This report outline was prepared by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
You are free to download a Word template version (53 KB) of this document for use in your office. Individuals may copy and file this document for personal use, however, you may not sell, or reproduce it in any group or commercial venture, without written permission from the copyright holder.
SOCIAL SECURITY #:
DATE OF INJURY/ONSET:
Incident of Injury: The
patient states: (Whatever happened, in their own words)
Patient's Complaints: The patient presented (HIM/HER) self to this clinic on (DATE) exhibiting the following complaints and symptoms:
List all complaints in order, from the most serious to the least serious.
Grade every complaint on a 1-10 scale...
1= the least and 10= the worst imaginable.
Grade PAIN and STIFFNESS as separate entities
A sample paragraph:
James Patient presented to my office on 8-29-2005, following a rear-end motor vehicle collision (MVA) on 8-19-2005, with these complaints:
(1) Constant left shoulder pain of a 2/10 severity, which increases to 8/10 severity with raising the arm slightly or moving it slightly. This pain started the morning after being struck from the rear in his motor vehicle. He had no previous shoulder complaints.
(2) Constant neck pain of a 3/10 severity that increases to 7/10 severity with head rotation or lateral bending. This pain had been disturbing his sleep, awakening him several times each night.
(3) Paresthesia of the left forearm in the C5-C6 dermatomal region, which first started several days after the MVA of 8-18.
Objective Findings: A
thorough orthopedic, neurologic and chiropractic exam was given on (DATE):
NOTE: All the observations listed below can be woven into paragraph format.
Visual inspection demonstrated: Comment on head, shoulder
or pelvic tilt, guarding, antalgia, sense of balance, symmetry of arms and legs (is one more externally rotated?), or any other observations you made.
Palpatory inspection revealed: Muscle spasm and
tenderness elicited with static palpation; Motion palpation findings---> such as
vertebral rotations, loss of coupled motion in rotation or
lateral bending. You may also note pain referral suggesting myofascial trigger points of the...
(Name the region). I use a separate table [Word document] to tally trigger point exam findings.
A sample (Boiler Plate) paragraph:
Visual inspection demonstrated a patient mildly/moderately/very
guarded in all/certain movements at the neck, upper torso, at the
waist. Palpatory inspection revealed muscle spasm
present at the (XXX) regions. Tenderness was elicited at
those same regions with static palpation. Loss of
coupled motion was noted in the upper, mid, lower cervical spine,
upper, mid, lower thoracic spine, upper, mid, lower lumbar spine,
and loss of fluid motion and normal joint "end-feel" was observed
with motion palpation.
Reductions in range of motion (ROM) was noted in:
See the enclosed table(s) for Cervical or Thoracolumbar ROM testing, which compares the patient to the "normals".
CERVICAL RANGE OF MOTION
L. LATERAL FLEXION
R. LATERAL FLEXION
THORACOLUMBAR RANGE OF MOTION
L. LATERAL FLEXION
R. LATERAL FLEXION
NOTE: * DENOTES PAIN ON THAT MOTION
Muscle testing revealed:
(Graded weakness for upper or lower extremity muscles using AMA's 0-5 grading scheme)
Dynamometer testing of hands may also included when indicated
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.
ROLE LIMITATIONS DUE TO PHYSICAL HEALTH
ROLE LIMITATIONS DUE TO EMOTIONAL STRESS
OSWESTRY LB PAIN INDEX
NECK DISABILITY INDEX
NOTE: Dr. Howard Vernon has released the NDI to the LINKS section for your use. You can find
a downloadable "Adobe Acrobat" version @ the Neck Disability Index ( http://www.chiro.org/LINKS/OUTCOME/Neck_disability.PDF )
You may also review citations for it @
NDI Citations (http://www.chiro.org/LINKS/out-art.shtml#NDI )
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.
Care Recommendations: In
order to promote healing and to relieve the patient's pain, I recommend the following therapies and procedures:
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"
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)
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
Examination Forms Attached?
[ ] YES
Additional Evaluations Attached?
[ ] YES
Accident Report Attached?
[ ] YES