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INITIAL EVALUATION
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RE-EVALUATION
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DAILY SOAP NOTE
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DAILY NOTE SUBJECTIVE
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INITIAL SUBJECTIVE
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RE-EVALUATION SUBJECTIVE
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Chief Complaint 1
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Area of pain
• • •
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Location
• • •
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Onset
• • •
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Date of Onset
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Mechanism of injury
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Palliative
• • •
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Provacative
• • •
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Nature of pain
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VAS
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Chief Complaint 2
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Area of pain
• • •
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Location
• • •
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Onset
• • •
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Date of Onset
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Mechanism of injury
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Palliative
• • •
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Provacative
• • •
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Nature of pain
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VAS
• • •
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Chief Complaint 3
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Area of pain
• • •
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Location
• • •
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Onset
• • •
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Date of Onset
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Mechanism of injury
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Palliative
• • •
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Provacative
• • •
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Nature of pain
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VAS
• • •
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Chief Complaint 4
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Area of pain
• • •
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Location
• • •
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Onset
• • •
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Date of Onset
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Mechanism of injury
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Palliative
• • •
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Provacative
• • •
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Nature of pain
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VAS
• • •
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Additional info
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Denies numbness/tingling
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Other Doctors
• • •
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Denies Night Sweats/Unexplained Weight Loss
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Affecting Sleep
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Timing
• • •
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Past medical history
• • •
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If selected, comment
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Additional info
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Denies numbness/tingling
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Affecting Sleep
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Denies Night Sweats/Unexplained Weight Loss
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Timing
• • •
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Functional Questionnaire
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Neck Pain Questionnaire
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Section 1 - Pain Intensity
• • •
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Section 2 - Personal Care
• • •
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Section 3 - Lifting
• • •
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Section 4 - Reading
• • •
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Section 5 - Headache
• • •
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Section 6 - Concentration
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Section 7 - Work
• • •
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Section 8 - Driving
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Section 9 - Sleeping
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Section 10 - Recreational Activities
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Neck Score (Sum/#Q answered)
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Oswestry Low Back Questionnaire
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Section 1 - Pain Intensity
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Section 2- Personal Care
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Section 3 - Lifting
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Section 4 - Walking
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Section 5 - Sitting
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Section 6 - Standing
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Section 7 - Sleeping
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Section 8 - Sex Life (if applicable)
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Section 9 - Social Life
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Section 10 - Travelling
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LOW BACK PAIN SCORE SUM/#Answered
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Review of Systems
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General
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General
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General abnormal findings
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HEENT
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HEENT
• • •
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HEENT abnormal findings
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Cardiovascular
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Cardiovascular
• • •
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Cardiovascular abnormal findings
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Pulmonary:
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Pulmonary
• • •
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Pulmonary abnormal findings
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GI
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GI
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GI abnormal findings
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GU:
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GU
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GU abnormal findings
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Musculoskeletal:
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Musculoskeletal
• • •
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Musculoskeletal abnormal findings
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Neurological
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Neurological
• • •
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Neurological abnormal findings
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Psychiatric
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Psychiatric
• • •
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Psychiatric abnormal findings
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Skin [-]
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Skin
• • •
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Skin Comments
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Breasts [-]
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Breasts
• • •
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Breasts Comments
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Genital (Male) [-]
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Genital (Male)
• • •
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Genital (Male) Comments
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Genital (Female) [-]
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Genital (Female)
• • •
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Genital (Female) Comments
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Periph. Vasc. [-]
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Periph. Vasc.
• • •
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Periph. Vasc. Comments
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Neurological [-]
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Neurological
• • •
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Neuro Comments
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Endocrine [-]
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Endocrine
• • •
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Endo Comments
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Psychiatric [-]
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Psychiatric
• • •
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Psychiatric Comments
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Medications
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Surgeries
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Objective
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Observation:
• • •
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Gait
• • •
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CERVICAL SPINE
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Cervical Muscle Palpation
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Tender Facets
• • •
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Cervical Subluxations
• • •
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Cervical ROM:
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Flexion
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With Pain?
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Extension
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With Pain?
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Rt. Rot
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With Pain?
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Lt. Rot
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With Pain?
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Lt.Lat. Flex
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With Pain?
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Rt.Lat. Flex
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With Pain?
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Cervical Spine Orthopedic Tests
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Cervical Compression Test
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Right Max. C/S compression
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Left Max. C/S Comp. Test
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Cervical Distraction
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Jacksons Cervical test
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Shoulder Depression Test
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Bakodys
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Adsons
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U.E. myotomes
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Left C5 shoulder abduction
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Rt.
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Left C6 elbow flexion/wrist extension
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Rt.
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Left C7 elbow extension/wrist flexion
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Rt.
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Left C8 finger flexion
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Rt.
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Left T1 finger abduction
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Rt.
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Cervical Light touch
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C5
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Side
• • •
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C6
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Side
• • •
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C7
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Side
• • •
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C8
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Side
• • •
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T1
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Side
• • •
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Thoracic:
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Visual:
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Adams Sign
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Spinous Percussion
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Palpation
• • •
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Tender Facets
• • •
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Thoracic Subluxation
• • •
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LUMBAR SPINE:
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Palpation:
• • •
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Muscle Issue
• • •
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Tender Facets
• • •
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Lumbar Subluxations
• • •
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Lumbar AROM:
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Flexion
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With Pain?
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Extension
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with pain?
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Lt. Rot
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With pain?
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Rt. Rot
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with pain?
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Lt.Lat. Flex
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With pain?
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Rt.Lat. Flex
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With pain?
