractic clinical assistant" means a nonlicensed employee of a chiropractic physician whose duties
include (i) collecting general health data, such as the taking of an oral history or vital sign measurements, (ii)
applying therapeutic procedures, such as thermal, sound, light and electrical modalities, and hydrotherapy,
and (iii) monitoring prescribed rehabilitative activities. Nothing in this section shall be construed to allow a
chiropractic clinical assistant to provide a chiropractic adjustment, manual therapy, nutritional instruction,
counseling, or any other therapeutic service that requires individual licensure.
The law goes on to set the requirements as follows:
(b) Any person employed as a chiropractic clinical assistant shall obtain a certificate of competency from the
State Board of Chiropractic Examiners (Board) within 120 days after the person begins employment.
Certification shall not be required for employees whose duties are limited to administrative activities of a
nonclinical nature. Except as otherwise provided in this section, it shall be unlawful for any person to practice
as a chiropractic clinical assistant unless duly certified by the Board.
(c) An applicant for certification under this section shall be (i) at least 18 years of age,
(ii) a high school graduate or the equivalent, (iii) of good moral character, and (iv) able to demonstrate
proficiency in the following subjects:
(1) Basic anatomy.
(2) Chiropractic philosophy and terminology.
(3) Utilization of standard therapeutic modalities.
(4) Contraindications and response to emergencies.
(5) Jurisprudence and patient privacy protection.
(d) If an applicant for certification is already certified or registered as a chiropractic clinical assistant in
another state, the Board shall issue a certificate of competency upon evidence that the applicant is in good
standing in the other state, provided the requirements for certification or registration in the other state are
substantially similar to or more stringent than the requirements for certification in this State.
(e) Any certificate issued under this section shall expire at the end of the calendar year unless renewed in a
time and manner established by the Board. Applicants for initial certification or renewal of certification shall
pay to the secretary of the Board a fee as prescribed and set by the Board, which fee shall not exceed fifty
dollars ($50.00).
(f) The Board may adopt rules pertaining to initial educational requirements, course approval, instructor
credentials, examination of applicants, grandfathering, reciprocity, continuing education requirements, and
the submission and processing of applications as are reasonably necessary to enforce this section." Page 2
Session Law 2013-290 House Bill 371
A Certified Chiropractic Clinical Assistant (CCCA) is an individual who has completed
the required number of hours in a clinical setting to be exempted from the education hours
and then passed a certification test, or one who has obtained the required education and
then passed the certification exam given by the North Carolina Board of Chiropractic
Examiners.
This certification does not extend to radiographic procedures. A separate certification is
required to be eligible to perform these duties. It also does not include manipulative
therapy, manual therapy, nutritional instruction or any other service that requires licensure.
Clinics may choose to utilize massage therapy as a service to patients. This type of body
work is considered to be within the scope of practice for a licensed massage therapist. The
chiropractic physician may perform this type of service on a patient but may not direct a
chiropractic assistant (certified or not) with no other licensure to perform the service.
A chiropractic assistant (CA) is an individual who performs administrative duties only and
does not interact with any treatment performed on the patient.
The North Carolina Board of Examiners is empowered to pass rules that will help to
administer the law described above. As part of those rules, some chiropractic assistants
may be certified as part of a “grandfather” process described as follows:
Grandfathered Applicant - An employee of a chiropractic physician who has amassed a
minimum of 500 hours of clinical employment by July 1, 2014. The employing physician
must confirm the hours and state that he/she has performed on the job training for the
chiropractic assistant.
Reciprocity Applicant - An applicant who is already certified or registered in another state
as a certified clinical assistant and the requirements are substantially similar or more
stringent than the requirements in North Carolina.
New Applicant - An applicant who has not amassed a minimum of 500 hours by July 1,
2014.
Requirements for certification for a new applicant:
Completion of an approved educational program consisting of a minimum of 24 hours.
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1) 18 hours may be obtained online. 6 hours must be in-person didactic training.
2) Complete and submit an application, fee of $20.00 and an affidavit attesting to
good moral character.
When this has been received and processed, the applicant would be eligible for a
competency examination and certification. These examinations shall be available at
least 4 times per year.
