http://chiroconceptions.com/ This is an actual New Patient Soap Note created in under 6 minutes. (name changed of course). Dr. Bohn had received many questions asking "how long does it take to create a new patient soap note?" and "what does one of these soap notes look like?"

1. WatXXXX, Daniel Accent on Health Jan 12, 2011
359 National Highway
LaVale, MD 21502
301-777-3710
SUBJECTIVE:
Daniel reports that his bilateral neck and upper back pain continues to bother and is the reason for this visit. Pain is a stiffness
with an associated ache that occasionally causes headaches. His pain was rated as a 4/10 "nagging/uncomfortable" today on the
0-10 scale and Daniel can do most of his activities so long as there are frequent rest periods. His problem is only bothersome
intermittently being present between 26-50% of the time. His normal daily activities are mildly affected by the current
symptoms. The problem appeared gradually over many years and it has not significantly changed.
Care is also directed at the dull, aching lower back pain that goes into his right hip. This has bothered on and off for years and at
times is a sharp stabbing sensation. At worst it reaches a 8/10 for short periods. Running and long periods of standing increase
the pain. Heat seems to help. OTC medications offer little relief. No trauma.
OBJECTIVE:
CERVICAL (neck) ROM (range of motion) normal values: This is an actual new patient 1st
Forward flexion / 45 degrees
Extension / 45 degrees visit note produced with
Left Lateral Flexion / 45 degrees QuickSOAPnotes in 5 minutes, 42
Right Lateral Flexion / 45 degrees
Left Lateral Rotation / 80 degrees seconds.
Right Lateral Rotation / 80 degrees www.chiroconceptions.com
He had normal motion in all active ranges.
LUMBAR (low back) ROM (range of motion) was compared to the following normal values:
Flexion / 90 degrees
Extension / 30 degrees
Left lateral flexion / 35 degrees
Right lateral flexion / 35 degrees
Left rotation / 30 degrees
Right rotation / 30 degrees
Limitations noted in his active range of motion:
Extension abnormal at 20 degrees.
Right lateral flexion abnormal at 15 degrees.
==>VBI Test, VAS or vertebral artery screening test (George's Test) was normal and is a positioning test of the neck to screen
for risk of dissecting (tearing) of the vertebral artery during a neck adjustment, and/or to screen for those who may be at risk of
having a stroke due to a neck adjustment. The test was normal with no increased risk identified today.
==>Dejerine's Triad Sign was negative.
==>Shoulder Depression Test was positive on his right side. This indicates possible adhesions of the dural sleeves, the spinal
roots, or the adjacent structures of the joint capsule on the side of the shoulder being depressed.
==>Jackson's Compression Test, which is usually indicative of cervical nerve root compression, was normal or negative.
==>Cervical Distraction Test was normal today with nerve root compression less likely.
==>Lhermitte's Sign was negative or absent.
==>Slump test increased the pain in his lumbar spine and was deemed positive for "neural tension" originating in the lumbar
region.
==>Gaenslen's test was painful on his right an this suggests right hip joint dysfunction.
==>Miner's sign was not present.
==>The Lasegue (Straight Leg Raise) Test was negative bilaterally.
==>Lumbar quadrant test was abnormal on the right with increased pain and was performed with extension and side bending
toward the involved side.
==>Piriformis Test was abnormal on his right. During the Piriformis Test (Piriformis Syndrome) the patient is asked to flex and
bend the knee and hip while lying down. The examiner then gently pushes on the leg to check hip joint mobility and flexibility of
the piriformis muscle. A positive test indicates piriformis spasm.
==>Iliac Compression Test was painful on his right side. This is suspicious for a right sided sacroiliac lesion.
==>Spinal segmental fixations or restrictions: bilateral cervical region and thoracic region.
==>Vertebral motion limitations: right lumbar region and lumbosacral.
==>Extraspinal subluxations noted: right sacroiliac joint and hip joint.