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Lumbar Spine Orthopedic Tests
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Trendelenburg
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Dejerines Triad
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Minors sign
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Braggards
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SLR
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SLR Angle
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Milgram's
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Yeomans
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Toe Walk
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Heel Walk
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Slump Test
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Kemps Test
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Well Leg Raise
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L.E. Myotomes
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L2/3
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Rt.
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Left L3/4
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Rt.
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Left L4/L5
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Rt.
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L5
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Rt.
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S1 Lt
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Rt.
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Lumbar Light touch
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L1
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Side
• • •
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L2
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Side
• • •
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L3
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Side
• • •
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L4
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Side
• • •
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L5
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Side
• • •
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S1
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Side
• • •
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DTRs
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Lt C5
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Rt
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Lt. C6
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Rt.
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Lt. C7
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Rt.
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L4 Lt.
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Rt.
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S1 Lt.
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Rt.
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Shoulder Exam
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Shoulder Range of Motion
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Left Shoulder
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Flexion
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With Pain?
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Extension
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With Pain?
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Abduction
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With Pain?
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Adduction
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With Pain?
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External Rotation
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With Pain?
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Internal Rotation
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With Pain?
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Right Shoulder
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Flexion
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With Pain?
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Extension
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With Pain?
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Abduction
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With Pain?
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Adduction
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With Pain?
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Internal Rotation
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With Pain?
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External Rotation
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With Pain?
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Shoulder Palpation
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Shoulder Palpation
• • •
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Muscle Issue
• • •
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Shoulder Palpation
• • •
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Muscle Issue
• • •
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Shoulder Palpation
• • •
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Muscle Issue
• • •
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Shoulder orthopedic exams
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Neer's test
• • •
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Speeds Test
• • •
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Empty Can
• • •
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Dawburns Test
• • •
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Yergason's Test
• • •
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Hawkin's - Kennedy
• • •
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Apleys Scratch test
• • •
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Hip
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Hip Range of Motion
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Right Hip Range of Motion
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Hip Flexion
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With Pain?
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Hip Extension
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With Pain?
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Hip Abduction
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With Pain?
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Hip Internal Rotation
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With Pain?
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Hip External Rotation
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With Pain?
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Left Hip Range of Motion
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Hip Flexion
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With Pain?
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Hip Extension
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With Pain?
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Hip Abduction
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With Pain?
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Hip Internal Rotation
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With Pain?
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Hip External Rotation
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With Pain?
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Hip Palpation
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Palpation
• • •
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Muscle Issue
• • •
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Palpation
• • •
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Muscle Issue
• • •
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Palpation
• • •
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Muscle Issue
• • •
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Palpation
• • •
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Muscle Issue
• • •
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Hip Orthopedic Exam
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Patrick Faber
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Laguerre's Test
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Piriformis Test
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Thomas Test
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Iliac Compression
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Yeoman's Test
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Nachlas
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Lewin-Gaenslen's Test
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Ober's Test
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Additional Comments:
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Elbow/Wrist/Hand
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Observation:
• • •
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Palpation (Spasm)
• • •
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Elbow/Wrist/Hand AROM
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Right Elbow Extension
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Left Elbow Extension
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Right Elbow Flexion
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Left Elbow Flexion
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Right Forearm Pronation
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Left Forearm Pronation
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Right Forearm Supination
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Right Forearm Supination
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Right Wrist Extension
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Left Wrist Extension
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Right Wrist Flexion
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Left Wrist Flexion
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Knee/Ankle/Foot
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Observation:
• • •
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Palpation (Spasm)
• • •
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Palpation (Trigger Points)
• • •
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Knee/Ankle/Foot AROM
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Right Knee Extension
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Left Knee Extension
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Right Knee Flexion
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Left Knee Flexion
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Right Ankle Plantarflexion
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Left Ankle PlantarFlexion
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Right Ankle Dorsiflexion
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Left Ankle Dorsiflexion
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Additional Tests/Info
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Treament Plan:
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Short-Term Goals
• • •
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Long-Term Goals:
• • •
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Treatment Frequency Weeks:
• • •
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Treatment Duration week
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Re-examination:
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Prognosis
• • •
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Changes to condition: (re-eval only)
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Diagnosis and Treatment
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M54.12 - Cervical Radiculopathy
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M54.16 - Lumbar Radiculopathy
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M54.2 - Cervicalgia
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M54.5 - Lumbago
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M54.6 - Pain in Thoracic Spine
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M62.830 - Muscle Spasm in Back
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M25.511 - Right Shoulder Pain
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M25.512 - Left Shoulder Pain
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M25.551 - Right Hip Pain
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M25.552 - Left Hip Pain
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M99.01 - Subluxation: Cervical
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M99.03 - Subluxation: Lumbar
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M99.02 - Subluxation: Thoracic
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M99.07 - Subluxation: Upper Extremity
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M99.06 - Subluxation: Lower Extremity
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Write your own DX
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Treatment Plan
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SPINAL ADJUSTMENT - 98940
• • •
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EXTREMITY ADJUSTMENT: 98943
• • •
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MANUAL THERAPY - 97140
• • •
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ACTIVITIES OF DAILY LIVING - 97535
• • •
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THERAPEUTIC EXERCISES - 97110
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BCBS/CIGNA THEREX 97110x2 (UNCHECK Other Therex!)
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(extra 97110)
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ACUTE CERVICAL
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SUBACUTE CERVICAL
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STRENGTHENING CERVICAL
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ACUTE LUMBAR
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SUBACUTE LUMBAR
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STRENGTHENING LUMBAR
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THERAPEUTIC ACTIVITIES - 97530
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CERVICAL SPINE
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LUMBAR SPINE
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ELECTRIC STIMULATION - 97014/G0283
• • •
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Medical Supplies
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Tens Unit
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Lumbar Brace
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ASSESSMENT
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