If there is a lapsed certification due to non-renewal and the lapse does not exceed 12
months, the certificate holder may obtain reinstatement by making up the continuing
education and submitting the renewal fee. If the lapse is longer than 12 months, it would
be necessary for the candidate to re-take and pass the proficiency examination for new
applicants and pay a renewal fee.
History
Dr. Daniel D. Palmer, also known as D.D. Palmer, was the founder of chiropractic in 1895
when a man by the name of Harvey Lillard, who was an acquaintance of Dr. Palmer,
became the very first chiropractic patient. Mr. Lillard had been deaf for approximately 17
years after having an injury in his cervical spine. Dr. Palmer performed an adjustment and
Mr. Lillard’s hearing was restored. After the news spread regarding this new form of
healthcare, other patients began to seek Dr. Palmer’s care. Palmer Chiropractic College
was the first chiropractic college formed in 1897. D.D. Palmer had a son, Dr. B.J. Palmer,
who continued with chiropractic after his father’s death. Other chiropractic colleges were
then formed.
Chiropractic is from Greek words meaning “done by hand”. A chiropractic physician
may use their hands to perform a manipulation or various types instruments may also be
used for this purpose.
Chiropractic care does not involve the use drugs or surgery. Chiropractic treatment has
very few risks or side effects. Chiropractic physicians may treat acute and chronic
conditions. They examine patients, especially the spine, to determine the cause of the
patient’s condition. The doctor of chiropractic will then make recommendations for
correction, or prevention of future conditions.
Chiropractic has repeatedly been shown to be more cost-effective for certain conditions
while maintaining some of the highest patient satisfaction with outcomes. Depending on
the severity of the complaint and after a thorough examination, the doctor may recommend
a number of treatments which may include spinal manipulative therapy, physiological
therapeutics, rehabilitative exercises, supports, nutrition and other procedures to
accomplish correction.
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Chiropractic Philosophy and Physiology
The principle of chiropractic is that the body is designed to heal itself, up to the point of the
limitation of matter. The system in the body that controls all other systems is the nervous
system. The nervous system normally maintains a steady environment or “steady state” in
the body. An example is the body shivering to generate heat when the nervous system
perceives that the environmental temperature is cold. The nervous system is what
“senses” the cold, and the nervous system tells the muscles to shiver until enough heat is
generated. The body’s ability to maintain this steady state is called “homeostasis”.
Homeostasis literally means – steady state.
When the spine is in normal alignment and the nervous system is functioning properly, and
if all other conditions necessary for health are present such as sleep and nutrition, then the
body is allowed to maintain homeostasis in all areas and the person experiences health.
Health can be defined as optimum physical, mental, and social well-being, not just the
absence of disease.
If the spine is misaligned or fails to function as designed, this can cause a poorly
functioning nervous system resulting in nerve impairment and poor function of the same
areas that are supplied or innervated by that nerve. The result is that the body cannot
maintain homeostasis and therefore cannot achieve health. Interestingly, sometimes this
can be the case but there are no symptoms or pain.
Accidents, injuries, overexertion and poor posture are some of the most common reasons
for misalignment.
Some of the common terminology that refers to this spinal misalignment or loss of function
in its various clinical presentations include:
Subluxation
Fixation
Vertebral Subluxation Complex
Joint Dysfunction
Joint Immobility
Spinal Manipulable Lesion
You should adopt the language that is preferred by your employing doctor of chiropractic.
The danger of this lesion is that it can cause: pain, spasm, swelling, degeneration
(arthritis) and most importantly- nerve irritation and decreased health in the part of
the body supplied by that nerve.
The correction for the lesion described above i.e. subluxation is called an adjustment.
An adjustment is given by hand or with an instrument to restore normal function to the
joint, relieve interference to the nerves, and allow the body to maintain homeostasis and
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therefore, health.
Sometimes there is so much degeneration, tissue damage, or scarring that the body will
NEVER be able to fully regain health. In that case the patient may be managed by the
doctor of chiropractic to prevent additional damage and manage the symptoms, or the
patient may have to be referred for other treatment such as drugs or surgery.
ANATOMY
Anatomy is the study of the body’s structure.
Physiology is the study of the body’s function.
