About this template
This Chiropractor's note template is designed for chiropractors to document patient visits comprehensively. It includes sections for subjective symptoms, objective findings, assessment, and treatment plans, making it ideal for tracking musculoskeletal conditions and chiropractic interventions. Chiropractors can use this template to record detailed patient histories, physical examinations, and treatment responses, ensuring thorough documentation of chiropractic care. This template is particularly useful for managing cases involving spinal adjustments and musculoskeletal health, providing a structured format for evaluating patient progress and modifying treatment plans as needed.
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Subjective:
- The patient reports experiencing sharp lower back pain that began two weeks ago after lifting a heavy object. The pain radiates down the right leg and is aggravated by sitting and bending.
- The patient has a history of chronic lower back pain due to a herniated disc diagnosed two years ago.
- The patient denies any neurological symptoms but reports occasional numbness in the right foot.
- Past medical history includes a lumbar discectomy performed last year.
- The patient works as a warehouse manager, which involves heavy lifting and prolonged standing. The patient exercises occasionally but reports poor sleep quality and high stress levels.
- Current medications include ibuprofen 400 mg as needed for pain.
- Family history is significant for osteoarthritis in the patient's mother.
Objective:
- Vitals: BP 120/80 mmHg, HR 72 bpm, RR 16 breaths/min, Temperature 36.8°C.
- Physical examination reveals poor posture with anterior pelvic tilt, limited range of motion in lumbar flexion and extension, and tenderness upon palpation of the L4-L5 region.
- Neurological assessment shows normal reflexes and motor strength, but decreased sensation in the right foot.
- Reviewed MRI results showing a herniated disc at L4-L5.
Assessment:
- Diagnosis: Lumbar disc herniation with radiculopathy.
- Areas requiring adjustment: L4-L5 vertebrae.
- Diagnosis codes: M51.26 (lumbar disc displacement), M54.16 (radiculopathy, lumbar region).
Plan:
- Treatment plan includes spinal adjustments at L4-L5, soft tissue therapy, and therapeutic exercises focusing on core strengthening.
- Frequency: Twice a week for four weeks.
- Goals: Short-term - pain relief and improved range of motion; Long-term - enhanced posture and functional mobility.
- Prescribed home exercises include pelvic tilts and hamstring stretches.
- Referral to a physical therapist for additional rehabilitation.
Interventions:
- Performed spinal adjustments at L4-L5 and soft tissue therapy on the lumbar region.
- The patient reported immediate relief in pain intensity post-treatment.
Evaluation:
- The patient shows progress towards short-term goals with reduced pain and improved mobility.
- Plan to continue current treatment regimen and reassess in two weeks.
Additional Notes:
- Educated the patient on proper lifting techniques and ergonomic adjustments at work.
- Scheduled follow-up visit in one week to monitor progress.
- The patient expressed a preference for non-surgical interventions.
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