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Subjective
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Patient Area
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Chief Complaint
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History of Present Illness
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No pain = 0, Worst pain imaginable = 10
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Right Now
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Best Day
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Worst Day
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Description of Pain
• • •
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Better When
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Worse When
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Makes Better
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Makes Worse
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Home Exercise Plan
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Mood/Sleep
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Home Exercise Plan
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ROS
• • •
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ROS (Other)
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Physical Examination
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Vitals
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Physical Exam
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General
• • •
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Affect
• • •
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Abnormal
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Eyes
• • •
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Eyes (Abnormal Notes)
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Heart
• • •
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Heart (Abnormal Notes)
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Lungs
• • •
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Lungs (Abnormal Notes)
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Skin
• • •
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Skin (Abnormal Notes)
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Abdomen
• • •
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Abdomen (Abnormal Notes)
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Neuro/Vasc
• • •
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Neuro/Vasc Abnormal
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MSK
• • •
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MSK other
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Additional Physical Exam:
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PPE worn by patient
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PPE worn by physician
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OMT Procedure Note
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Procedure Start Time
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Verbal Consent Given By
• • •
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Procedure Risk/Benefit
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Pre-Procedural Soreness
• • •
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Chaperone Present
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OMM Procedure
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OMT discussed with patient and performed to above noted areas of Somatic Dysfunction using
• • •
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Patient Tolerated
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Post-Procedural Pain
• • •
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Patient notified of possible post-treatment soreness, etc., that may last 24-48 hours; advised to increase water and apply ice.
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Procedure End Time
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Plan
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Rx/Medical Supply/Lab/Radiology
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Counseling
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minutes spent with patient
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at least "x" minutes in counseling on
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Counseling Options
• • •
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Home Exercise Program
• • •
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Home Exercise
• • •
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Other
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Notes
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Follow Up
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# Days
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# Weeks
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# Months
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PRN
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Provider Signature
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Signature (iPad Only)
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Assisted/Observed
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Date
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Time
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