Other Definitions:
Anomaly - A marked deviation from the normal standard, especially as a result of
congenital or hereditary defects.
Nerve - A cordlike structure comprising a collection of nerve fibers which convey
electrical impulses between the brain and some other region of the body.
SPINAL ANATOMY AND CURVES
Cervical Spine
1. The first seven spinal bones (called vertebrae) make up the cervical spine or neck.
They are numbered one through seven from top to bottom. So the 4th bone from the
top is referred to as 4th cervical or C4.
2. The skull sits on top of the cervical spine, infact it sits on top of C1 also known as
the atlas.
3. There is no disc between the atlas (C1) and the second bone known as C2 or axis.
4. The normal curvature of the cervical spine is called a lordotic curve. This means
it curves forward in the middle of the curve (remember “forward with the lord”)
Clinical Note: A common x-ray finding of an injured or damaged cervical spine is a loss of,
or actual reversal of the normal cervical curve.
Thoracic Spine
1. These are the twelve vertebrae of the mid - back which articulate (form joints) with
the ribs. They are numbered one through twelve from top to bottom. For
example, the fourth thoracic vertebra is referred to as T4.
2. The normal curvature in this area is known as a kyphotic curve or backward curve.
3. The thoracic vertebra are the only ones with ribs. There are 12 pair of ribs, one
pair for each of the twelve thoracic vertebra.
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Clinical Note: Hyper-Kyphosis is an exaggerated kyphotic curvature in the thoracic
region and is commonly known as “humpback”.
Clinical Note: Normally if the spine is viewed from behind the patient, the spine should be
straight. Scoliosis is when the spine grows with a curve to the right or left when viewed
from behind.
Lumbar Spine
1. There are the five vertebrae of the lower back. They are numbered one to five
from top to bottom and the last, or bottom-most vertebra in the spine is L5.
2. The normal curve in this area is known as lordotic. It is a forward curvature just
like the cervical curve.
Clinical Note: Hyper-Lordosis is an exaggerated curvature in the lumbar region
commonly known as “swayback”.
Sacrum
1. This is a bone composed of 5 united/fused vertebrae situated below the lumbar
spine. It is one solid bone soon after birth. When viewed from behind it looks
like an upside down triangle. When viewed from the side, it has a kyphotic curve
like the thoracic spine.
2. The sacrum sits under, and supports, the 24 moveable vertebra of the spine.
Coccyx
1. Last bone of the vertebral column, commonly known as the tail bone. It too is
composed of multiple small vertebra that were fused soon after birth into the bone
we call the coccyx.
Vertebral Disc ( also Intervertebral Disc)
1. These are the somewhat soft cushions between most of the spinal bones (vertebrae).
They act as shock absorbing cushions and allow for flexibility. They consist of
rings of ligament much like tree rings, around a center of gelatin-like material.
Sometimes, the gelatin-like material oozes out of the disc and puts pressure on a
nerve or the spinal cord. This is called a herniated or bulging disc.
Clinical Note: A herniated disc or bulged disc is usually the result of some type of
excessive strain of the disc. This can be gradual as in poor posture, or sudden as in an
accident.
Additional Skeletal Anatomy
Please be familiar with some of the major bones as follows:
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Occiput
(the skull bone at
the back of the head that sits on top
of C1)
Humerus
(Upper arm bone)
Radius and Ulna
(Lower Arm bones)
Femur
(The longest bone in the body)
Tibia
(the larger of the two lower leg
bones, called the “shin”)
Fibula
(Smaller and more outside/lateral)
Cervical
Spine –top
7 vertebra
Thoracic
Spine- 12
vertebra
Lumbar
SpineLast 5
moveable
vertebra
Sacrum
Coccyx
Lateral (Side) View
Antero-Posterior View
(AP View)
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Bulging or Herniated Disc
Spinous Process
Disc
(Intervertebral Disc)
Vertebral Body
Hole for Nerve
(called a Foramen)
NOTE: In this case the disc is bulging backward into the hole (foramen) where the nerve
exits between the spinal bones (vertebra).
Scoliosis on X-ray
Ribs
Thoracic Spine with
abnormal curve into lumbar
spine
Pelvis
Sacrum
Hip Joint
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The Nervous System
The brain and Spinal cord are protected by the skull and vertebral column. The spinal
nerves exit the spinal column between two vertebra through a hole called an
intervertebral foramen.
