Chapter 4734-8 Chiropractic Physicians
(A) A doctor-patient relationship is any relationship between a chiropractic physician and a patient wherein the chiropractic physician provides professional services to the patient. Except as provided in paragraph (B) of this rule, a chiropractic physician shall comply with the following requirements in order to dismiss the doctor-patient relationship:
(1) Send notice to the patient that includes all of the following:
(a) A statement that the doctor-patient relationship is terminated;
(b) A statement that the chiropractic physician will provide emergency treatment for up to thirty days from the date the letter was mailed to allow the patient an opportunity to secure care from another chiropractic physician;
(c) An offer to transfer records to a new chiropractic physician upon receipt of a signed authorization.
(2) The notice shall be sent in one of the following ways:
(a) A letter sent via certified mail, return receipt requested, to the last address for the patient on record, with a copy of the letter, the certified mail receipt, and the mail delivery receipt maintained in the patient record;
(b) An electronic message sent via a HIPPA compliant electronic medical record system or HIPPA compliant electronic health record system that provides a means of electronic communication to the patient and is capable of sending the patient a notification that a message is in the patient's portal and confirming the message was viewed by the patient.
(c) If a notice sent via an electronic message as authorized in paragraph (A)(2)(b) of this rule is not viewed within ten days of having been sent, a letter sent in accordance with paragraph (A)(2)(a) of this rule.
(B) The requirements of paragraph (A) of this rule do not apply to the following:
(1) The chiropractic physician rendered professional services to the person on an episodic basis or in an emergency setting and the chiropractic physician should not reasonably expect that related services will be rendered to the patient in the future;
(2) The chiropractic physician formally transferred the patient's care to another chiropractic physician who is not in the same practice group;
(3) The patient terminated the relationship, either verbally or in writing, or has transferred care to another chiropractic physician and the physician maintains documentation in the patient record of the patient's action terminating the relationship.
(A) A chiropractic physician is responsible for the care of his or her patients. Such responsibility includes ensuring that all unlicensed supportive personnel are competent and properly qualified by education, training, and/or experience to perform their assigned duties.
(B) A chiropractic physician may delegate certain professional responsibilities to unlicensed supportive personnel who are qualified by education, training, and/or experience to perform such duties.
(C) Unlicensed supportive personnel means an individual or individuals who are on the job trained by a chiropractic physician and who participate in chiropractic patient care delivery. Unlicensed supportive personnel do not hold professional licensure and work under the direction of a chiropractic physician utilizing their education, training, and/or experience to perform designated tasks and duties related to the practice of chiropractic. This does not include any activity that would require performance, clinical interpretation and/or treatment by a licensed professional.
(D) A licensed chiropractic physician must properly supervise all unlicensed supportive personnel to whom responsibilities are delegated. Properly supervise within the meaning of this rule is defined as on-site initial and ongoing direction, procedural guidance, observation, and evaluation by a licensed chiropractic physician.
(E) Professional responsibilities shall only be delegated by the order of a licensed chiropractic physician. Professional responsibilities within the meaning of this rule include:
(1) Taking measurements for height, weight, blood pressure, respiration, pulse, and temperature;
(2) Recording observable signs and symptoms;
(3) Collecting bodily fluids for diagnostic purposes;
(4) Applying hot and/or cold packs;
(5) Applying mechanical traction;
(6) Applying electrical stimulation;
(7) Applying vasopneumatic devices;
(8) Applying diathermy;
(9) Applying therapeutic ultrasound;
(10) Exercise instruction and supervision of exercise activities;
(11) Supervision of therapeutic procedures;
(12) Assist patients to safely perform activities related to the development of strength and endurance;
(13) Other services or procedures as deemed appropriate by the board.
(F) A chiropractic physician shall not delegate duties to unlicensed supportive personnel in a negligent manner.
(A) Description. The "Quality Intervention Program" (hereinafter "QIP") is a voluntary program designed to address practice and communication complaints which do not appear to warrant intervention by formal disciplinary action, but may indicate that the licensee involved has developed poor practice patterns or has failed to keep up with current standards of chiropractic and/or acupuncture practice. The primary candidates for referral are those licensees who appear to demonstrate a practice deficiency and who do not demonstrate any physical, mental, or chemical impairment problems which would render educational intervention ineffective or dangerous to the public. As long as there is no identifiable impairment issue, an educational intervention may be all that is needed to bring the licensee up to current standards of practice. The key component of this program is the "Quality Intervention Panel," a panel of experts whose responsibility and purpose are to assess each licensee referred to the program and make recommendations to a designated board member and the executive director based upon their peer assessment.
