|
Subjective
|
|
|
Patient reports (complaint)
|
Pain Scale
|
|
Pain Frequency
|
Pain Quality
• • •
|
|
Pain Timing
• • •
|
Palliative/Provocative Factors
• • •
|
|
Status since last visit
|
Status since treatment began
|
|
History Details
|
|
|
Objective
|
|
|
Postural Findings
|
|
|
Head
• • •
|
Shoulders
• • •
|
|
Ribcage
• • •
|
Pelvis
• • •
|
|
Hip
• • •
|
Knee
• • •
|
|
Ankle
• • •
|
Postural improvements since last examination
• • •
|
|
ROM
|
|
|
CS
|
|
|
WNL
|
|
|
Flexion ___/50
|
Pain
|
|
Extension ___/70
|
Pain
|
|
Left Lateral Flexion ___/45
|
Pain
|
|
Right Lateral flexion___/45
|
Pain
|
|
Right Rotation ___/85
|
Pain
|
|
Left Rotation ___/85
|
Pain
|
|
ROM Improvement Since Last Exam
• • •
|
|
|
TS
|
|
|
WNL
|
|
|
Flexion ___/50
|
Pain
|
|
Extension ___/70
|
Pain
|
|
Left Lateral Flexion ___/45
|
Pain
|
|
Right Lateral Flexion ___/45
|
Pain
|
|
Left Rotation ___/85
|
Pain
|
|
Right Rotation ___/85
|
Pain
|
|
ROM Improvement Since Last Exam
• • •
|
|
|
LS
|
|
|
WNL
|
|
|
Flexion ___/90
|
Pain
|
|
Extension ___/30
|
Pain
|
|
Left Lateral Flexion ___/35
|
Pain
|
|
Right Lateral Flexion ___/35
|
Pain
|
|
ROM Improvement Since Last Exam
• • •
|
|
|
Extremities
|
|
|
Extremity Complaint Area
• • •
|
Flexion
/
|
|
Extension
/
|
Abduction
/
|
|
Adduction
/
|
Internal Rotation
/
|
|
External Rotation
/
|
Plantar Flexion
/
|
|
Dorsiflexion
/
|
|
|
ROM Improvement Since Last Exam
• • •
|
|
|
Segmental Dysfunctions
|
|
|
Cervical Spine
|
|
|
Cervical Dysfunctions
• • •
|
Pain and Tenderness
|
|
Muscle Spasm
|
Additional Notes
|
|
Thoracic Spine
|
|
|
Thoracic Dysfunctions
• • •
|
Pain and Tenderness
|
|
Muscle Spasm
|
Additional Notes
|
|
Lumbar Spine
|
|
|
Lumbar Dysfunctions
• • •
|
Pain and Tenderness
|
|
Muscle Spasm
|
Additional Notes
|
|
Pelvis
|
Pain and Tenderness
|
|
Muscle Spasm
|
Additional Notes
|
|
Extremities
|
|
|
Extremity Complaint Area
• • •
|
|
|
Orthopedic and Neurological Testing
|
|
|
Neuro Deficits Upper
|
Neuro Deficits Lower
|
|
Positive Orthopedic Tests
|
Negative Orthopedic Tests
|
|
Pathological Reflexes
|
Neuro tests found to be WNL
• • •
|
|
Assessment
|
|
|
Patient presentation is consistent with ...
|
|
|
Assessment
• • •
|
Additional Assessment
|
|
Goals
|
|
|
Short term goals
• • •
|
Long Term Goals
• • •
|
|
Medical Necessity
• • •
|
|
|
Plan
|
|
|
Plan
• • •
|
Additional Info
|
|
At Home Corrective Measures
• • •
|
Patient Education Macro
|
|
Treatment Macro
|
Additional NMR
|
|
Patient completed treatment without incident?
|
|