The nervous system controls ALL other systems and function of the body.
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PHYSIOLOGICAL THERAPEUTIC MODALITIES
(Also known as Physiotherapy)
Physiological therapeutics can be defined as “Any physical agent applied to produce
therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light,
mechanical, or electric energy.” They can be attended (by a doctor or assistant) OR
non-attended (meaning the patient does not have anyone supervising the therapy).
The primary intended responses are to exert changes on the human body through increased
blood flow, heating of tissues, relaxing contracted tissues, or accelerating cell metabolism.
This results in rehabilitation and restoration of function, provides a reduction in disability,
improved activities of daily living, and improved function and health to the patient.
The attending chiropractic physician must determine which modality is most appropriate
for use. This determination is based upon the four (4) stages of healing. The 4 stages of
healing include:
a. Acute stage is often considered within the first 72 hours (3 days) following an injury.
The acute stage of care is directed at reducing pain, spasm, edema or loss/reduction of
function.
b. Sub-acute stage of healing continues for an additional 1-3 weeks but tissue healing may
continue for up to 12 weeks. Treatment during the sub-acute stage shall be for the
continued control of pain, spasm and edema with the intent of improving range of motion
more than what was observed in the acute stage. In this stage, the improvement in muscle
strength, reduction in ligamentous instability, improved soft and hard tissue healing and
continued progress in bodily function is to be noted.
c. Chronic stage begins when the sub acute stage ends and may continue for an indefinite
period of time if the condition is not previously resolved. Chronic stage treatment provides
for additional mobility and function with further increased strength and range of motion.
At this stage, there may not be a possibility of fully resolving the patient’s condition so the
goal becomes to manage it while allowing the patient to live the most complete lifestyle
possible.
d. Chronic recurrent stage includes intermittent exacerbations and remissions requiring
additional therapy. The chronic recurrent stage may occur from overuse, instability, poor
nutrition, underlying disease, poor case management or a return to activity too soon. The
goal in this stage would be to control pain, edema and spasm and maintain mobility and
function so not to regress. The goal is to treat the patient for the acute exacerbation, then
return them to supportive care for their chronic condition.
Factors that affect the patient’s ability to heal include:
1. Age of patient
2. Underlying disease
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3.
4.
5.
6.
7.
8.
Nutritional deficiencies
Mechanism of injury
Degree of injury or illness
Tissues involved in the injury or illness
Patient’s current state of health or prior injuries or illnesses
Compliance with doctor’s recommendations
A modality is a type of electrical, thermal or mechanical energy that causes physiological
changes. It is used to relieve pain, improve circulation, decrease swelling and reduce
muscle spasm. Typical types of modalities include electrotherapy i.e. electrical muscle
stimulation, thermotherapy i.e. ultrasound or heat/ice packs, mechanotherapy
i.e.traction and others.
ULTRASOUND
Ultrasound is high frequency sound waves that produce a form of deep tissue vibration
and heating. It is used for relief of pain and muscle spasm, promotes circulation and
relaxes tight muscles and soft tissue.
The doctor must determine several factors prior to performing ultrasound treatment in
order to achieve the desired effects. The desired depth of penetration, intensity of
treatment and whether the wave is continuous or pulsed should all be considered. The
frequency of the application determines the depth of treatment. The ultrasound wave can
be continuous or intermittent (pulsed). Continuous treatment means the ultrasound is
always generating energy. This treatment produces deep heat. Pulsed ultrasound
treatment means that sound waves are very quickly turning on and off. This treatment
creates mainly non-thermal effects.
The intensity determines how much heat is produced. The higher the intensity, the more
heat the patient should feel. The intensity should never be at a higher level than where a
warming sensation is felt, but never when pain or burning is reported by the patient.
During ultrasound treatment, the sound head should never be lifted from the patient
or it may damage the ultrasound machine. ALSO- during continuous ultrasound
treatment, the ultrasound head SHOULD NEVER STOP MOVING .
There must be continuous contact of the sound head against the patient’s skin. There is
an exception to this and that is when ultrasound treatment is being used under water. In
this situation, there should be a gap between the soundhead and the patient, but the gap
should be filled with water.