==>Soft tissue palpation findings were normal with the exception of spasm in his left thoracic paraspinal region, posterior cervical
muscles on the right, and right thoracic paraspinal region. There was tenderness in the muscles of the left lumbar area, muscles
of the right lumbar area, and right gluteal region.
RADIOLOGY IMPRESSIONS:
Diagnostic imaging was deemed necessary and after the risks and benefits were explained the images were obtained using
shielding as appropriate. Exposures included cervical spine, weight bearing (5 View) series of his lumbar spine, and AP weight
bearing pelvic area (1 View). The report on this study was reviewed, signed and placed in his chart as part of his permanent
record.
DIGITAL POSTURE ANALYSIS:
Daniel has poor posture that is likely contributing to his current complaints. I evaluated his posture today and comparison was
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2. WatXXXX, Daniel Page 2 Jan 12, 2011
made to ideal normal erect human posture under the conditions of static equilibrium using digital technology. See his posture
report in his chart. In the lateral view, normal postural ali gnment is defined as balance about a coronal line of reference or
gravity line that passes through the external auditory meatus, acromioclavicular joints, greater trochanters and lateral malleoli.
On the lateral view Daniel's head is in an abnormal anterior position over his thoracic or chest cavitiy. The forward head posture
is an abnormality of posture routinely observed in subjects with a wide variety of musculoskeletal complaints. Both medical and
chiropractic researchers have devised reliable methods to assess the posture and skeletal alignment of the spine and skull of
patients with such abnormalities. Methods which have been shown to reduce the magnitude of the forward head posture include
both the McKenzie protocols of neck retraction exercise and extension traction protocols. The right hip is low on posture analysis
today. The pelvis is rotated anteriorly when viewed from his side.
ASSESSMENT:
CURRENT DIAGNOSIS:
723.2 Cervical cranial syndrome, 721.01 Cervical spondylosis, 724.1 Thoracic pain, 728.85 Muscle spasm
724.6 Lumbo Sacral Dysfunction/Disorder, 719.45 Hip pain
PROGNOSIS:
Daniel has a good prognosis in this case. Permanency is not likely.
TREATMENT TIME TO MAXIMUM IMPROVEMENT:
I expect him to reach MMI (maximum medical improvement) in the next 24-30 visits.
PLAN:
==>Manipulation was performed on the cervical, thoracic regions lumbar, sacral regions per palpatory findings.
==>Osseous manipulation was performed on his shoulders and hips to restore normal motion and remove restrictions.
==>Physical therapy modalities ordered for the neck, upper back, shoulders low back, lower thoracic region, and hips:
- Deep tissue to triggerpoints and muscle spasm in the cervical, thoracic, shoulder region, lumbar and hip region.
- Therapeutic stretching/exercise to muscles in the neck, mid back, and shoulders and to the low back and hips.
- Compression/extension cervical traction for up to 10 minutes at 10 lbs per patient tolerance.
- Mechanical lumbar traction for up to 10 minutes or patient tolerance.
- Pulsed electrical stimulation (EMS) to muscles in his neck, shoulders, low back, and thoracic region for 10 mins.
- Moist Heat for 10 mins over the neck, upper back, and shoulder regions over the lower back.
ORTHOTICS (FOOT CORRECTION) LETTER OF MEDICAL NECESSITY:
Foot supportive custom orthotics were molded to Daniel's feet today to stabilize the biomechanical chain and support the arch of
the foot. These orthotics should help him hold his adjustment longer and allow him to improve faster since the stress load on the
plantar fascia, his arches and his entire biomechanical chain will be decreased. If left uncorrected, his structural deficiencies of
his feet will create gait abnormalities that will slow or prevent proper spinal and pedal biomechanics and normal gait. Therefore
these orthotics should be considered medically necessary and considered for payment by his insurance carrier. After
discussing Daniel's needs and activity levels and also reviewing his gait and kinetic chain I prescribed and ordered full length
orthotics. The need for these custom orthotic foot devices was based on his following problems (diagnoses):
728.71 (plantar fascitis) - an acute or semi acute injury which occurs due to the stretching and/or partial rupture of the firm band
of connective tissue on the sole of the foot due to excessive stretching of the fascia that may be produced by long periods of
foot pronation, landing hard on the sole of the foot, instant foot acceleration and de-acceleration and or repetitive shock caused
by heel strike.
