Chiropractic Spinal Manipulative Treatment Procedure Note

Date of Service: [Date of service]

Patient: [Patient name and identifier]

Provider: [Provider name, credentials]

Visit Type: [Initial visit in episode / Subsequent visit / Re-exam day / Exacerbation day]

Indication / Medical Necessity

[Chief symptom(s) prompting treatment, including location, severity, frequency, and aggravating/relieving factors] [Functional impact on daily activities] [Working diagnosis linked to treated region(s)/segment(s)] [Statement connecting today's symptoms and objective findings to the specific spinal segments addressed] (Write as a concise narrative paragraph clearly justifying why SMT is warranted today.)

Interval History

[Change since last visit: improved / worsened / unchanged, with specific metric or percent change if available] [Current pain scale if used] [Red flag symptom screen: new progressive weakness / bowel or bladder changes / saddle anesthesia / unexplained fever / major trauma] [If exacerbation or re-injury: mechanism and date] (Include for subsequent/re-exam/exacerbation visits only; omit entirely on initial visits when a separate initial evaluation exists.)

Pre-Treatment Objective Findings

(Document specific findings that guided segment selection today. Focus only on regions/segments treated.)

• [Region/Segment(s) targeted]: [Pain/tenderness location and palpatory findings] [Asymmetry/misalignment findings] [Range of motion abnormality: plane, method, values if measured] [Tissue tone/texture changes] [Ortho/neuro screening results if radicular pain or neurologic deficit suspected] (Repeat for each region/segment considered for SMT.)

Safety Review

Attestation: [No contraindications or precautions identified today / Precaution present—SMT modified / Contraindication present—SMT deferred]

[If precaution or contraindication present: specific factor(s) identified and exact modification(s), deferral(s), or referral(s) made; if technique modified, specify mitigation and where applied] (Do not leave blank; explicit attestation required.)

Consent

Consent type: [Verbal / Written]

[Discussion included: nature of SMT and anticipated benefits; common side effects; material risks including cervical SMT risks when applicable; alternatives; option to decline] [For subsequent visits: ongoing consent confirmed today; if clinical situation changed, document new risk discussion]

Procedure Details

(Provide segment-level specificity for each treated area. Region-only documentation is insufficient.)

• Region: [Cervical / Thoracic / Lumbar / Sacral / Pelvic-SI]
  • Segments Treated: [Exact levels and side(s), e.g., C5-C6 left, T4-T6, L4-L5 bilateral, Right SI]
  • Technique: [Diversified HVLA / Gonstead / Drop table / Instrument-assisted / Flexion-distraction / Mobilization] [Patient position] [Force characterization] [Modifications due to precautions if applicable]
  • Findings Supporting Treatment: [Brief reference to specific objective findings from today justifying these segment(s)]
  • Immediate Response: [Patient tolerance; immediate change in pain and/or ROM if assessed]

(Repeat for each region treated. If SMT was planned but not performed at any region, document "SMT deferred" with reason and alternative plan. Do not infer segments from regions; if segment information is missing, use placeholder text indicating completion needed.)

Post-Procedure Assessment

Tolerance: [No adverse effects / Transient soreness expected / Adverse event occurred]

[Post-treatment pain score and comparison to pre-treatment if assessed] [Adverse event attestation: "No adverse events noted during or after SMT" or detailed description including onset, symptoms, exam findings, actions taken, and disposition]

Instructions & Plan

• Home care: [Ice/heat, activity modification, exercises as provided; or "No new instructions"]
• What to expect: [Expected post-treatment effects and what to do if they occur]
• Return precautions: [Red flags to watch for, especially after cervical procedures; instructions to seek care if present]
• Follow-up: [Recommended timing and anticipated focus for next visit]

Signature

Provider Signature: [Electronic/handwritten signature]

Date/Time Signed: [Date and time]