Ultrasound treatment is most commonly administered with a water-soluble gel. There
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should be a sufficient amount of gel to allow good contact and ease when moving the sound
head on the patient’s skin. The sound head should be moved in a slow circular motion
with a small amount of pressure, but should never be held still.
Common Indications for Use
1. Soft tissue injuries
2. Chronic connective tissue and joint dysfunction
3. Osteoarthritis
4. Bursitis
5. Tendonitis, bursitis, capsulitis
6. Nerve entrapments
7. Chronic sprains / strains
8. Muscle spasm
Contraindications
1. Cancerous lesions
2. Pregnant uterus
3. Metal implants
4. Eyes, heart, reproductive organs
5. Over the spinal column / brain
(never over the bony spine, safe to use to the sides of the spine)
6. Impaired circulation or sensation
7. Fractures
8. Tissue under therapy with radiation
9. Growing bones
CRYOTHERAPY (Cold Therapy)
This is the application of cold temperatures for the purpose of
removing heat or altering temperature in the body or body tissue.
Cryotherapy includes ice packs, vaso-coolant sprays, cold pack or
compress, ice massage or other cooling devices. Altering
temperatures in the body or body tissue is usually superficial and
most of the time used in acute or sub-acute injuries for pain relief.
It also reduces swelling, inflammation and muscle spasms.
Sensations felt with the use of ice packs – initially cold sensation,
then stinging, and eventually numbness.
Patients can be given instructions on home care utilizing cold
packs. The patient should be instructed on use. For instance, how
long the ice packs should remain on the body before removing, how long to leave them off,
and a schedule for reapplying. Patients should never be instructed to lie on an ice
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pack.
Contraindications of cryotherapy include:
a. Impaired local circulation
b. Areas of impaired sensation or circulation
c. Raynauld’s symptoms
d. Cyanosis (blue colored skin)
e. Skin rashes or open wounds
f. Utricaria (rash)
Clinical Note:
a. Do not use any type of cryotherapy over the skin for greater than one hour
b. Watch for signs of frostbite (damaged skin due to freezing)
When treating in a bath of cold solution, it is important for the patient to move the body
part slowly and monitor the fingers/toes for aching sensation. Stop prior to this and
remove from solution to allow normal room temperature to equalize it.
When using direct application of ice, NEVER place directly onto skin. Place a paper
towel, plastic barrier, or cool wet towel directly on the skin surface.
An ice massage is an effective therapy for small treatment areas. Move the ice pack or
cube slowly over the area for trigger points, muscle spasms and contusion.
THERMOTHERAPY (Heat Therapy)
Thermotherapy is the use of therapeutic heat which promotes circulation and relaxes tense
muscles. This could include heating pads, hot compresses, hot water bottle, ultrasound,
diathermy, whirlpool, sauna, infrared and others that would increase localized temperature.
Effects of thermotherapy include:
a. Decreased pain
b. Decreased tense muscles
c. Decreased inflammation in the chronic state
d. Increased local circulation
Contraindications of thermotherapy include:
a. Reddening or burning of the area
b. Skin rashes
c. Increased swelling
d. Increased pain
e. Malignancy
f. Areas where blood or fluid is pooled
g. Pregnancy
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When using any heat therapy, the following rules should be observed:
a. Never heat over an area where there is already an open wound, burn, sunburn or rash
b. Use caution putting heat over bony areas
c. The skin should be clean, dry and free of grease, oil and dirt
d. Check the area within 5 minutes after initiating treatment and then periodically
during treatment.
e. Discontinue if patient complains of burning, nausea, dizziness or other signs of
distress
f. Patient should never lie on heat packs
Clinical Note:
Moist heat vs. dry heat: Moist heat does not dry out tissues. It penetrates better and is
useful in sub-acute and chronic conditions.
Clinical Note:
Hydrocollator packs (moist heat packs) provide superficial moist heat. They are usually
kept in a stainless steel tank at about 150-170 degrees. They are placed into a cloth case
prior to applying to patient. The body area should be clean and dry. The patient should
be instructed to remove the pack if it becomes too hot. Doctor or therapist should check
on the patient’s skin periodically. Thick towels can also be utilized with hydrocolators.
