Patient Information
Need an appointment? Call 573-882-2663 and ask for Dr. Miller, or Schedule your visit here

Dr. K. Jeffrey Miller, DC, FACO, MBA

Doctor of Chiropractic and Fellow of the Academy of Chiropractic Orthopaedics

Greetings! I am glad you have chosen chiropractic based care or acupuncture. It is my sincere hope that by working together we will reduce or resolve your healthcare concerns.

Please review the following information to assist in your recovery. The most immediate information you need starts here and more in-depth information is available by clicking the buttons below.

Immediate Information for Your Care

First Visit

First Visit Procedures
  • Check-in and new patient paperwork
  • Room placement and vital signs taken by a nurse
  • Doctor’s review of completed paperwork and additional questions
  • Physical examination
  • Imaging (determined on a case by case basis)
  • Time allotted for the visit: 30 minutes

First Visit in Detail

Appointment Times
The time allotted for an initial new patient visit is 30 minutes. Four important procedures are performed during this period of time:
  • Patient completion of paperwork
  • The doctor’s review of the patient’s paperwork and history
  • Physical examination
  • Imaging
A report of the doctor’s findings and the beginning of care may occur during this 30 minute visit. It is dependent on the completeness of the information gathered and the time remaining after the four initial procedures are completed.

Initial Paperwork
Each patient is required to provide information regarding their personal demographics, health history, and methods of payment. Patients under 18 years of age must be accompanied by a parent or guardian.

It is necessary to arrive at the office 20-30 minutes prior to your appointment to complete the required paperwork.

No one likes paperwork, but it is vital to the healthcare process. In the current healthcare environment, no paperwork usually means no insurance reimbursement.

Health History

History of the Present Illness (What Is Wrong Right Now)
Information in this category relates to the reason for the current visit. This is the most important information we gather. The majority of the doctor's questions are directed toward this portion of a patient’s history. This is logical as the patient is requesting care for his or her current state of health, not a previous health status.

Review of Systems
There are 14 major systems of the body. Chiropractic care typically focuses on the musculoskeletal and nervous systems. Other systems of importance include cardiovascular, respiratory, gastrointestinal, and genital urinary systems. These are the systems most associated with spinal symptoms.

Past, Family, Social, and Occupational Histories
It is important to know surgeries, hospitalizations, allergies, immunizations, injuries, pregnancies, disease processes, and inherited conditions you and your family members have experienced. It is also important to know details of your social history (exercise, eating, sleeping habits, and other factors). Your work history is also very important.


Physical Examination
The methods used to identify the source of your health concerns are the same as those used by all healthcare practitioners who treat conditions of the bones, joints, muscles, and nerves. Methods such as observation, vital signs, palpation, and physical maneuvers that stress tissues are universal.

Chiropractic Physical Examination
Methods unique to chiropractic based care are also used to identify sources of your health concerns. These methods are related directly to your body’s movement and posture to determine which areas of the spine and extremities to manipulate or adjust.

Doctors of chiropractic use standard x-rays, CT scans, and MR scans. Chiropractors order and interpret these studies routinely.

In years past, all chiropractic patients received x-rays as part of their initial examination. There were very few exceptions. Current practice is to determine if imaging is necessary based on the patient’s individual health history, physical examination findings, and sometimes the response to initial or previous care.

Imaging Considerations for Patients
  • Age
  • History of cancer
  • History of the chief complaint
  • Implanted medical devices
  • Joint instability
  • Neurological signs and symptoms
  • Overall physical condition/health of the patient
  • Pregnancy
  • Previous diagnoses of cancer, congenital defects, degenerative joint or disc disease, fractures
  • Previous spinal/joint surgery
  • Progress of symptoms: symptoms getting progressively worse
  • Recent or past trauma
  • Severe, unrelenting pain
  • The availability of previous studies
  • The age of previous studies
  • The number of previous episodes

Before Leaving the Office after the First Visit
Instructions for what to do and what not to do will be provided prior to leaving the office. The instructions will be provided through this website or in written form.

The Transition from Diagnosis to Treatment

The Transitional Period between the First and Second Visits

You may or may not be treated during your first visit. Multiple factors affect this decision. The two most common reasons for not being treated at an initial visit are the availability of the information to compete your diagnosis and the time allotted for the visit.

