Clinical EMR

Chief Concern / Reason for Visit

Chief Complaint (Free Text)

SUBJECTIVE (Patient Report)

Pain Scale (0-10)

Functional Limitation

Change Since Last Visit

Aggravating Factors

Relieving Factors

New Trauma?

No new trauma Yes, new trauma

Trauma Details

Additional Symptoms / Notes

OBJECTIVE (Exam Findings)

Blood Pressure

Heart Rate

Temperature

Weight (lbs)

Posture / Observation

Guarded Antalgic Normal Kyphotic Lordotic Scoliotic

Range of Motion Findings

Orthopedic / Neurological Tests

Palpation Findings

Other Observations

ASSESSMENT (Clinical Impression)

Diagnoses (ICD-10)

No diagnoses selected

Clinical Impression

Medical Necessity Statement

Response to Treatment (if follow-up)

PLAN (Treatment & Follow-up)

Treatment Summary

Follow-up Frequency

Next Re-Eval Date

Patient Education Given

Home Care Instructions

Patient Tolerance

-

Problem List

Care Plan

Visit History

Chief Concern / Reason for Visit

SUBJECTIVE (Patient Report)

OBJECTIVE (Exam Findings)

ASSESSMENT (Clinical Impression)

PLAN (Treatment & Follow-up)

Service Modules

Audit Checklist

Billing Codes

Diagnosis Pointers

Time Tracking

Chiropractic Manipulation (CMT)

Cervical

Thoracic

Lumbar

Sacral/Pelvic

IV Therapy

IM/SubQ Injection

Clinical EMR

-

Problem List

Care Plan

Visit History

Chief Concern / Reason for Visit

SUBJECTIVE (Patient Report)

OBJECTIVE (Exam Findings)

ASSESSMENT (Clinical Impression)

PLAN (Treatment & Follow-up)

Service Modules

Audit Checklist

Billing Codes

Diagnosis Pointers

Time Tracking

Select Patient

Chiropractic Manipulation (CMT)

Cervical

Thoracic

Lumbar

Sacral/Pelvic

IV Therapy

IM/SubQ Injection