(B) Program referral. Only a designated board member and the executive director of the board jointly have the authority to refer a licensee to the QIP.
(C) Panel. A panel of experts will be selected and contracted with upon advice and approval of the board. The panel shall be comprised of a minimum of three experts, at least two of whom shall be Ohio licensed chiropractic physicians. The experts shall be chosen based on their experience, diversity, and communication skills. Panel members must have a practice history of a minimum of fifteen years, with no disciplinary or malpractice record. QIP panel members shall sign a panel member agreement that outlines their duties and obligations to the panel and the board.
(D) Identifying a communication or practice deficiency. A board designate and the executive director shall review the evidence obtained from the board's initial investigation to determine whether a licensee should be referred to the QIP panel for possible participation in the QIP. Criteria to be used when making the determination may include, but are not limited to, the following:
(1) Whether the public will be adequately protected if the licensee enters the QIP;
(2) Whether the licensee's conduct resulted in harm or other problematic outcome for the patient;
(3) The likelihood that the deficiency at issue is a deficiency that can be corrected through education and/or remediation;
(4) The extent of the licensee's cooperation with the board during its investigation;
(5) Whether the licensee's deficiency represents an intentional or willful commission or omission by the licensee;
(6) The frequency of the occurrence of the identified deficiency.
(E) Assessment. It is the panel's responsibility to assess a licensee in order to affirm a practice deficiency, define the deficiency, determine if the defined deficiency can be corrected through a course of reeducation, and identify specific education and/or remediation to correct the identified deficiency. When the QIP panel is initially presented a referral, the panel members shall be provided with all relevant documents included in the investigative file of the licensee under review. Each panel member shall review the documents and discuss them as a group. This discussion may be accomplished via a teleconference call. If upon review, the panel believes that the documents demonstrate a practice deficiency on the part of the licensee, it may request that the licensee be called in for a meeting. At this meeting, the panel members may conduct a simulated case review and discuss with the licensee the minimal standards concerns that the documents revealed. By engaging in peer-based discussions, the panel is seeking to determine whether or not the licensee demonstrates a deficiency, to further identify that deficiency, and to determine whether educational intervention would be beneficial. In certain cases, the panel may refer the licensee to an educational institution for further in-depth evaluation.
(F) The QIP panel may determine the following after the assessment:
(1) The licensee has no practice deficiency;
(2) The licensee has an identified practice deficiency that can be corrected through educational intervention. The panel shall recommend a specific education program(s) to correct the deficiency;
(3) The board should conduct further investigation into the matter;
(4) The problem identified is too severe to be corrected through educational intervention and that formal disciplinary action is recommended.
(G) Eligibility. A licensee may participate in the QIP if all of the following apply:
(1) The public will be adequately protected if the licensee enters into the QIP;
(2) The licensee has not been the subject of formal disciplinary action by any regulatory board or entity in Ohio or any other jurisdiction, unless it is determined that the disciplinary action was for a violation which should not preclude participation in the QIP;
(3) The licensee is not concurrently under investigation by the board for a violation of Chapter 4734. of the Revised Code or the rules of the board which does not constitute a communication or practice deficiency;
(4) It is determined that the nature of the licensee's identified deficiency is such that it may be corrected through education and/or remediation;
(5) The licensee holds a current valid chiropractic license and is eligible to renew said license;
(6) The licensee does not have any identified impairment that would significantly affect learning abilities or the ability of the licensee to incorporate learned knowledge and skills into the licensee's practice;
(7) The licensee agrees in writing to be considered for participation in the QIP.
(H) Participation agreement. When the QIP panel determines that a licensee has an identified practice deficiency, the licensee shall be invited to participate in the QIP. Prior to acceptance into the QIP, the licensee shall execute a participation agreement with the board for the QIP which includes, but is not limited to, provisions which:
(1) Set forth the identified deficiency;
(2) Identify the specific education and/or remediation the licensee must complete, including identification of educational provider(s) that will provide the prescribed educational intervention;
(3) Specify the time frame during which the licensee must agree to abide by the recommendations set forth by the educational provider(s) that will provide the prescribed educational intervention;
(4) Require the licensee to pay all expenses incurred as a result of the required education and/or remediation;
(5) Require the licensee to cooperate with any QIP related entity, including, but not limited to, the educational provider(s) prescribed by the panel;
(6) Require the licensee to direct any educational provider(s) to send written progress reports regarding the licensee's progress in education and/or remediation to the QIP at specified intervals;
(7) Require the licensee to sign any and all waivers necessary to secure all reports required by the QIP;
(8) Specify that the prescribed education and/or remediation intervention may not be used to satisfy any continuing education requirements for license renewal;
(9) Specify the terms and conditions the participant must meet to successfully complete the education and/or remediation;
(10) Specify that the board may monitor the licensee's practice for a specific time period to ensure the licensee has corrected their practice deficiency;
(11) Specify that the board may consider termination from the QIP as an aggravating factor if the board proceeds with disciplinary action;
(12) Set forth the grounds for termination from the QIP.
