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S(SUBJECTIVE)
HISTORY:
History:
Chief Complaint: Patient complains of pain in LOCATION?
Cause of the pain
• • •
Patient reports above pain over the past (how many days ago)
Frequency of the Pain
Quality of the pain:
• • •
Radiation of Symptoms
Pain Scale
Relieved by what factors
• • •
aggravated by what factors?
• • •
Current Functional Deficit
• • •
Deficit Time
2nd Complaint: Patient complains of pain in LOCATION
Cause of the pain
• • •
Patient reports above pain over the past (how many days ago)
Frequency of the Pain
Quality of the pain:
• • •
Radiation of Symptoms
Pain Sclae
Relieved by what factors
• • •
aggravated by what factors?
• • •
Current Functional Deficit
• • •
Deficit Time
Objective:
Vitals
Musculoskeletal
- Inspection/Percussion +/or Palpation: l
• • •
- Postural Analysis:
• • •
Spinal/Extraspinal Restriction(s)/Subluxation(s)
• • •
ROM Concern(s):
• • •
ASSESSMENT:
DIAGNOSIS:
• • •
PLAN
- Chief Complaint Short Term Tx Goal:
- Home/Self Care: #1
• • •
- Home/Self Care: #2
• • •
Home Exercise Program:
• • •
- 2nd Complaint Short Term Tx Goal:
- Home/Self Care: #1
• • •
- Home/Self Care: #2
• • •
Home Exercise Program:
• • •
97813
• • •
97814
• • •
97811
• • •
97811
Statement

4ACU (99213) WITH STEM Medical Form

Acupuncture

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Published: March 6, 2024, 2:03 p.m.
Doctor: Dr. History Physical
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