chiropractic case notes

How to Get Referrals with Chiropractic Case Notes | FREE Template

Are you sending case notes?

If you're like most docs I speak with the answer is unfortunately "no." Maybe you think it takes too much time, perhaps you don't know what to send.

Either way, if you are not sending chiropractic case notes, then you are missing out on an enormous opportunity to showcase the co-management of patients, show off the fantastic results of your care, and begin the process of building referral relationships.

Sending chiropractic case notes is the foundation of building referral relationships with other healthcare providers in your community. If you think you are too busy, or that case notes are a waste of time- then keep reading. It's easier, faster, and more impactful than you think.

This article will show you the four key elements to have on every single case note that you send. Additionally, I'll show you the best time and cadence to send those notes (it's NOT on every visit). By the end of this short article, you'll have all the information you need to send out effective case notes quickly, start bridging the gap, and begin building referral relationships.


Spoiler alert: Case notes alone have never flooded a chiropractic office with referrals. Sending notes is not a silver bullet to building a relationship. But, sending timely and well-crafted case notes is an essential foundational layer of our physician outreach.

Benefits of Sending Case Notes:

1- Showcase the Great Results You Get with Your Patients (B2B Testimonial)

2- Social Proof of Co-Management

3- Additional Marketing Touch Point

I like to think of case notes as patient-centric testimonials. Most practices are hyper-focused on getting Facebook ratings and Google reviews. These type of reviews are known as B2C marketing. They are business (B) to (2) consumer (C) outreach. Reaching out with B2C testimonials is great...but, what about the other half of the coin?

The other half is your B2B channels. These are your business to business testimonials- and there is no better B2B communication than a case note. Your case notes show the social proof that you are actively co-managing, as well as the fantastic results you get with your patients in your practice.

If I asked you the question of what percentage of your patients leave your office happier and healthier than when they first walked in, I bet your answer would be over 90%.

My next question is, how often have you taken the additional 2 minutes to create a case note that shows off those unbelievably fantastic results? Probably not as often as you could or should!

Not sending case notes showing off the results of your care and the improvement of your patients is a huge missed opportunity that you need to start taking advantage of immediately.

So how often should you send case notes?

We have seen the best results by sending case notes at initial evaluation, any re-evaluation, and discharge from active care.

Discharge from active care is defined as the last visit before a patient goes to as needed, PRN, maintenance, or wellness care. Anytime you are billing a 99201-99204 or 99212-99214, that is a good indication that you should be sending a case note.

What to include in your case notes:

The 4 Essential Components of a Case Note

  1. Patient Name

  2. Date of Service

  3. Diagnosis

  4. Treatment Plan

Your case notes should not be long and include every test under the sun. Powerful, effective case notes are typically concise (under 1 page) and contain four critical pieces of information.


Just as a primary care doctor doesn't care about what size screw a surgeon uses during an operation, they don't care about every single orthopedic test you performed.

They do care about, who did you see (patient name), when did you see them (date of service), what did you find (diagnosis), and what are you going to do about it (treatment plan)? Keep it simple.

In an ideal world, your case note should be leaving your office as a one-page document. I say that for pragmatic reasons. When I was working in large scale orthopedic groups, we'd continuously get case notes from doctors in the community.

Unless they were relating to an emergency, the notes would be put into the patient chart by a medical assistant and not looked at until the patient came back into the office. The patients next appointment could have been two days, two weeks, or 2 months after the case note was sent.

Let's get real if the doctor is walking down the hall ready to see the patient, and they open the chart to find a 10-page case note from's not getting read! But, what if they open the chart and see a one-page note which clearly and concisely shows your name, the patient diagnosis, the date of service, and the expected treatment? You now have a high likelihood of them opening the door and asking the patient how they are doing in your practice.


As we went through earlier- the odds are in your favor! Chiropractors typically have sky-high patient satisfaction and remarkable results. So there is an excellent chance that the patient will praise your care- which is precisely the "win" you are looking for.

Think about how many patients you see each month in your practice. Then, think about how many in-active patients have been in your practice since you opened your doors.

Now imagine you had sent case notes for every eval, re-eval, and discharge visit for these patients. You could have hundreds, thousands, or maybe even tens of thousands "touches" to other healthcare providers showcasing the great results that you achieve. I KNOW that would make a massive difference in how many referrals you get each month.

Before you send a case note, you need to know who you are sending it to. The easiest way to do this is to make sure you have a spot on your intake form for patients to enter their primary care doctor.

Typically, this will be filled out 50-60% of the time. When it's left blank, I recommend asking a simple question:

“Hey, John, I noticed you left this blank. We'd love to have that information to communicate and coordinate your care. Do you mind if we have your primary care doc name?"

By asking that question, you should be able to collect the primary care doctor information on 90% of the people who begin care in your practice.


Case notes are one leg of the referral relationship stool. The others are sending research updates (marketing) and taking meetings (trust and rapport). At The Evidence Based Chiropractor, we've had the honor of working with hundreds of chiropractic practices. Using our system, they have generated tens of thousands of referrals that have resulted in millions of dollars in additional revenue.

Think about the amount of time you spend with your patients during treatment. Think about the energy, effort, and expertise it takes to help them get well. To not take 5 minutes and show off your results with case notes is crazy!

If you want to start getting more referrals from other physicians in your community, then become a member of The Evidence Based Chiropractor. I'd love to work with you. You'll receive the entire process, tools, support, and systems needed to bridge the gap. Get out there showcase your practice and improve the health and well-being of the people in your community.


The Importance of Sending Case Notes- by The Evidence Based Chiropractor

On nearly every implementation call for members of The Evidence Based Chiropractor I receive questions about case notes.  Doc's are concerned about the how, what, when, and where about sending them to other physicians.  


Often, they have been reluctant to do so because they don't want to send something amateurish or incorrect.  (Top priority is always to be in compliance with HIPAA and government law regarding sharing protected health information)

Research shows us that Primary Care Physicians received case notes approximately 70% of time when referred a patient to another MD.  PCP's only receive case notes 50% of the time when a patient is referred to a chiropractor.  

By sending case notes you are able to:

  1. Show off the results of your care

  2. Show that you are co-managing with the Primary Care Doctor

  3. Get an additional touch point of communication for branding/name recognition  

We recommend our members send case notes at 3 different times- Initial Evaluation, Re-Evaluation, and Discharge from Active Care.  Often these notes can be process and faxed directly from your EMR/EHR.


Your Case Notes should include:

  • Who- who is the patient? (patient name, DOB)

  • When- when did they visit your office? (date of service)

  • What- what did you find? (diagnosis)

  • How- how are you going to move forward?  (treatment plan)

As you can imagine, these items will usually take up less than a full page.  If a doc requests additional information, then you can by all means supply it; however, a vast majority of physicians prefer just the basics as they will look at this page in the patients record prior to entering their exam room.  

By supplying case notes you are increasing communication and "touches" with PCP's in your community, they can see the progress of your shared patients, and you are assisting your patients with keeping an accurate health record.

If you would like more information regarding case notes I recommend reading my book, "Marketing Chiropractic to Medical Doctors" which is now available worldwide on iBooks and Amazon. 

-The Evidence Based Chiropractor is the leading DC/MD marketing and outreach group in the world.  Our service is dedicated to increasing chiropractic utilization by showcasing research.  Marketing to medical doctors through research is efficient, cost effective, and can dramatically improve your incoming referrals.  Join us.  Lets grow chiropractic together.