ELECTROTHERAPY
Electrotherapy includes high volt currents, low volt currents and the combination of both in
either the alternating or direct currents.
ELECTRIC STIMULATION
Prior to beginning any type of therapy, the equipment should be checked for worn or
damaged parts. In the case of electrical stimulation, the electrodes should be checked to
verify there is no damage. The control should be in the “off” position prior to making
contact with the patient.
The machine should then be set to patient tolerance as all patients react differently to
this type therapy. There may be some patients that have the opinion “the stronger, the
better”. This is not accurate because if the therapy is too strong, it could decrease
maximum benefit to the patient or even cause harm.
Effects of electrotherapy include:
a. Pain control
b. increased range of motion
c. increased blood supply
d. muscle stimulation & re-education
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e. lymph and venous drainage
f. reduce muscle spasm
g. reduce edema and swelling
h. general tissue healing
i. improved strength and endurance in
muscle
Contraindications of electrotherapy
a. pacemakers or other implanted
electrical devices
b. malignancy (except pain control)
c. rashes, open lesions and sunburn
d. over the skull, eyes, uterus or throat
e. thrombophlebitis
f. advanced cardiovascular disease or other systemic disease
g. seizure disorders
Clinical Note:
Iontophoresis is the use of ultrasound or electric current to drive a topical substance
through the skin and into the body. The contraindications of iontophoresis are generally
the same as those for ultrasound and electrotherapy.
MECHANOTHERAPY
Mechanotherapy includes active and passive exercises, pressure point therapy, massage,
traction, supports, lifts, esthetics.
TRACTION
Traction is a pulling force to the spine to separate vertebra. Traction can be performed
either manually or mechanically. It may be designed to relieve pressure on a swollen
spinal segment, or it may be intended to restore motion to a section of the spine that has
decreased mobility, as in intersegmental traction.
Effects of mechanotherapy include:
a. increased circulation
b. decreased spasm
c. improved lymphatic flow
d. pain reduction
e. increase range of motion
f. decrease local edema (swelling)
Contraindications include:
a. Osteoporosis
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b.
c.
d.
e.
f.
g.
h.
Infection
Tumor
Pregnancy
Hernia
Circulatory disease
Fracture
Surgery
Responsibilities of CCCA
Each CCCA should become familiar with the privacy, safety, and procedures of the office.
In addition, they should be trained on and become familiar with the specific modalities in
the office prior to performing services with these machines. Utilization of modalities
must be directed and supervised by the chiropractic physician.
The applicable standard of care requires that a chiropractic physician be present in the
clinic when a CCCA applies therapeutic modalities, but the doctor is not required to
observe or oversee the application of the modality.
The NC Board of Chiropractic Examiners requires that each clinical assistant possess
knowledge of:
1. The application of physiological therapeutic modalities
2. How, when and why they are applied (Indications)
3. When to inform the doctor that changes have occurred in a patient
4. What risks and contraindications may be associated with the application of these
modalities
5. Proper maintenance of the therapeutic devices and other products utilized
6. Recording of information regarding utilization of therapy performed by the assistant
SEXUAL AND PERSONAL BOUNDARIES
When you are at work, you should strive to maintain a professional attitude and demeanor,
regardless of whether you are dealing with patients or co-workers. The hallmarks of
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professionalism include the following:
1. Limit disclosures about your personal life. Your attention should be devoted to the
patient’s health; talking about your own problems signals that you are not focusing
fully on the patient.
2. Always be pleasant, but don’t encourage patients to become your friends. Don’t
consider dating a patient while the patient is under active care.
3. To the extent possible without giving offense, don’t accept gifts from patients.
4. Do your best to protect the patients’ privacy by using sheets, gowns, shrouds,
trenchcoats, canvas tarps and/or plywood panels to cover their bodies.
5. Don’t tell off-color jokes or make sexual innuendoes. Do your best to discourage
patients from telling off-color jokes in your presence.
6. Don’t remark or comment upon:
 Anyone’s personal behavior
 The attractiveness of the patient’s body, or lack thereof
 Sex
7. Never touch a patient inappropriately. Limit your physical contact to
doctor-ordered therapeutic procedures only.