The doctor's report of findings may occur during the first or second visit. This will occur during the first visit when the information necessary for diagnosis and treatment is available and time allows. It will occur during the second visit when information necessary for diagnosis and treatment is not readily available or time does not allow.

Situations that may postpone the doctor’s report and the beginning of care include waiting on the availability of previous records, imaging results, lab results, or the doctor’s need to communicate with other healthcare providers prior to initiating care.

The Transitional Period between the First and Second Visits

The Doctor’s Report

The doctor’s report will include
  • Your diagnosis
  • The most likely reason for the diagnosis
  • The treatment plan
    • Procedures to be used
    • The frequency and duration of your visits
    • The expected prognosis
    • The reasoning behind the treatment plan
  • The time line for the recommended course of care
  • What is expected of you
  • What lies beyond the end of the treatment plan

Frequency and Duration of Visits

Chiropractic care is a process, not an event. This means it usually takes more than a single visit to address a patient’s needs. This makes sense considering the majority of joint and nerve problems for both the spine and extremities develop over time and/or have been present for weeks, months, or years. It is nearly impossible to undo long term damage and suffering in just a couple visits.

Care could range from 2-30 visits with an average of 16. Recent recommendations in Chiropractic Guidelines have stated 6-12 visits in 2-4 weeks with 12 additional visits if the case warrants, but there is no magic number.

Some doctors recommend the same pattern of visits for every patient, but “one size does not fit all.” Patients’ needs vary greatly. A doctor using the same visit pattern for every patient is like a medical doctor prescribing the same medication for every condition. The frequency and duration of visits is recommended on an individual basis.

Factors in Healing

Factors Effecting Healing and Visit Patterns (Visit Frequency and Duration of Care)

  • Age
  • Activity level
  • Availability of third party benefits
  • Body weight/BMI index
  • Congenital deformations/conditions
  • Delays in seeking care/finding the right type of care
  • Employer support
  • Family and friend support
  • General health and condition
  • Multiple areas of complaint
  • Occupation
  • Pain over the majority of the previous year
  • Patient pain tolerance
  • Personal finances
  • Presence of degenerative disease(s)
  • Previous episode(s) occurring more than a year prior to the current episode
  • Previously successful chiropractic care
  • Previous surgery in the area of complaint
  • Smoking
  • The patient’s ability to follow through
  • Trauma (degree, severity, timing)
  • Type of employment/work schedule/available time off

Second Visit

  • Check-in and room placement (recording of vital signs may or may not be performed)
  • Patient report of the effects of the first treatment (if treatment occurred during the first visit)
  • The doctor’s assessment of the effects of the first treatment
  • Continued treatment
  • Second visits are shorter than first visits. The time allotted for first visits is 30 minutes. Time allotted for second and subsequent visits is 15 minutes.

Second Visit in Detail

The visit will begin with the doctor’s report if it was not performed during the first visit. There will be a brief check for changes that may have occurred between the initial visit and this visit. Care will then proceed.

Once care for the day is completed, additional appointments will be scheduled based on the recommended frequency and duration of care.

Home Care

Cold/Ice or Heat

Do not use heat or cold unless the doctor tells you to and you understand the following information:


  • Apply ice for acute pain, spasm, and swelling.
  • Ice is the best choice in the first 48-72 hours after injury.
  • Never apply ice for longer than 30 minutes. Set a timer to avoid over use or falling asleep during use.
  • Apply ice for 20-30 minutes in most areas; 10-15 minutes on hands/feet/face.
  • Allow 30-60 minutes between applications.
  • Place a warm, damp towel between your skin and the ice.
  • Return to ice with re-injury or a painful flare-up.


  • Never apply heat for acute pain, spasm, or swelling.
  • Never apply heat during the first 48-72 hours after injury.
  • Never apply heat for longer than 30 minutes. Set a timer to avoid over use or falling asleep during use.
  • Apply heat for mild aches, soreness, and stiffness.
  • Apply heat for 20-30 minutes in most areas; 10-15 minutes on hands/feet/face.
  • Allow 30-60 minutes between applications.
  • Place a warm damp towel between your skin and the source of heat.
  • Do not use an electric heating pad unless approved by the doctor.

