Osteopathic Manipulative Treatment: Established Patient Example

Source: http://www.md-do.org/omm.htm

SOAP Note - Established Patient Example

S
Patient is here for re-evaluation. He states that the pain has decreased in his low back and that he can get around better. He states that he has no radiation of pain into his legs. He does state that he feels stiff and achy if he tries to do his normal daily activities. He is still taking aspirin with some relief.

O

Tenderness with palpation and stretch of the erector spinae muscles
Pain with extention and rotation left of L5
Pain along with right SI joint with sacral extension
No muscle spasms noted with active or passive range of motion
Negative neurological exam of lower extremities
A
1. Lumbosacral sprain/strain; improving 846.0

2. Somatic dysfunction - lumbar, sacral; improving 739.3 and 739.4

P
1. OMT (appropriate techniques used*), applied to the lumbar and sacral regions

2. Instructed on proper posture when lifting

3. Increase home activities gradually and to tolerance

4. Follow up if improvement does not continue



CODING FOR THIS CASE

Evaluation/management; established patient 99213-25

OMT two body regions; lumbar/sacral 98925

*See AOA Glossary of Osteopathic Terminology for appropriate techniques