(I) Educational intervention/remediation. The board shall approve individual programs and/or select providers of education and assessment services for QIP utilization. Panel members may review the content of and recommend programs for board approval.
(J) A licensee determined by the board to be eligible for the QIP who refuses to enter into the participation agreement as set forth in this rule within the time frame specified by the QIP shall be subject to disciplinary action for the identified deficiency in accordance with section 4734.31 of the Revised Code.
(K) Termination. A licensee determined by the panel to have a deficiency that may be corrected through participation in the QIP may be terminated from the QIP for any of the following reasons:
(1) Failure to comply with any term of the participation agreement entered into by the licensee;
(2) Receipt of evidence from the educational provider indicating that the licensee has failed to progress through or to successfully complete the education and/or remediation in the manner and during the time frame prescribed by the panel;
(3) Committing or showing to have another deficiency that falls within the parameters of the QIP during an existing intervention;
(4) Failure to complete the education and/or remediation; or
(5) Failure to maintain eligibility for the QIP.
(L) If a licensee is terminated from the QIP, the board may continue with disciplinary proceedings in accordance with Chapter 4734.31 of the Revised Code. The board may consider a licensee's termination from the QIP when determining discipline to be imposed.
(M) Completion of the QIP. A licensee who participates in the QIP shall comply with all the terms and conditions set forth in the agreement and shall provide or direct to be provided to the QIP a written report or transcript from the educational provider(s) verifying that the participant has successfully completed the educational intervention.
(N) Upon completion of all participation requirements, the QIP panel shall review all information relevant to the licensee's education and/or remediation to make a recommendation to the board designate as to whether the licensee's practice as a chiropractic physician meets the accepted standards for the profession.
(O) When the board or its designee determines that the licensee's identified deficiency has been sufficiently corrected so as to conform to the accepted standards for the profession, the licensee shall be notified in writing that the education and/or remediation has been successfully completed and participation in the QIP is concluded.
(P) Legal representation. Meetings of the QIP panel and a licensee are meant to be a peer to peer interaction. The licensee may have an attorney present, although the meeting is not a formal disciplinary proceeding. If the licensee decides not to attend the meeting, there is no need to send an attorney in his or her place.
(Q) Confidentiality. The case review and assessment conducted by the QIP is part of the investigatory process pursuant to section 4734.45 of the Revised Code and is confidential and not subject to discovery in any civil proceeding. Accordingly, records of discussions held by the panel and/or board members or staff are confidential investigatory material and not subject to public disclosure. Regular reports to the board shall be made detailing the general activities of the QIP. The identity of the licensee under review and the patients whose records were reviewed shall not be provided to the board or disclosed to the public.
R.C. 119.032 review dates: 03/11/2013 and 06/01/2018
Promulgated Under: 119.03
Statutory Authority: 4734.42
Rule Amplifies: 4734.42
Prior Effective Dates: 5/2/2003, 8/1/2007, 11/15/2007
(A) Chiropractic physicians shall maintain proper, accurate, and legible records in the English language documenting each patient's care. If non-standard codes or abbreviations are used, a key for interpreting this information shall be included in the file.
(B) Each patient's health care record shall include documentation of all services performed in the chiropractic physician's office.
(C) All diagnostic studies performed or ordered by a chiropractic physician shall be documented in the patient's health care record. A report shall accompany each diagnostic procedure performed or ordered by the chiropractic physician.