Contrasting Cold and Heat

Alternating the use of hot and cold can be beneficial for reducing swelling and pain in the extremities (mostly feet and hands). Containers, one filled with hot water and one filled with cold water are suggested. If this is recommended for you, use the following formula:

  • Always start and end with heat.
  • Never alternate heat and cold for more than 25 minutes.
  • Alternate
    • Heat - 5 minutes
    • Cold - 5 minutes
    • Heat - 5 minutes
    • Cold - 5 minutes
    • Heat - 5 minutes

Dos and Don’ts

  • Do not “test” the manipulation/adjustment by immediately twisting, bending, etc.
  • Do not use a TENS unit, traction device, brace, ointment, cream, or other health aide without consulting the doctor.
  • Do not lay on your stomach except to apply heat or cold as directed by the doctor.
  • Do not sleep on your stomach or use more than one pillow for your neck and head.
  • Sleep on a firm surface lying on your side or back. Keep your knees bent.
  • If a cervical pillow is recommended by the doctor, you must allow 2-3 weeks for your body to adapt to the new pillow. If you are already using a cervical pillow, you should bring the pillow to the office so the doctor can determine if the pillow is appropriate and properly sized.
  • Do not stay completely inactive (on bed rest) for more than 3-4 days.
  • Do not use a brace prescribed for someone else. If you want a brace and the doctor feels it is necessary, the doctor will fit you with the correct type.
  • Do not drive a vehicle while wearing any type of cervical collar.
  • Do not use any form of traction which was not prescribed by the doctor currently treating you.
  • Do not use home remedies recommended by friends, relatives, loved ones, or anyone else without consulting the doctor.
  • Avoid unnecessary lifting during an episode of back or neck pain.
  • Laughing, coughing, sneezing, and deep breaths all increase the pressure in the lower back. If you are going to sneeze or cough, bend your knees. This will decrease the pressure.
  • Cases involving disc and pelvic pathology will be irritated by prolonged sitting and especially by driving. Do not sit longer than 20 minutes without changing positions. Avoid long drives, and do not stay in an automobile for more than one hour without a break.
  • Cases involving the facet joints of the lumbar spine will be irritated by standing and leaning backwards.
  • Sitting up-right with the legs extended will irritate lower back and leg pain. (Such as sitting in a recliner with the leg support raised but not leaning back, sitting in a bathtub, etc.)
  • Do not under any circumstances allow anyone other than your doctor of chiropractic to attempt to manipulate your neck or back.
  • Do not under any circumstances attempt to manipulate (pop/crack) your own neck or back.
  • Do not let anyone “walk on your back.” These activities are not adjustments and can hurt you.
  • Avoid alcohol and smoking during an acute episode of pain.
  • Once you begin to feel better, it is not an indication that you should immediately return to your normal level of activity or begin new activities. Discuss all changes in activity with the doctor prior to making the changes.
  • Do not continue or start exercising unless the program has been approved by the doctor.
  • Do not exercise on a day you receive a manipulation unless it is before the manipulation.
  • Tractors, heavy equipment, tow motors, and lawn tractors will irritate the lower back and pelvis. The combination of sitting and vibration is harmful.
  • Tractors, lawn mowers, and other machinery which require repeated or prolonged turning of the head should be avoided.
  • Avoid sweeping, vacuuming, mopping, and raking.
  • Take a shower, not a bath.
  • Avoid bathing a child or pet.
  • Do not take prescription medication that was prescribed for another condition or that was prescribed for another person. Consult your medical practitioner regarding all over the counter and prescription medications.
  • Doctors of chiropractic do not prescribe medications. Again, consult your medical practitioner regarding all over the counter and prescription medications.
  • A true second opinion regarding chiropractic care can only be obtained from a doctor of chiropractic.
  • In cases of intolerable pain after clinic hours, go to an emergency room or call 911.
  • Please do not sit or lie on the chiropractic tables or equipment until asked to do so by the doctor. The tables have moving parts that can shift with your weight. Sudden movements could irritate your condition. This also applies to friends and family accompanying patients.
  • When being lowered or raised on one of the hydraulic tables, establish and maintain full body contact until the table stops moving.
  • Please do not move or attempt to operate any of the equipment in the treatment rooms.

