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Chiro Soap Note

The patient presented with complaints of pain in various areas of the head, neck, back, and extremities. Upon examination, the doctor found muscle hypertonicity and range of motion restrictions. Joint misalignments were detected and adjusted. The treatment plan included chiropractic manipulation, therapeutic modalities like ultrasound and massage, and a home exercise program. The doctor recommended continuing the care plan to manage the patient's clinical issues.

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drhbj81
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483 views

Chiro Soap Note

The patient presented with complaints of pain in various areas of the head, neck, back, and extremities. Upon examination, the doctor found muscle hypertonicity and range of motion restrictions. Joint misalignments were detected and adjusted. The treatment plan included chiropractic manipulation, therapeutic modalities like ultrasound and massage, and a home exercise program. The doctor recommended continuing the care plan to manage the patient's clinical issues.

Uploaded by

drhbj81
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as TXT, PDF, TXT or read online on Scribd
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Date: ____/____/_______

___________________________________________________

Patient's Name

SUBJECTIVE COMPLAINTS
The patient entered the office reporting that, in general, their overall conditi
on has:
Improved-----No Change----- Worsened
since their last office visit. Complaints today include the following:
Pain
Level
HEADACHE:
Occipital Frontal Temporal Global
L / R
Minimal Mild
Moderate
Severe
____
NECK:

Pain
Stiffness
Paresthesia
Minimal Mild
Moderate
Severe

Spasm

L / R
____

UPPER BACK:

Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
MIDBACK:
Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
LOWBACK:
Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
UPPER EXTR:
Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
LOWER EXTR: Pain
Stiffness
Paresthesia
Spasm
L / R
Minimal Mild
Moderate
Severe
____
Shoulder__Elbow__Wrist__Fingers____Hip____Knee____Ankle___Toes____ Notes:___
_____________________________
________________________________________________________________________________
________________________
OBJECTIVE / EXAMINATION
Muscle / Myofascial Hypertonicity was present in the following paraspinal region
s with the following degree of intensity.
(Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate, 4 = Moderate, 5 = Mod
erate to Severe, 6 = Severe)
CERVICAL
__L / __ R Suboccipital
__L / __ R Mid Cervic
al
__L / __ R Upper Trapezius
THORACIC
__L / __ R Paraspinal
__L / __ R Mid Scapu
lar
__L / __ R Lower Trapezius
LUMBOSACRAL
__L / __ R Upper Paraspinal
__L /
__ R Lower Paraspinal
__L / __ R Piriformis / Psoas
Range of Motion, was evaluated with the following findings:
___Global
___Segmental
___Both
( Level of Restriction Key: 1 = Minimal, 2 = Mild, 3 = Mild to Moderate
, 4 = Moderate, 5 = Moderate to Severe, 6 = Severe)
Cervical : ___L / ___R
Thoracic: ___L / ___R Lumbar: ___L / ___R
Extremity.____________: ___L / ___R
ASSESSMENT / ACTION
____________
___L / ___R
___ Patient is improved ___ Patient is unchanged
___ Patient is worsened
____Exacerbation
______New injury
Joint misalignments / Fixations were detected in the following areas:---- Misalignment/fixations adjusted without incident
C0, C1, C2, C3, C4, C5, C6, C7 ___________________________ (prone
: supine: diversified
T1, T2, T3, T4, T5, T6, T7, T8, T9, T10, T11, T12 ____________
_________ (diversified)
L1, L2, L3, L4, L5, Sac, L-Ilium, R-Ilium _______ (diversified)
L / R Shoulder, L / R Elbow, L / R Wrist, L / R Hip, L / R Kn

ee, L / R Ankle, __________ (instr: manual: drop)


PLAN /PROTOCOL/ RECOMMENDATIONS
Based upon presenting symptoms, objective findings and clinical assessme
nt, treatment consisted of the following procedures:
___ Chiropractic Manipulative Therapy ___CMT 1-2, ___ CMT 3-4, ___ Extremity
__________________________
Therapeutics Modalities: Myofascial Release -- Mechanical Traction -- EMS/I
F -- Hot/Cold Therapy -- InfraRed
Ultrasound(attended) Pulsed/Con.__________ Massage Therapy-15/30min.____
_
Location____________________________________Inten
sity_________Time___________
Kinetic / Therapeutic Activity__
Neuromuscular Re-Ed___
Attend
ed Active Exercise______________________________
Location_____________________________________Time
: 15min. / 30min. Stretching
Strengthening / Conditioning
Dr.'s Initi
als______________ Frequency of Treatments_____________
___ Home Instruction: ___ Ice Therapy, ______ Traction _______,
Strapping/Ta
ping_______________________________
___ Personal Stretch / Exercise Program: __ neck, __ back, __ UE, __ LE, __ whol
e body, ____________________________
The following recommendations are made for Clinical Management of this p
atient: MMI Dismissal (Failure to Follow Treatment Plan)
___ Continue Care Plan, ____ Modify Care Plan, ___ Re-Examination, ___ Refer
ral for Further Evaluation: _____________
___ Referral for diagnostic / imaging assessment to include: ______________
COMMENTS:_______________________________________________________________________
________________________________
________________________________________________________________________________
___________________________________
________________________________________________________________________________
___________________________________
Goals___________________________________________________________________________
___________________________________
________________________________________________________________________________
___________________________________
Doctor's Signature_______________________________D.C.
ignature____________________________________________

Patient's S

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