INITIAL REPORT: A GENERAL OUTLINE FOR THE D.C.
 
   

Initial Report:
A General Outline for the D.C.

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 & file this document for personal use, however, you may not sell, or reproduce it in any personal or commercial venture, without the written permission of the copyright holder.
 
   

TO: ___________________________
re: PATIENT: ___________________________
MEMBER ID #: ___________________________
EMPLOYER: ___________________________
DATE OF INJURY/ONSET: ___________________________


1.    Incident of Injury:   The patient states: (Whatever happened, in their own words)



2.    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.



3.   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.

Vital statistics are:   Height __",   Weight __#,   BP __/__ (R/L),   Pulse __ BPM.

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).

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:   (Planes tested)
See the enclosed table(s) for Cervical or Thoracolumbar ROM testing, which compares the patient to the "normals".

CERVICAL RANGE OF MOTION

FLEXION

EXTENSION

L. LATERAL FLEXION

R. LATERAL FLEXION

LEFT ROTATION

RIGHT ROTATION

INITIAL

/60

EXAM

/75



/45


/45


/80


/80

RE-EXAM

/60



/75


/45


/45


/80


/80

THORACOLUMBAR RANGE OF MOTION

FLEXION

EXTENSION

L. LATERAL FLEXION

R. LATERAL FLEXION

LEFT ROTATION

RIGHT ROTATION

INITIAL

/90
EXAM

/30


/40


/40


/55


/55

RE-EXAM

/90



/30


/40


/40


/55


/55

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


Algometer testing of pain sensitivity revealed...

(You can get an algometer from ACTIVATOR for around $200)

I don't do this very often, unless it's a PI or WC claim.

Literature support for algometry as a clinical DX tool is
EXTENSIVE.

Review the Algometry Citations
(http://www.chiro.org/LINKS/out-art.shtml#Algometry)


Reflex testing was:   (GRADED)

Dermatomal testing revealed:   (GRADED)

Orthopedic testing was positive for:   (Foraminal encroachment etc.)

I add this final paragraph for closure, and to explain the presence of the next section.

Cervical, thoracic, lumbar films were deemed necessary/unnecessary to determine the presence of ligamentous stability, occult injury, and for biomechanical analysis.



4.    X-ray Findings:   SEE ATTACHED REPORT
        ( http://www.chiro.org/LINKS/radiology_report.shtml )



5.    Diagnosis:   SEE ATTACHED REPORT
        ( http://www.chiro.org/LINKS/dx.shtml )



6    Comments:   Here I review factors in the patient's work, home life, or other activities of daily living that may effect recovery or cause exacerbations.

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
( http://www.chiro.org/LINKS/outcome.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


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 )


Download The Adobe (PDF) Acrobat Reader for Free



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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