Providing Important Information about Your Situation

Always Tell the Doctor If You:
  • Have any concerns/questions
  • Have any implanted medical devices, especially any implanted devise that is electrical or uses a battery i.e., pacemaker, stimulator, or pump
  • Are or could be pregnant
  • Have pain (scored 0-10)
    • 0 = No Pain
    • 10 = Terrible pain (you cannot drive, work, or attend school, etc.)
  • Have experienced changes in your symptoms
    • No change
    • Symptoms have improved
    • Symptoms have moved
    • Symptoms have increased
  • Have limited your activities due to your condition (changed your work, school, or household activities)
  • Are having trouble following home instructions
  • Have allergies to Latex or adhesives
  • Are afraid of needles
  • Have been injured since your last visit
  • Have seen another doctor since your last visit and why
  • Are having trouble with bladder or bowel functions
  • Are having thoughts of suicide
  • Don’t feel safe at home
  • Are being verbally, physically, or sexually abused

Other Areas of Interest:

What to Expect Once Treatment Begins

How You Should Feel

The majority of patients feel some relief after their first few treatments. Occasionally no changes are experienced until care is beyond the first few visits.

Unfortunately, it is necessary to reproduce the patient’s pain in order to formulate a diagnosis. This may leave the patient with a slight increase in symptoms for 24-48 hours. A similar situation may occur when a patient receives their first manipulation or their first manipulation in a long time. Symptoms may increase slightly for 24-48 hours.

These increases in symptoms are often described as being similar to the feeling encountered after exercising for the first time in a long time.

Pain can change locations. It may move left or right or up or down compared to its original location.

Symptoms may also increase naturally during the first few days after an injury if swelling develops slowly, usually over 48-72 hours. If swelling is present, pain may be worse during morning hours. Report all changes in pain to the doctor.

Family and Friends

Traditionally the majority of chiropractic patients find chiropractic through personal referrals. This fact has held true for my practice for more than thirty years. There is nothing like the support of family and friends when you have healthcare needs, and there is nothing like the support of people who appreciate chiropractic care when you practice chiropractic.

Unfortunately, the opposite can occur. There are those who don’t support the use of chiropractic care. I recommend a word of caution when being advised to not seek chiropractic care. Many of those who advise against chiropractic have never been to a chiropractor or been inside a chiropractic office. Many have never openly considered chiropractic, and most have never read a book on chiropractic care. Be careful when taking advice from the uninformed.

Types of In Office Care

Adjusting and Manipulation

Chiropractors use the term "adjustment" to describe the most important treatment we deliver. In today’s chiropractic care, the term "manipulation" is gaining popularity. I use the terms interchangeably.

Manipulation is the art of treating joints through localized low force movements that help restore movement. In some cases, it can improve the alignment of joints. The effects of manipulation also extend into the structures around the joint: muscles, nerves, and other related tissues.

Manipulation can be performed through a variety of techniques.

  • Manual manipulation can be performed strictly by hand.
  • Table assisted manipulation can be performed using special tables that move to provide traction and leverage to assist the doctor.
  • Instrument assisted manipulation can be performed using spring loaded or electric instruments to deliver the thrust.
  • Soft tissue manipulation can be performed by using the hands or a scraping instrument to address muscle problems.

Chiropractic Techniques Available

I am trained in the five most commonly used chiropractic techniques. Most of these were/are taught as part of a combined system termed “The Palmer Package.” The Palmer Package is part of the training at my alma mater, Palmer College of Chiropractic in Davenport, Iowa.

The five most commonly used techniques are
  • Diversified
  • Gonstead
  • Thompson (Table Assisted Adjusting)
  • Activator (Instrument Assisted Adjusting)
  • Flexion Distraction (Cox)
I also have training in additional chiropractic techniques:
  • Extremity manipulation
  • Soft tissue manipulation


In addition to chiropractic techniques, I am also certified in Meridian Therapy, Acupressure/Acupuncture. I utilize the following procedures in these areas:
  • Needle acupuncture
  • Non-needle electrical stimulation of acupuncture points (For patients who don’t do well with needles)
  • Cupping
  • Gua Sha (Scraping)

Electrical Therapies

I utilize a number of electrical therapies in patient care. Each therapy has its own unique effects to help with inflammation, pain, muscle stimulation, and healing. The therapies include
  • Interferential current
  • Electrical muscle stimulation
  • Russian stimulation
  • Pulsed ultrasound
  • Electrical stimulation of acupuncture points

Braces and Supports

I recommend a variety of braces and supports in my practice. Some are simple and inexpensive, and some are complicated and expensive. I try to use braces and supports only when absolutely necessary and restrict the length of their use. Initial use of a device for acute cases can be great, but extended use can promote dependency.

