Inpatient Osteopathic Consult Note (OMT)

Date/Time of Service: [Date and time]
Patient: [Full name], [MRN], [DOB], [Age], [Sex]
Location: [Hospital], [Unit/Room], [Bed] [; ICU / ED / observation] (Include designation only if applicable)
Requesting Service/Clinician: [Service and clinician name/role]
Consulting Clinician: [Name, credentials, service]
Source of History: [patient / family / chart / RN / other] (Note limitations such as intubation, delirium, language barrier, or sedation if present)

Consult Request

[Reason for consult in one line] (Address: Is somatic dysfunction present contributing to symptoms? Is OMT appropriate and safe today?)

[Scope statement] (Note that OMT is adjunctive; primary team retains responsibility for medical/surgical management.)

Clinical Context

[One-liner: admitting diagnosis, key comorbidities, hospital day, relevant devices/lines]

• [Pertinent hospital course events related to consult indication]
• [Anticoagulation status; recent INR/anti-Xa/platelets if relevant to OMT safety]
• [Lines/tubes/drains and access sites with side/level if relevant to positioning]
• [Mobility or spine precautions] (e.g., weight bearing status, cervical collar, TLSO, log-roll only)
• [Isolation or positioning limitations] (e.g., prone intolerance, oxygen delivery requirements, hemodynamic monitoring)

Subjective

Chief Concern: [Patient concern in own words] (Avoid generic phrasing like "for OMT")

History of Present Illness: [Onset, location, duration, character, severity with pain scale if used, aggravating/relieving factors, functional impact on ambulation/sleep/pulmonary toilet/PT participation, red flag screening for neurologic deficits and bowel/bladder changes] (Include prior OMT response and patient goals if known. If history is limited, state reason and source of collateral information.)

Pertinent Past History: [Conditions affecting OMT safety or technique selection] (Include only if relevant: osteoporosis, malignancy with bone metastases, connective tissue disorder, spinal instability, recent surgery, chronic anticoagulation)

Objective

• [Pertinent vitals: pain score, respiratory rate, oxygen requirement, hemodynamics if relevant]
• [General appearance and respiratory effort]
• [Mental status and ability to cooperate with OMT]
• [Region-specific physical exam relevant to complaint: rib excursion, chest wall/abdominal tenderness, neuro screening, edema, skin changes]
• [Contraindication screening: fracture, instability, active infection over treatment site, focal neurologic deficit, open wounds, surgical constraints]
• [Pertinent imaging/labs reviewed with dates]

(If patient is unstable, explicitly state that OMT is deferred with rationale documented in Plan.)

Osteopathic Structural Exam

Exam Approach: [Focused / comprehensive] osteopathic exam performed in [seated / supine / prone / lateral decubitus / standing] position(s). [Limitations due to lines/tubes/precautions]

(Document only regions examined. For each dysfunctional region, include at least one TART element with segment/landmark specificity. Include respiratory phase qualifiers for ribs/diaphragm when relevant.)

• Head: [TART findings with landmarks]
• Cervical: [Segments with TART findings]
• Thoracic: [Segments with TART findings, paraspinal tone]
• Lumbar: [Segments with TART findings]
• Sacrum: [Diagnosis pattern with TART elements]
• Pelvis: [Innominate/iliosacral findings with TART]
• Ribs: [Rib levels, TART, inspiratory/expiratory restriction]
• Upper Extremity: [Joint TART and ROM findings]
• Lower Extremity: [Joint TART and ROM findings]
• Abdomen/Viscera/Diaphragm: [Myofascial tension, diaphragmatic motion, Chapman's points if relevant]

Assessment

[Medical necessity statement linking symptoms/functional limitations to somatic dysfunction findings and explaining why OMT is appropriate as adjunctive care today]

• Medical Diagnoses: [Active problems driving the consult]
• Osteopathic Diagnoses: [Somatic dysfunction by region with segment specificity]
• Differential: [Differential diagnosis] (Include only if uncertainty affects management)

Plan

• OMT Today: [Yes / No] (If no, state reason: instability, contraindication, patient refusal, pending imaging)
• Target Regions and Rationale: [Regions planned for treatment and linkage to symptoms/function]
• Technique Strategy: [Indirect / direct / balanced] emphasis with [gentle / moderate] force dosing; [anticipated techniques: myofascial release, BLT, muscle energy, FPR, counterstrain, articulatory, lymphatic]
• Anticipated Goals: [Pain reduction, improved rib excursion, ease of breathing, improved mobility, enhanced bowel motility, PT/OT participation, sleep quality]
• Recommendations to Primary Team: [Analgesia optimization, mobilization/PT/OT, nursing positioning, pulmonary hygiene, bowel regimen, other recommendations]
• Red Flags Prompting Re-contact: [New/worsening neurologic deficits, sudden severe pain, fever/infection signs, hemodynamic or respiratory instability]
• Communication: Recommendations communicated via [note / phone / secure chat] to [name/role]
• Follow-up: [Timing for re-evaluation or repeat OMT; criteria for earlier reassessment]

OMT Procedure Note

(Include only when OMT is performed. If deferred, state "OMT not performed this encounter" with rationale in Plan above.)

Consent: Risks, benefits, and alternatives discussed; [patient / surrogate] provided informed consent.

Contraindication Screening: [No fracture/instability at treatment sites; anticoagulation status reviewed; no active infection over treatment areas; no new focal neurologic deficits; patient able to cooperate; other relevant findings]

Treatment: (List each body region treated with position and techniques. Include only regions treated; note rationale if treating compensatory regions.)

• Head: [Position]; [Techniques]
• Cervical: [Position]; [Techniques]
• Thoracic: [Position]; [Techniques]
• Ribs: [Position]; [Techniques including respiratory/lymphatic focus]
• Lumbar: [Position]; [Techniques]
• Sacrum: [Position]; [Techniques]
• Pelvis: [Position]; [Techniques]
• Upper Extremity: [Position]; [Techniques]
• Lower Extremity: [Position]; [Techniques]
• Abdomen/Viscera/Diaphragm/Lymphatics: [Position]; [Techniques]

Response: [Patient tolerance; absence of adverse events; immediate pain score change; ROM/mobility improvement; rib excursion or breathing ease; post-treatment reassessment findings] (If treatment was limited or aborted, state reason.)

Post-Treatment Instructions: [Hydration as allowed; expected transient soreness; activity guidance; call nurse for dizziness; fall precautions; when to notify team]