Chiropracter Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Subjective:
(hyphenated list)
- [Description of current symptoms, including onset, duration, and characteristics (e.g., sharp, dull, radiating)]
- [History of present illness or condition leading to consultation]
- [Pertinent review of systems, including neurological symptoms, previous injuries, or musculoskeletal conditions]
- [Past medical and surgical history, especially related to spine, joints, and musculoskeletal health]
- [Lifestyle factors affecting health (exercise habits, occupational hazards, posture, sleep quality, stress levels)]
- [Current medications and supplements]
- [Family history of musculoskeletal or spinal conditions]

Objective:
(hyphenated list)
- [Vital signs (BP, HR, RR, Temperature)]
- [Physical examination findings: posture analysis, spinal alignment, range of motion, muscle tone and strength, palpation for tenderness or abnormalities]
- [Neurological assessment: reflexes, sensory testing, motor strength (if indicated)]
- [Diagnostic test results, including imaging studies]

Assessment:
(hyphenated list)
- [Chiropractic diagnosis or functional assessment based on findings]
- [Identification of areas requiring adjustment or manipulation]
- [Diagnosis codes, prioritizing chief complaint and including spinal/extremity subluxations]

Plan:
(hyphenated list)
- [Detailed treatment plan: specific adjustments, manipulation techniques, adjunctive therapies (e.g., soft tissue therapy, therapeutic exercises, modalities)]
- [Frequency and duration of treatment plan]
- [Short-term and long-term treatment goals]
- [Self-care recommendations or home exercises]
- [Referrals, if indicated]

Interventions:
(hyphenated list)
- [Details of chiropractic adjustments and other therapeutic interventions performed during the visit]
- [Patient's response to treatment, including immediate improvements or adverse reactions]

Evaluation:
(hyphenated list)
- [Evaluation of patient progress towards treatment goals]
- [Modifications to treatment plan based on progress and response]

Additional Notes:
(hyphenated list)
- [Patient education provided (ergonomics, lifestyle modifications, preventive measures)]
- [Plans for follow-up visits and continued care]
- [Patient concerns or preferences]