8. Don’t gossip about other patients or your co-workers.
DOCUMENTATION
All documentation should be complete, accurate and legible. If another doctor is filling in
for the main doctor, he/she should be able to look at the notes and get a complete picture of
the patient.
It is acceptable to utilize abbreviations but all should take care to use common
abbreviations. Any usage of notations that are not considered common should have a key
or explanation of the abbreviation.
If hand written notes are made, they should be in ink and never in pencil. The daily notes
should be in chronological order and treatment rendered should be signed by the individual
performing that particular portion of the treatment.
There should never be any erasures, blacked out portions or white-out used. If it becomes
necessary to change or correct an entry, it should be drawn through with a single black line,
corrected, and signed or initialed.
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When documenting physiotherapy modalities, a CCCA should list what modality was
used, the duration of the therapy, and any applicable setting. The documentation should
then be signed.
The accuracy of records and daily notes is important because these are considered legal
documents when presented in court.
Documentation on the initial intake form for patients should include but not limited to:














Demographic information, birthday, age, M/F, marital status, spouse’s name
Employer information and type of duties patient performs
Health history
Chief complaint followed by secondary complaints (if applicable)
How long problem has existed
When and how complaint began
Previous treatment and by whom
Current pain grade as expressed by patient
Smoker or non smoker
What worsens pain
What relieves pain
Does the pain radiate
Type of pain (sharp, dull, etc.)
Has the pain interfered with ADLs (Activities of Daily Living)
Clinical Note:
Subjective information is that which is reported by the patient i.e. patient report of
symptoms.
Objective information is that which is observed by the doctor i.e. limited range of motion.
PROTECTING PATIENT PRIVACY
Protecting the privacy rights of patients is one of the most basic legal duties imposed upon
chiropractic clinics. Federal statutes such as HIPAA and HITECH, along with rules
adopted by various regulatory agencies, describe a broad range of situations where privacy
rights can be compromised. In order to comply with privacy laws, you and your co-workers
should always observe the following protocols:
1. Protected Health Information (PHI) consists of treatment records, billing records,
sign-in sheets and any other records containing patient identifiers such as name,
address, place of employment, telephone number, email address or social security
number.
2. In general, do not disclose a patient’s PHI to anyone other than the patient unless
the patient has authorized you to make disclosure to a third person. The patient’s
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authorization must be in writing and no more than six months old. However, there
are exceptions to this rule. No patient authorization is required when:
 You send PHI to your clinic’s billing service or debt collection service;
 You send PHI to workers compensation carriers;
 You send PHI to a law enforcement agency at the agency’s request (the
Board of Chiropractic Examiners is a law enforcement agency).
 You send PHI in response to a subpoena or court order.
3. Do not disclose PHI to a patient’s spouse or other family member or caregiver
unless the patient authorizes the disclosure.
4. Each patient must sign a Notice of Privacy Rights that informs the patient how your
clinic protects PHI. If your clinic sends out birthday cards or appointment
reminders, make sure the Notice of Privacy Rights alerts patients to expect these
types of communication.
5. Do not discuss PHI where non-employees might overhear your conversation.
Examples of potential problem situations include:
 Telephone calls in the vicinity of patients
 Conversations over the intercom
 Conversations at the waiting room counter
 Conversations in the hallway when patients are entering or leaving treatment
rooms.
6. Computers containing PHI must be password-protected. Computer monitors must
be placed so only clinic personnel can view the screen. Before leaving a computer
unattended, close any active file and bring up the log-on window.
7. If PHI is maintained on paper documents, you must protect against accidental
disclosure to unauthorized persons. Insert charts in wall holders so that no PHI,
including the patient’s name, can be read. Do not leave charts face-up at your
workstation. Do not leave charts unattended at photocopiers or fax machines unless
this equipment is located in a secure area that is inaccessible to non-employees.
8. One staff member should be designated the privacy protection officer, and that
person should maintain a log of all disclosures of PHI, including the legal
justification for making a disclosure, such as “authorized by the patient per attached
release.”
9. When the clinic’s answering machine is on and unattended, the volume setting
should be low so that messages left by patients cannot be overheard.
