By the time you finish looking at this, you may come to realize that the patient is at maximum medical improvement or the patient needs additional treatment, and you should argue a justification in your report.
The Progress Report sections are listed with what material is discussed in each and a sample report attached so you can get an idea of how a final report reads.
List the patient’s initial complaints in order of treatment priority with the first one being the one you primarily treated.
This is what the patient tells you about the chief complaint. Include the patient’s history and if important, the past history. Note how the condition began, including the onset, symptoms, frequency, intensity and duration. What makes the chief complaint better or worse? Describe the quality or description of the pain if there is pain. Does the pain move, travel or radiate? If so describe from where to where and how often it does this and duration of it. Is there a difference in the condition with change in location? For example: work vs. home vs. athletic field, outside vs. inside, in the car, etc. Does the condition change with the time of day?
Then describe the most recent or last visits subjective complaints. Compare the most current subjective in each area to the first. What you are hopefully seeing is an improvement from the first visit or the last re-evaluation until now.
Note: If there is important system review history or past medical history like prior motor vehicle accidents, surgeries, hospitalizations, etc. that may be pertinent, include it in this section also.
To remember the components of a subjective history (H) for the chief complaint (CC), use the pneumonic OPQRST which stands for:
Onset/Occurrence Palliative/Provocative Quality/Quantity Radiation/Region Site Time of Day
Copyright 2010 by Dr. Kevin McNamee, DC, LAc. Please do not duplicate in any manner.