Manual Therapy/Manipulation Procedure Note

Date of Service: [Date and time if applicable / Not documented (completion required)]

Setting/Location: [Outpatient clinic / Inpatient / Home / Athletic training room / Other: specify]

Clinician: [Name, credentials / Not documented (completion required)]

Patient Position: [supine / prone / sidelying / seated / standing / varies by technique]

Related Evaluation/POC Date: [Date linking to evaluation/POC]

Procedure and Indication

[Procedure performed and primary indication linked to functional limitation or symptom] (1–3 sentences; clearly link intervention to functional limitation. If indication unclear from dictation, state: "Indication not documented—unable to link to functional limitation.")

Safety Screen and Precautions

• Precautions/Contraindications Screen: [No contraindications identified / Precautions present with modifications / Contraindication identified—procedure deferred / Not documented (completion required)]
• Relevant Comorbidities/Risk Factors: [Factors affecting technique selection and modifications made / None relevant] (e.g., bone fragility, anticoagulation, inflammatory arthropathy, neurologic changes)
• Cervical Vascular Risk Screening: (Include when cervical treatment performed)
  • [History features suggesting vascular pathology: documented / denied / not documented]
  • [Neurovascular symptoms: documented / denied / not documented]
  • [Clinical reasoning: proceed as planned / modify technique / defer and refer / Cervical vascular screening not documented (completion required)]
• Red Flag Screening: (Include when clinically indicated: new/worsening symptoms, trauma, systemic signs, progressive neuro findings) [Performed—negative / Performed—positive with findings and actions / Not clinically indicated today]

Consent

[Verbal / Written / Both / Consent not documented] consent obtained after discussion of risks, benefits, alternatives, and opportunity for questions. [Patient agreed to proceed / Patient declined; alternative offered: describe]. (For higher-risk scenarios such as thrust techniques or cervical interventions, briefly note salient risks discussed.)

Pre-Treatment Status

• Patient-Reported: [Primary symptom(s) and location] [Pain: x/10 / Not assessed] [Functional limitation] [Change since last visit: better / same / worse]
• Objective Findings: [Key ROM / Palpation findings / Segmental mobility / Neuro screen if indicated] (Targeted to treated regions; include at least one baseline metric expected to change)

Procedure Details

(Document each intervention performed. Use standardized region names with laterality/segments when relevant.)

• Intervention 1
  • Region treated: [cervical / thoracic / lumbar / sacral-SI / shoulder / elbow / wrist-hand / hip / knee / ankle-foot; laterality and segment(s)]
  • Technique: [soft tissue mobilization / joint mobilization non-thrust Grade I-IV / manipulation thrust / muscle energy / manual traction / myofascial release / neural mobilization / other: specify]
  • Specifics: [Method description, parameters such as duration, sets, direction, segment(s) as relevant]
  • Tolerance: [tolerated well / limited by pain / guarding / required modification / tolerance not documented]
  • Complications: [None / describe event and immediate response]
• Intervention 2 (Repeat structure for additional regions/techniques)

Post-Treatment Findings

• Patient-reported change: [Pain change x/10 → y/10 / Symptom quality or distribution / No immediate change]
• Clinician-observed change: [ROM / Segmental mobility / Functional task / Neuro status if relevant / No immediate change]

Assessment

(Include when findings meaningfully changed or management updated; omit if redundant with other sections)

• [Response supports or prompts reconsideration of working diagnosis]
• [Rationale for continued manual therapy vs progression]
• [Modifications planned based on today's response]

Aftercare and Home Program

• Post-treatment precautions: [Expected soreness vs warning signs warranting evaluation]
• Home program: [Exercise(s) or self-mobilization with dose, activity modifications]
• Education: [Topics covered] [Patient understanding: teach-back demonstrated / verbalized understanding / barriers noted]

Plan

• Next visit: [Timing or recommended frequency]
• Planned focus: [Next-step techniques or regions]
• Reassessment criteria: [Criteria for escalation or referral]

Billing and Time

• Interventions Billed: [List each billed intervention/modality / Not documented (completion required)]
• Timed Code Treatment Minutes: [Total minutes of timed services / Not documented (completion required)]
• Total Treatment Time: [Combined skilled treatment time in minutes / Not documented (completion required)]

Signature

Clinician Signature: [Name, credentials / Not documented (completion required)]

Date/Time Signed: [Date and time / Not documented (completion required)]

Authentication: [Scribed and reviewed by clinician / AI-assisted draft reviewed and authenticated by clinician] (Include if applicable)