The following are among the braces and supports I recommend on a case by case basis:
  • Shoe orthotics
  • Ankle braces
  • Knee braces
  • Trochanteric belts
  • Back braces
  • Cervical (neck) collars
  • Cervical pillows
  • Lumbar supports (chair, car seat)
  • Elbow braces
  • Wrist braces
  • Thumb braces
  • Taping

Home Care Devices

Home care is important to all joint and muscle conditions. The following are among the home care devises I recommend on a case by case basis:
  • Ice packs
  • TENS Units
  • Over-the-door cervical spine traction devises
  • Beds
  • Chairs
Ice is often the best method for home care of spinal and extremity conditions and injuries. It helps reduce swelling and inflammation which in turn helps reduce pain. Proper use of ice at home was detailed earlier on this page.

TENS stands for Transcutaneous Electrical Nerve Stimulation. The devise stimulates the nerves in the skin over a symptomatic area to assist in pain relief. Please note that this devise is not the same as the electrical stimulation devises used in the office. TENS is superficial and the effects are temporary. The electrical stimulation machines used in the office penetrate deeper into the body, offer a variety of physical effects, and provide longer lasting relief.

Over-the-door Cervical Spine Traction Devises
These are very helpful devises, but they can be a concern if used improperly. Unfortunately, improper use is common. The majority of instructions accompanying these devises are vague and the pictures on the box are inaccurate. The pictures are taken for display purposes and do not represent correct clinical use. Instructions for proper use of the traction devise will be provided if the devise is recommended.

Beds and Chairs
I am frequently asked to make recommendations regarding beds and chairs. This is done on an individual basis as every patient has different needs.

I recommend the Apple App “Vertebra” for exercise. You will be instructed to download the app if necessary and I will help establish a program for you.

Exercises not included in the Vertebra app will be assigned as needed.
  • Flexibility vs Strength: more spinal/joint conditions are the result of a lack of flexibility rather than a lack of strength. Exercises for flexibility will usually be assigned first.
Good shoes and the use of orthotics (shoe inserts) are very important and one of the best investments you can make in your health.

I offer very limited nutritional advice as part of my practice. I recommend patients seek help from certified nutritionists and bariatric medical specialists for diet and weight control.

Home Activities

Driving long distances should be avoided during periods of back and neck pain. Patients wearing any form of cervical collar should not drive.

Work, School, Home, and Recreational Activities
There are times when it is necessary to remove patients from work or school. When this is necessary, there are a few things of which patients should be aware:
  • Restrictions apply to all types of activities: work, school, and household. Example: Reducing work and/or school activities also means reducing home and recreational duties. If you cannot work, you cannot participate in lawn and garden work, exercise, sporting events etc.
  • I do not issue doctor’s notes if I have not seen a patient for his or her current complaint.
  • There is a difference between a simple work or school excuse and a set of forms that is required by an employer or outside party. Fees may apply for completing multiple and/or lengthy forms that go beyond daily notes for routine office visits.
  • Long periods of time off from activity ultimately end up doing more harm than good.

Conservative Care

In today’s healthcare environment, efforts are being made to avoid invasive procedures like spine or other joint surgery. Doctors and insurance carriers have moved toward utilizing 4-6 weeks of conservative care (chiropractic, physical therapy, etc.) to help accomplish this goal. This has allowed many patients’ problems to improve or resolve without the risks and costs associated with surgery.

In many cases, insurance carriers will not reimburse for second opinions, advanced imaging, or surgery until conservative methods have first been attempted and/or exhausted.

Continued Care

Scheduling Care
It is recommended that multiple visits be scheduled in advance. This allows you to lock in times convenient to you and reduces the number of times you must call the office or wait for scheduling during your visits.

Thirty minutes is allotted for each new patient visit. Fifteen minutes is allotted for each follow-up visit.

When you enter the office, please sign in. If anything regarding your insurance or method of payment has changed, please inform the staff. If you are on a multiple appointment schedule, you should also confirm your next appointment at this time. If you are not on a multiple appointment schedule, please stop at the desk before leaving to arrange your next appointment.