(D) Records, including x-ray films shall be maintained on site for current patients and may be stored off-site for former patients. Records shall be maintained in a safe, confidential, and secure location. Patient records shall be destroyed in a confidential manner, such as shredding or burning, and retained as follows:
(1) Five years from the last date of clinical encounter when a patient either terminates care or is dismissed from care by the chiropractic physician;
(2) Records pertaining to minors shall be maintained for two years beyond the minor's eighteenth birthday, or five years from the last date of clinical encounter, whichever is longer;
(3) Records containing information pertinent to contemplated or ongoing legal proceedings which the chiropractic physician has knowledge or notice of shall be kept for two years beyond the conclusion of the legal proceedings, or five years from the last date of clinical encounter, whichever is longer;
(A) A chiropractic physician shall conduct an appropriate evaluation of a patient prior to initiating treatment. Such evaluation shall include at a minimum the following elements:
(3) Clinical impression(s);
(B) The history, examination, findings, and clinical impression(s) shall be documented in the patient's paper or electronic file or in another readily accessible medium. Further evaluation and management shall be conducted as needed, based on each patient's condition in accordance with prevailing standards of care.
(C) Once a chiropractic physician prescribes care for the management of any condition, the chiropractic physician shall record the treatment plan, which shall include documentation of the frequency, duration, and procedures recommendedfor management of the diagnosed condition(s).
(A) Each disciplinary case involves unique facts and circumstances. In striving for fair disciplinary standards, consideration will be given to the specific professional misconduct and to the existence of aggravating or mitigating factors. In determining the appropriate sanction, the board shall consider all relevant factors; which may include precedent established by the board and the following:
(1) Aggravating factors. The following shall not control the board's discretion, but may be considered in favor of recommending a more severe sanction:
(a) Prior disciplinary offenses;
(b) Dishonest or selfish motive;
(c) A pattern of misconduct and the cumulative effect of the conduct;
(d) Multiple offenses;
(e) Lack of cooperation in the disciplinary process;
(f) Solicitation or submission of false evidence, false statements, or other obstructive or deceptive conduct during the disciplinary process;
(g) Refusal to acknowledge wrongful nature of conduct;
(h) Vulnerability of and resulting harm to any victims of the misconduct;
(i) Negative public perception of the chiropractic profession;
(j) Failure to make restitution or other appropriate amends.
(2) Mitigating factors. The following shall not control the board's discretion, but may be considered in favor of recommending a less severe sanction:
(a) Absence of a prior disciplinary record;
(b) Absence of a dishonest or selfish motive;
(c) Timely good faith effort to make restitution or to rectify consequences of misconduct;
(d) Self-reporting of any violation(s) and full disclosure to the board and/or cooperative attitude toward proceedings;
(e) Character, reputation and positive social contributions of the chiropractic physician;
(f) Imposition of other penalties, sanctions or liability;
(g) Evidence of rehabilitation;
(h) Chemical dependency and/or mental illness, where there has been:
(i) A diagnosis of a chemical dependency or mental illness by a qualified health care professional or alcohol/substance abuse counselor;
(ii) A determination that the chemical dependency and/or mental illness contributed to cause the misconduct;
(iii) A certification of successful completion of an approved treatment program or course of treatment; and
(iv) A prognosis from a qualified health care professional or alcohol/substance abuse counselor that the chiropractic physician will be able to return to safe, competent, and ethical professional practice under specified conditions, restrictions or limitations.
(3) Compliance programs. Operation or participation in a bona fide compliance program may be considered by the board as a mitigating factor. Bona fide compliance programs shall contain the following elements;
(a) Auditing and monitoring the practice for deficiencies and violations;
(b) Written compliance standards and procedures for the practice;
(c) A designated compliance officer to monitor compliance and practice standards;
(d) Employee training and education;
(e) Appropriate response to detected violations, including self reporting and correction action plans;
(f) Developing open lines of communication;
(g) Enforcing disciplinary standards through guidelines;
(B) Alternative sanctions. In accordance with its statutory authority, the board may issue letters of admonition, letters of caution, warnings or similar notices to chiropractic physicians in appropriate cases. The board may use the factors listed in this rule in making its determination to issue an alternative sanction in lieu or initiating formal charges through the Revised Code Chapter 119 process.
119.032 review dates:
Promulgated Under: 119.03
Statutory Authority: 4734.10
Rule Amplifies: 4734.31, 4734.36, 4734.37, 4734.38, 4734.39, 4734.50
Prior Effective Dates: 5/2/03
(A) Except as provided for in paragraph (D) of this rule, a chiropractic physician who is an independent contractor or who has an ownership interest in a chiropractic practice shall provide notice when leaving, selling, or retiring from the chiropractic office where the chiropractic physician has provided chiropractic services. Notification shall be sent to all patients who received services from the chiropractic physician within the two years immediately preceding the chiropractic physician's last date for seeing patients and shall be sent no later than thirty days prior to the last date the chiropractic physician will see patients.
