The NBCE Part IV exam is the final practical step in most chiropractic students’ journey toward licensure — and it’s unlike any of the earlier written board exams.

Instead of multiple-choice screens…

You’ll be evaluated on real-world clinical skills — from history and examination to technique, case management, communication, documentation, and professionalism.  

Here’s everything you need to know — built directly from NBCE resources — so your Part IV prep is accurate, strategic, and confidence-building.

What Is the NBCE Part IV Exam?

Part IV is a hands-on practical board exam.

It tests whether you can:

• Gather a clinical history

• Perform physical and orthopedic examinations

• Make sound clinical decisions

• Effectively communicate with patients

• Perform chiropractic technique proficiently

• Accurately document care (SOAP notes)  

In short:

Part IV evaluates whether you are ready for practice, not just whether you know the subject matter.

Part IV Format (2026 Redesign)

NBCE is actively redesigning Part IV to better reflect real-world patient encounters while maintaining fairness and reliability.  

According to NBCE’s advancement documentation:

• Stations will mimic complete patient interactions

• History + exam → decision making → technique → documentation  

Here’s what the pilot structure looks like:

Case Management Encounters

Each station includes:

• 2 min pre-encounter chart review

• 14 min patient interaction

• 6 min SOAP note documentation  

Technique Stations

Each technique station includes:

• 2 min chart review

• 14 min hands-on adjustment setup & execution  

These practical interactions are graded on multiple domains including:

• Evaluation & case history

• Examination skills

• Clinical decision making

• Communication & professionalism

• Documentation accuracy

• Technique execution  

What Part IV Tests (Core Skills)

According to NBCE’s official pilot test plan, Part IV assesses:

Clinical Reasoning

Can you decide the safe and effective next step based on your findings?

This isn’t about memorizing — it’s about thinking like a clinician.  

Communication & Professionalism

Clear communication is essential in practice, and NBCE scores you on:

• Patient rapport

• Professional demeanor

• Clarity of instructions

• Respectful interaction  

Documentation Skills

You’ll write SOAP notes documenting:

• History

• Exam results

• Clinical decisions

• Recommended care plan
  This shows you can justify your choices clearly and professionally.  

Technique Proficiency

You must demonstrate technique skills — including:

• Doctor and patient positioning

• Line-of-drive

• Setup accuracy

• Safety considerations
  All under timed practical pressure.  

Former vs. Updated Part IV

In the past, Part IV also included a Diagnostic Imaging (DIM) section, but this has been removed and moved to Part III.  

That means Part IV is now even more focused on hands-on clinical practice, communication, and documentation.

Who Is Eligible for Part IV?

Per NBCE eligibility criteria:

You may apply for Part IV if you:

✔ Have passed all subjects of Part I, and

✔ Are within 6 months of graduation or already graduated from an eligible chiropractic college, and

✔ Receive registrar approval from your college.  

This ensures Part IV is taken at a point where clinical skills have been developed through coursework and patient care.

Fees & Registration (What You Need to Know)

Part IV application and testing windows are posted on MyNBCE once the registration period opens.  

Make sure you:

• Apply while your eligibility is active

• Submit registrar approval in time

• Choose an available test site early
  Many test sites have limited slots and fill up quickly.  

Passing Score

NBCE recommends a scaled score of 375 for Part IV, consistent with other NBCE parts, but note that state boards may set different requirements.  

Always confirm your specific state licensure board’s criteria — Part IV requirements vary by jurisdiction.

How to Prepare for NBCE Part IV

Training for Clinical Application

Part IV isn’t about memorization — it’s about doing.

Focus your study on:

• Practical technique drills

• Patient communication practice

• SOAP note writing

• Case management scenarios

Practice Under Pressure

Simulate real exam pacing:

• Practice full patient encounters

• Time your chart interpretation

• Build stamina for back-to-back stations

Focus on Documentation

Many students overlook documentation until late —

but your SOAP notes are scored, and clarity matters.

Communication Is a Skill

Your ability to explain findings and plan care is evaluated — so practice clear, concise language.

Frequently Asked Questions (FAQ)

What is the NBCE Part IV exam format?

Part IV is a hands-on clinical exam with stations evaluating technique, patient evaluation, decision making, communication, and documentation.  

Is imaging tested in Part IV?

Not anymore — Diagnostic Imaging (DIM) has been moved to Part III.  

How accurate is the Part IV passing score?

NBCE recommends a passing score of 375, but state licensure boards may require different scores.  

Where is Part IV administered?

Part IV may be offered at chiropractic college campuses or at NBCE Assessment Centers (e.g., Greeley, CO) depending on testing window and location.  

What’s the biggest challenge in Part IV?

Students often struggle most with:

• Time management

• Documentation clarity

• Clinical decision logic

• Communication skills

These are practical skills, not recall facts.

Still stuck on how to study for your chiro board exam?

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