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!
- CHIEF COMPLAINT
- HISTORY (HPI): Chronological description
- symptoms changing?
- VAS rating: now/ave/best/worst
- ADL scale (1-10)
- Disability index (Oswestry, NDI, etc)
- Activities that make symptoms better/worse
- PAST, FAMILY & SOCIAL HISTORY (PFSH)
- Seen other providers for current problem? Who/when/past tests & treatments/response.
- Similar problems in the past?
- Prior major illnesses and injuries.
- Prior surgery.
- Prior hospitalizations.
- Current medications.
- Dietary status/regular exercise?
- Health status of parents, sibling and children.
- Problems identified in the chief complaint or system review.
- Diseases of family members which may be hereditary or place patient at risk.
- Marital status.
- Work Hx & Current employment.
- Level of education.
- Use of drugs, nutritional supplements, alcohol or tobacco
- REVIEW OF SYSTEMS (ROS)
- Constitutional (eg fever, sleep ok? weight normal?, appetite ok)
- Integumentary, etc.
- General: vitals, neck supple? masses, bruits or thyromegaly? Heart rate, regular rhythm, murmurs? Lungs clear? Pulses normal? Abdomen negative?
- Provocative palpation/percussion
- ROM – Passive & Active
- Ortho tests
- Neuro: motor strength, MSR’s, Sensory
- Wadell Signs/ Abnormal Illness Behaviors
- Spinal Functional Assessment
- X-RAY- when indicated
- OBJECTIVES Short & Long Term
- Passive modalities & manual therapies with transition to therapeutic exercise as soon as clinically appropriate.
- SMT of fixations to improve Jt. Function
- PIR of tight muscle groups to restore normal length
- Motor control training of spinal, scapular and pelvic stabilizers using rocker board, balance sandals, and manual facilitation techniques.
- Endurance training of Spinal stabilizers (eg dead bug tract progressing to co-extremity motions)
- HEP: spinal stabilization/McKenzie/Therapeutic Stretching
- PRE-Strength Training: torque production of large prime movers, esp. trunk flexors & extensors
- PROCEDURE: see rehab menu
- COUNSELING: Discussion with patient and/or family concerning one or more of the following areas:
- Diagnostic results, impressions, and/or recommended diagnostic studies.
- Risks and benefit of management options.
- Instructions for management and/or follow-up.
- Importance of compliance with chosen management options.
- Risk factor reduction.
- 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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