(1) The notice shall include all of the following:
(a) A statement that the chiropractic physician will no longer be practicing chiropractic at the practice;
(b) The date on which the chiropractic physician will cease to provide services;
(c) Contact information that enables the patient to obtain the patient's records.
(2) The notice shall be sent in one of the following ways:
(a) A letter sent via regular mail to the last address on record for the patient with the date of the mailing of the letter documented;
(b) An electronic message sent via a HIPPA compliant electronic medical record system or HIPPA compliant electronic health record system that provides a means of electronic communication to the patient and is capable of sending the patient a notification that a message is in the patient's portal.
(B) A chiropractic physician who because of acute illness or unforeseen emergency is unable to provide notice thirty days prior to the last date of seeing patients shall provide the notice required by paragraph (A) of this rule no later than thirty days after it is determined that the physician will not be returning to practice.
(C) Chiropractic physicians employed by non-Ohio licensed chiropractic physicians shall comply with the notice required by paragraph (A) of this rule.
(D) If a chiropractic physician is the employee of another Ohio licensed chiropractic physician, the patient records belong to the employer and the employee chiropractic physician is not required to comply with this rule. It is the licensed Ohio chiropractic physician employer's responsibility to maintain continuity of care, or to comply with this rule if patient care will be terminated upon a chiropractic physician employee's leaving employment or retiring.
(E) In the event a chiropractic physician dies and there is no other chiropractic physician in the practice, the deceased chiropractic physician's executor, guardian, administrator, conservator, next of kin, or other legal representative shall endeavor to comply with the notice required by paragraph (A) of this rule. The chiropractic physician, executor, guardian, administrator, conservator, next of kin, other legal representative, or probate court shall notify the board of the location of the patient files.
(A) Licensees should utilize universal precautions recommended by federal and state regulatory agencies to minimize the risk of exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply.
(B) When performing any procedure that risks exposure to blood, body fluids containing visible blood, and other fluids to which universal precautions apply, protective barriers such as gloves, gowns, masks and protective eyewear should be available to reduce contamination and supplement infection control and used in accordance with universal precaution guidelines recommended by federal and state regulatory agencies.
(C) A licensee who performs any procedure that requires the use of needles shall utilize aseptic techniques and only sterile, disposable needles.
(D) Infectious waste such as laboratory, pathological, blood and sharps waste shall be disposed of according to requirements established by federal, local, and state environmental regulatory agencies.
(A) General population.
(1) Each licensee who assesses, diagnoses and/or treats concussed patients shall do so in accordance with nationally accepted standards and guidelines.
(2) Each licensee who assesses, diagnoses and/or treats concussed patients shall maintain a level of continuing education that keeps pace with the evolving topic of concussion management.
(3) Licensees may do all of the following in regard to concussion management:
(d) Grant clearance to return to activities of daily living;
(e) Consult with, refer to, or collaborate with other licensed healthcare providers.
(B) Youth sports participants.
(1) As used in section 3707.51 of the Revised Code, "youth sports organization" means a public or nonpublic entity that organizes an athletic activity in which the athletes are not more than nineteen years of age and are required to pay a fee to participate in the athletic activity or whose cost to participate is sponsored by a business or nonprofit organization.
(2) As used in this section, "physician" means a person authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery.
(3) Diagnosis and treatment
(a) Each licensee who treats youth sports participants shall diagnose and treat concussions in accordance with the "Consensus Statement on Concussion in Sport" issued by the fourth "International Conference on Concussion in Sport" held in Zurich, November 2012 (available from the website of the state chiropractic board at: http://www.chirobd.ohio.gov) or with nationally accepted standards and guidelines consistent with that statement.
(b) Each licensee who assesses, diagnoses and/or treats concussed patients shall maintain a level of continuing education that keeps pace with the evolving topic of concussion management.
(4) Assessment and clearance
Subject to the exemptions provided in paragraph (B)(5) of this rule, licensees shall only make an assessment and/or grant clearance to a youth sports participant to return to play:
(a) In consultation with a physician;
(b) Pursuant to the referral of a physician;
(c) In collaboration with a physician;
(d) Under the supervision of a physician.
(5) A licensee with one or more of the following current credentials is exempt from the provisions of paragraph (B)(4) of this rule and may assess and/or grant a clearance to return to play to a youth sports participant:
(a) Diplomate in chiropractic neurology recognized by the american chiropractic neurology board;
(b) Diplomate in chiropractic sports medicine recognized by the american chiropractic board of sports physicians;
(c) Certified chiropractic sports physician recognized by the american chiropractic board of sports physicians and listed on the american chiropractic board of sports physicians national concussion registry.