Chiropractic Re-Examination/Progress Evaluation Note

Patient Name:

DOB:

Date of Service:

Rendering Clinician:

Note Type: Re-Examination / Progress Evaluation

Start of Care Date: [Start of care date]

Last Re-Exam Date: [Last re-exam date]

Visit Number: [Visit number]

Reason for Re-Examination

[Primary reason: [scheduled progress evaluation / exacerbation or new complaint / plateau or lack of expected progress / authorization continuation / pre-discharge evaluation]] [Significant changes since last evaluation if applicable] (1-2 sentences stating the clinical trigger for today's re-exam.)

Subjective

Chief Complaint & Current Status: [Chief complaint] [Status: [improved / unchanged / worse]] [Brief qualifier] (Focus on changes since last evaluation.)

Symptom Characterization: [Location(s)] [Severity (pain 0-10)] [Frequency/pattern] [Aggravating/relieving factors] (Include only changed or newly relevant elements for treated areas.)

Functional Status: [Specific ADL/work/sport limitations] [Tolerance metrics (sitting/standing/walking duration, lift tolerance)] (Include only if explicitly mentioned.)

Outcome Measures: [Instrument name] [Baseline date/score] → [Current date/score] (Label prior values as baseline; use multiple lines if more than one instrument.)

Interval History: [Visits since last re-exam] [Patient-perceived response pattern] [Home program adherence] [Adverse events or tolerance issues if present]

Interval Red Flags/Neurologic Symptoms: [New concerning symptoms] (Omit entirely if unchanged.)

Objective

• General Observation: [Posture] [Guarding] [Gait] (Brief.)
• Problem Area(s): (Repeat for each region being treated.)
  • Palpation: [Specific structures/levels and findings (tone, tenderness, trigger points, edema, joint restriction)]
  • Range of Motion: [Motion type/plane] [Numeric values with units and side] [End-feel/pain]
  • Orthopedic/Provocative Tests: [Test name and side] [Result: [positive / negative]] [Reproduced symptoms] (Only tests performed.)
  • Neurologic Screen: [Myotomes] [Dermatomes] [Reflexes] [Neural tension tests] (Include only if indicated.)
• Subluxation Documentation: [Spinal level(s)] [Method: [imaging / PART criteria]] [PART elements satisfied with findings] [Link to symptoms/function] (Include when required for billing.)
• Objective Outcome Measures: [Pain by location and scale] [Disability score] [ROM metrics] (Show baseline → current trend.)
• Tests Not Performed: [Expected test(s) not performed and reason] (Include only if applicable.)

Assessment

Progress Summary: [Overall trajectory: [improving / plateau / worsening]] [Evidence-based justification referencing objective findings]

Diagnoses:

• [Primary diagnosis (ICD-10 if supported)]
• [Secondary/associated diagnoses as applicable]

Medical Necessity Determination: [[Continue active/corrective care with expectation of measurable improvement] / [Transition to discharge—goals met or maximal benefit reached] / [Transition to supportive/maintenance care]] [Rationale] [Prognosis] (Include barriers to progress or need for escalation/referral if applicable.)

Plan

• Treatment Plan: [Manipulation approach/technique] [Targeted regions/segments] [Adjunctive procedures] [Home program updates] (State "Plan unchanged" if no modifications.)
• Frequency & Duration: [e.g., 2x/week for 4 weeks] [Rationale if frequency not decreasing]
• Goals:
  • [Goal 1: metric, target value, timeframe, functional linkage]
  • [Goal 2: metric, target value, timeframe, functional linkage]
• Next Reassessment: [Date or trigger] [Discharge criteria]
• Referrals/Coordination: [Specialist referral, work status, or interdisciplinary communication] (Include only if applicable.)
• Today's Encounter: [[No treatment performed today; re-exam only] / [Treatment rendered as below]]
  • Procedures Performed: [Procedure names/codes] [Parameters]
  • Segments Addressed: [Specific spinal levels and/or extremity joints]
  • Response/Tolerance: [Immediate post-treatment response]
  • Post-Treatment Instructions: [Activity modifications, self-care, precautions]

Clinician Signature/Credentials/Date: