ASSESSMENT AND PLAN
 
   

Assessment and Plan

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org

This page is devoted to a full description of what is considered "complete" patient file documentation, as described by National Associations and Third party Payors. It is the intention of this page to inform our profession of the most efficient means of communicating patient information as well as outlining what is considered adequate.

 
   

History & Physical for a "New Patient" using CPT code 99203

Thanks to Fred Deutsch, DC, DACRB of Deutsch Chiropractic, Watertown, SD for the use of this document!

  1. CHIEF COMPLAINT

  2. HISTORY (HPI): Chronological description
    1. location
    2. duration/frequency
    3. nature/quality
    4. symptoms changing?
    5. VAS rating: now/ave/best/worst
    6. ADL scale (1-10)
    7. Disability index (Oswestry, NDI, etc)
    8. Activities that make symptoms better/worse

  3. PAST, FAMILY & SOCIAL HISTORY (PFSH)
  4. A) Past

    1. Seen other providers for current problem? Who/when/past tests & treatments/response.
    2. Similar problems in the past?
    3. Prior major illnesses and injuries.
    4. Prior surgery.
    5. Prior hospitalizations.
    6. Current medications.
    7. Allergies.
    8. Dietary status/regular exercise?

    B) Family

    1. Health status of parents, sibling and children.
    2. Problems identified in the chief complaint or system review.
    3. Diseases of family members which may be hereditary or place patient at risk.

C) Social

  1. Marital status.
  2. Work Hx & Current employment.
  3. Level of education.
  4. Use of drugs, nutritional supplements, alcohol or tobacco
  1. REVIEW OF SYSTEMS (ROS)
    1. Musculoskeletal
    2. Arthropathies
    3. Constitutional (eg fever, sleep ok? weight normal?, appetite ok)
    4. EENT
    5. Cardiovascular
    6. Genitourinary
    7. Gastrointestinal
    8. Respiratory
    9. Neurologic
    10. Integumentary, etc.
  1. EXAMINATION
    1. General: vitals, neck supple? masses, bruits or thyromegaly? Heart rate, regular rhythm, murmurs? Lungs clear? Pulses normal? Abdomen negative?
    2. Observation
    3. Provocative palpation/percussion
    4. ROM – Passive & Active
    5. Ortho tests
    6. Neuro: motor strength, MSR’s, Sensory
    7. Wadell Signs/ Abnormal Illness Behaviors
    8. Spinal Functional Assessment
  1. X-RAY- when indicated
  1. IMPRESSION
  1. OBJECTIVES Short & Long Term
    1. Subjective
    2. Objective
    3. ADL’s/Functional
  1. PLAN:
    1. Passive modalities & manual therapies with transition to therapeutic exercise as soon as clinically appropriate.
    2. SMT of fixations to improve Jt. Function
    3. PIR of tight muscle groups to restore normal length
    4. Motor control training of spinal, scapular and pelvic stabilizers using rocker board, balance sandals, and manual facilitation techniques.
    5. Endurance training of Spinal stabilizers (eg dead bug tract progressing to co-extremity motions)
    6. HEP: spinal stabilization/McKenzie/Therapeutic Stretching
    7. PRE-Strength Training: torque production of large prime movers, esp. trunk flexors & extensors
    8. Other
  1. PROCEDURE: see rehab menu
  1. COUNSELING: Discussion with patient and/or family concerning one or more of the following areas:

    1. Diagnostic results, impressions, and/or recommended diagnostic studies.
    2. Prognosis.
    3. Risks and benefit of management options.
    4. Instructions for management and/or follow-up.
    5. Importance of compliance with chosen management options.
    6. Risk factor reduction.
    7. Family and patient education.

12) EDUCATION/CONSENT TO PLAN: Patient provided written treatment plan. Verbalizes good understanding of treatment goals & plan, and provided clinical instructions?


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