The above is then followed by a paragraph discussing results from any Outcome Assessment questionnaires the patient fills out. Then the results are listed in table form.
For examples of questionnaires, please see the:
Outcome Assessment Questionnaires
( https://chiro.org/LINKS/Outcome_Assessment.shtml )
I include the following paragraph, IF questionnaires were filled out:
This office utilizes the SF-36 Health Survey, RAND modification 1.0, the Global Well Being Scale (GWBS), the Oswestry Low Back Pain Index (OLB) Questionnaire and the Neck Disability Index (NDI) Questionnaire(s) as outcome assessment tools.
The RAND SF-36 questionnaire measures the impact of the patient's presenting illness on eight aspects of their lifestyle. Below is the patient's score on the 8 components of the RAND and their GWBS scores.
NOTE: The ideal score for the RAND is 100%, but mean scores for the general population are listed in the right-hand column.
For both the OLB and NDI, scores above 18 (out of 50) are clinically significant, with scores from 20-40 suggesting moderate disability and scores over 40 suggesting increasingly severe disability.
A score of 0 is ideal on the GWBS.
RAND SF-36 |
INITIAL SCORE |
PRESENT SCORE |
NORMS |
PHYSICAL FUNCTIONING |
|
|
84.2 |
ROLE LIMITATIONS DUE TO PHYSICAL HEALTH |
|
|
81.0 |
ROLE LIMITATIONS DUE TO EMOTIONAL STRESS |
|
|
81.3 |
ENERGY/FATIGUE |
|
|
60.9 |
EMOTIONAL WELL-BEING |
|
|
74.7 |
SOCIAL FUNCTIONING |
|
|
83.3 |
PAIN LEVELS |
|
|
75.2 |
GENERAL HEALTH |
|
|
72.0 |
Other QA's |
|
|
|
GLOBAL WELL-BEING |
|
|
> 2/10 |
OSWESTRY LB PAIN INDEX |
|
|
> 5/50 |
NECK DISABILITY INDEX |
|
|
> 5/50 |
7.
Disability Data/Restrictions:
YOU MUST ANSWER: Are they disabled now? List work/home
restrictions (on lifting, head placement etc.)
State plainly if the prognosis is good, guarded, or if it is unclear at this time.
If the patient's complaints are caused by an injury (such as a motor vehicle accident) then you need to state whether your exam findings are consistant with the mechanism of injury and if it is your professional opinion that the chief complaint(s) were directly caused by that trauma.
A sample paragraph:
Following a thorough exam of the regions of complaint on 8-29-2005, as listed above, it is my expert opinion that the symptoms he described are all typical of injuries that occur in a rear-end collision, and that these specific injuries were sustained as a result of the MVA of 8-19-2005.
8.
Care Recommendations: In
order to promote healing and to relieve the patient's pain, I recommend the following therapies and procedures:
Chiropractic adjustments/manipulation,
consisting of specific correction of osseous subluxations, to return functional biomechanics of the (NAME REGION) region for (NUMBER OF VISITS) X/week for (NUMBER) weeks, then reducing to
(NUMBER OF VISITS) X/week for (NUMBER) weeks, followed by a
re-evaluation on the 12th visit or 4th week,
whichever comes first.
Myofascial release for trigger points
found in the (NAME REGION) region for relief of symptoms,
reduction of muscle spasm, and to return the muscle to "normal"
resting length.
The patient is advised to ice at home for pain relief in the (NAME REGION) region. Specific directions detailing frequency and duration were provided and reviewed with the patient.
High Volt DC current therapy to reduce
edema, muscle spasm and pain in the (NAME REGION) region.
Ultrasound therapy to reduce edema and
inflammation as well as to deep heat tissues to increase protein
production at the site of injury and to increase elasticity of
the new collagen fibers being laid down.
Interferential therapy to reduce muscle
spasm, pain and to tonify weakened muscles in the (NAME REGION)
region.
A prescription may be made for a managed care,
rehabilitative exercise program, utilizing resistance tubing and
other devices. The purpose of this program is to
provide a low
resistance and high repetition workout leading to gradual
strengthening of the cervical/thoracic/lumbar/upper
extremity/lower extremity region's muscles and ligaments.
This program is specifically designed to relieve pain, increase
capillary action, to loosen adhesions, and to increase the
structural strength and stability at the region of complaint.
The patient will be advised on proper exercises and
stretches to support the care at home, and will be encouraged to
move into an active role early, so that he/she will continue to
stretch the healing tissues during and after the office rehab
program ends.
9.
Examination Forms Attached?
[ ] YES
[X] NO
10.
Additional Evaluations Attached?
[ ] YES
[X] NO
11.
Accident Report Attached?
[ ] YES
[X] NO
_________________________________
_______________
Doctor's Signature
Date
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