10. Patient sign-in sheets must be partially covered so that when presenting for an
appointment, the patient cannot see who signed in ahead of him or her.
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11. When not in use, patient records must be stored in locked cabinets or storage
rooms.
12. Old charts and other records that contain PHI cannot be discarded as ordinary trash;
they must be shredded or otherwise destroyed to prevent unauthorized disclosure.
13. Patients who are younger than 18 must have a parent or legal guardian sign all
documents in their behalf, including authorizations to disclose PHI. Be certain that
you know the relationship between a minor patient and anyone claiming to be the
patient’s guardian.
14. If you suspect that a patient’s PHI has been disclosed inappropriately or otherwise
compromised, report the breach to your employing physician immediately. Your
physician may have a duty to notify affected patients or, in cases of large-scale
breach, to regulatory authorities.
15. If a patient requests a copy of his or her records, the clinic must honor the request
within 14 days. You are allowed to charge a copying fee as follows: $.75 per page
for the first 25 pages, $ .50 per page for pages 26-100, $ .25 per page for each page
over 100. The right of patients to have copies of their own records upon request is
absolute and must be honored in every case, regardless of whether the patient has
an unpaid balance.
Emergency Procedures
Heart Attack
As with other parts of the body, the heart must have a supply of oxygen and nutrients.
Two coronary arteries supply this oxygen to the heart muscle. If one of the arteries is
blocked too long, the heart is not receiving the needed oxygen and heart tissue could die.
Some heart attacks can last several hours, so it is important to seek help quickly.
Some of the signs of a myocardial infarction (heart attack) are squeezing chest pain,
shortness of breath, nausea, pain into the shoulder and back, cold sweats, vomiting, feeling
faint and possibly breast and arm pain in women.
There is a possibility the patient is suffering a heart attach without pain. If that is the case,
there may be symptoms such as weakness, dizziness, pounding heart, shortness of breath,
nausea or vomiting.
If there are any of the signs of a possible heart attack, seek help. If in an office setting,
notify the doctor and call 911.
Stroke
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When arteries that supply oxygen to the brain rupture or become blocked, it could lead to a
stroke. Some signs of a stroke are paralysis of arms or legs or one side of the face,
tingling, numbness, confusion, dizziness, double vision, slurred speech or weakness on one
side of the body.
Other emergencies that may be seen in a chiropractic office:
Head trauma
Suspected spinal injury
Bleeding
Cardiac arrest
Stroke
Convulsion or seizure
Choking
Heart attack
Clinical staff should be trained in areas of emergencies and instructed what steps should be
followed when one arises. Most of these will require emergency medical intervention.
When in doubt, call 911.
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TERMINOLOGY
Abduction Away from the midline of the body
Acute New, sudden
Adduction Movement towards the center of the body
Antalgic Leaning away from pain
Anterior To the front
Atlas First cervical vertebra
Axis Second cervical vertebra
Caudad Towards the feet
Cephalic Towards the head
Chronic Long standing
Coccyx Last bone of the vertebral column
Congenital Existing at or before birth
Contralateral Opposite side
Degeneration Deterioration which causes some degree of loss of function
Distal Away from point of reference
Extension Bending backward
External rotation - Turning away from midline
Flexion Act of bending forward
Humerus Arm bone
Inferior Beneath, lower
Inflammation Tissue reaction producing symptoms of swelling, heat, redness
Internal rotation Turning to midline
Intervetebral disc - Fibro elastic cartilage between the vertebrae
Ipsilateral On the same side
Lateral To the side
Lateral recumbent - Lying on side
Mandible Jaw bone
Medial Toward the mid line
MUA Manipulation under anesthesia
Objective Information observed by a provider
Palmer Palm of the hand
Plantar Sole of foot
Posterior Back or behind
Prone Lying face down
Proximal Near the point of reference
Scapula Shoulder bone
Sprain Injury in which the ligaments are stretched or lacerated
Sternum Chest bone
Strain Over stretching or overexertion of a muscle
Subjective Information a patient may tell a Dr.
Subluxation Misalignment of a vertebra
Superior Higher, above
Supine Lying on back, face up
Ventral Anterior
Vertebra Bony segments forming the spine
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