Chiropractic Documentation Template

Subjective:
- The patient describes experiencing acute lower back pain that started two weeks ago after lifting a heavy object. The pain extends down the right leg and worsens with sitting and bending.
- The patient has a history of chronic lower back pain due to a herniated disc identified two years ago.
- The patient denies any neurological symptoms but mentions occasional numbness in the right foot.
- Past medical history includes a lumbar discectomy performed last year.
- The patient is employed 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.