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Subjective
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Chief Complaint:
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History of Present Illness (HPI)
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Current Complaint:
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ADL Limitations:
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Outcome Measure:
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Objective:
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Inspection:
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Palpation:
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Motion Palpation:
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Range of Motion:
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Cervical:
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Lumbar:
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Note:
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Thoracic
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Extremity ROM:
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Shoulder
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Hip
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Note:
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Orthopedic Testing:
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Cervical / Upper Extremity
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Lumbar / Hip Orthopedic Tests
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Thoracic Orthopedic Tests
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Muscle Strength
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Cervical / Upper Extremity
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Lumbar / Lower Extremity
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Diagnostic Imaging / X-Ray Results
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Assessment
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Dx:
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Clinical Impression
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Short Term Goal (4-6 Weeks)
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Long Term Goal (6-12 Weeks)
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Plan of Care
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Treatment Today
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99203 – New Patient Evaluation and Management
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99213 – Established Patient Evaluation and Management
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98940 – Chiropractic Manipulative Treatment (1-2 Regions)
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98943 – Extraspinal Manipulation
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97012 – Mechanical Traction
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97110 – Therapeutic Exercise
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97140 – Manual Therapy
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97530 – Therapeutic Activities
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97535 – Self-Care/Home Management Training
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G0283 – Electrical Stimulation (Unattended)
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97032 – Electrical Stimulation (Attended)
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72040 – Cervical Spine Radiographs (2-3 Views)
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72100 – Lumbar Spine Radiographs (2-3 Views)
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