Patients are seen in the order of their appointment times, not in the order of their arrival. If you arrive early and we can get you in before your scheduled time, we will, but please remember this would be an exception and should not be expected to be routine.

The number one complaint regarding doctors’ offices nationwide is excessive waiting time. Because we are acutely aware of this fact, you will find our office usually runs on time. The average wait in our office is only a few minutes. If we do run behind, it is usually for a very good reason, such as an unexpected circumstance with a patient or an emergency. Your patience is appreciated in these situations.

Every patient will encounter situations that result in having to re-schedule an appointment or miss an appointment. We appreciate a call whenever possible in these situations.

Afterhours Care
Currently we do not offer care after hours. If you have an emergency or are experiencing intolerable pain, call 911 or go to your local emergency room.

Progress Examinations
The doctor generally assesses patient progress from visit to visit. However, in more complicated cases, a formal progress examination is often performed. In either case, there are expectations related to patient progress.

If progress is slower than expected or not evident at the end of the first two weeks of care, we will look further. Additional examinations will be performed and/or changes in the methods of care will occur. If improvement continues to be slower than expected or does not occur, care will be discontinued.

Patients always want immediate relief and a quick recovery. In a few cases this will be possible. However, as stated earlier, chiropractic care is a process and rarely a single event. Please be patient.

Here is a word of advice: I have been practicing for over thirty years and have worked through chiropractic related conditions with thousands of patients. I know what to expect and when to worry about the direction of a case. For the most part, I encourage patients not to worry unless I become worried.

Patient Populations

General: I treat patients of all ages. The majority of my patients range from 13-64 years of age.

Worker’s Compensation Cases: I have a long history as an occupational healthcare provider from a stand point of treatment and prevention. Worker’s compensation has been a specific interest of mine for over 25 years.

Personal Injury: Cases in this category are usually the result of motor vehicle accidents. Patients from these accidents often have difficult cases, but they respond well to chiropractic care.

Pregnancy: Chiropractic care is safe during pregnancy. With simple modifications, it can be provided up to the point of delivery. Chiropractic also plays an important role in the vital 3-4 months post-partum stage. In some ways, this is the most important time. At any time I am usually treating several pregnant patients.

Athletes: I treat all levels of athletes: amateur, middle school, high school, college, and professional.

Geriatric: ADD INFORMATION HERE <<<- >Medicare offers chiropractic care benefits.

Children: Children under 12 are not my specialty, but I have treated many during my career.

Patient Difficulties with Compliance

When doctors train, we are taught to diagnose diseases and injuries and render the appropriate treatment. In some cases there is more than one treatment option. This is good, as no two patients are alike.

Unfortunately, unrelated issues often come into play when a doctor is attempting to use diagnostic and treatment methods. Many of these factors involve a patient’s finances and insurance coverage.

A lack of finances and/or insurance coverage can often negatively affect a patient’s situation, preventing complete follow through of care.

Incomplete follow through effects outcomes of care.

Patients may also experience other issues that prevent follow through. For example, difficulties can occur with work schedules, transportation, family support, and other issues. The results are the same. Incomplete follow through means the possibility of incomplete resolution or control of health problems.

We make all efforts to work with patients experiencing these struggles, and we ask for the following consideration in return; your situation plays a significant role in your results.

Referrals and Other Professional Care

I frequently work with healthcare providers from all fields. The circumstances vary depending upon patient needs.
  • I accept referrals from other providers.
  • I refer patients to other providers.
    • Opinion referral: The patient is sent to another doctor for an opinion only, not for care.
    • Concurrent care referral: The patient is sent to another doctor who will be delivering care while I continue caring for the patient.
    • Frank referral: The patient is dismissed from my care completely and care proceeds with the next doctor.
When considering a referral to another doctor, I use the following standard: “If I would not see a doctor myself or send a friend or loved one to that doctor, I will not send any other person to that doctor.”

Extra Paperwork

Doctors are required by law to keep records of patients’ visits. Time is allotted in the doctors’ office schedule and beyond for this basic requirement. However, patients often request that additional paperwork be completed above and beyond the routine required paperwork. In these situations, a fee is required. The fees will be discussed at the time of the request. Additionally, the paperwork will be completed as time permits. Requesting that paperwork be completed the same day does not work. The office will not put everything on hold for paperwork that is not considered routine.