781.92 (abnormal posture-acquired) - changes in structural global posture alignment resulting in abnormal stress loads on the
human frame acquired as a result of trauma or chronic postural stress.
734.0 (pes planus) - congenital or acquired flat foot creating structural and postural imbalances in gait and alignment and
contributing to the foot and or back pain.
***********RIGHT 9 mm HEEL LIFT ADDITION TO HIS ORTHOTIC DUE TO STRUCTURAL SHORT LEG ON WEIGHT
BEARING X-RAY OF 9.35 mm.
LETTER OF MEDICAL NECESSITY FOR A COMPRESSION EXTENSION CERVICAL TRACTION UNIT. (E0941)
Daniel received a home compression/extension traction unit today to distract his cervical spinal joint surfaces, stretch his
anterior longitudinal ligament, reduce the amount of forward translation of his skull over the thorax and to reduce the hydrostatic
pressure within his cervical discs. Biomechanical studies have established that long-term biomechanical adaptation requires a
constant force over a period of time. Compression-extension traction delivers this required constant force over time to change
structure and improve function. Compression-extension traction is used to correct posture and to restore the sagittal spinal
curvatures and has been shown to increase intervertebral disc height in clinical trials. Daniel was advised to begin using the
traction unit without the compression strap and to build up the time of traction from 1 minute to 10 minutes per day. he was
instructed to begin using the traction strap when he is able to do 3 minutes comfortably without the strap. Daniel demonstrated
competency in the use of the traction unit and was advised that should he experience any dizziness or nausea or any unusual
symptoms to discontinue the traction immediately and to not resume traction use until he has discussed it with me or a qualified
health care provider. This traction device should be considered medically necessary and paid as such.
TREATMENT PLAN:
Chiropractic treatment recommendations include:
* Adjustments to key joint dysfunctions
* Modalities to improve soft tissue healing and pain control, such as ultrasound, electrical stimulation, and traction
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* Exercises to improve muscles balance, strength, and coordination
* Patient education to improve posture and motor control
* Other treatments such as massage, heat/cold application, and education on nutrition depending on his progress.
GOALS OF CARE:
* Short-term goals include reducing pain and restoring normal joint function and muscle balance
* Long-term goals include restoring functional independence and tolerance to normal activities of daily living.
To reach these goals, a specific number of chiropractic visits, such as 1 to 3 chiropractic visits/week for 6 to 10 weeks, has
been prescribed and will be followed by re-examination every 12-18 visits.
CONSENT TO CARE IN THIS OFFICE:
Daniel and I discussed the performance of chiropractic adjustments and other chiropractic procedures likely to be used in his
treatment in this office, including various modes of physical therapy and spinal decompression traction, by me and/or other
licensed doctors of chiropractic who now or in the future work in this office.
Daniel had the opportunity to discuss the nature and purpose of chiropractic adjustments and other procedures and indicated
understanding that results are not guaranteed.
I explained that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not
limited to fractures, disc injuries, strokes, dislocations and sprains. I explained that they should not expect a doctor to be able to
anticipate and explain all risks and complications, and if he decides to pursue treatment that he will need to rely upon the doctor
to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to
him or her, is in the patient's best interest.
Daniel had an opportunity to ask questions about treatment content, and agreed to the above-named procedures. Daniel
understood that this consent form will cover the entire course of treatment for his present condition and for any future
condition(s) for which Daniel seeks treatment in this office.
I will see Daniel again on Thursday.
Seen by Dr. David Bohn, D.C.
CA Therapy Completed As Ordered: ______ Front Desk CA: ______ Visit Number: _____ /_____
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