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S(SUBJECTIVE)
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HISTORY:
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History:
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Chief Complaint: Patient complains of pain in LOCATION?
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Cause of the pain
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Patient reports above pain over the past (how many days ago)
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Frequency of the Pain
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Quality of the pain:
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Radiation of Symptoms
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Pain Sclae
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Relieved by what factors
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aggravated by what factors?
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Current Functional Deficit
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Deficit Time
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2nd Complaint: Patient complains of pain in LOCATION
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Cause of the pain
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Patient reports above pain over the past (how many days ago)
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Frequency of the Pain
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Quality of the pain:
• • •
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Radiation of Symptoms
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Pain Sclae
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Relieved by what factors
• • •
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aggravated by what factors?
• • •
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Current Functional Deficit
• • •
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Deficit Time
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Objective:
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Vitals
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Musculoskeletal
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- Inspection/Percussion +/or Palpation: l
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- Postural Analysis:
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Spinal/Extraspinal Restriction(s)/Subluxation(s)
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ROM Concern(s):
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ASSESSMENT
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ASSESSMENT:
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DIAGNOSIS:
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PLAN
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- Chief Complaint Short Term Tx Goal:
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- Home/Self Care: #1
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- Home/Self Care: #2
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Home Exercise Program:
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- 2nd Complaint Short Term Tx Goal:
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- Home/Self Care: #1
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- Home/Self Care: #2
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Home Exercise Program:
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97810
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97811
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97811
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Manipulation #1
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Manipulation #2
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Statement
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