Manual Therapy/Physical Medicine Treatment Note (Naturopathic Medicine)

Date of Service: [Date]

Patient: [Patient full name and identifier]

Clinician: [Clinician name, credentials]

Visit Type: [treatment / follow-up / acute flare / maintenance]

Visit Number: [Visit number within episode, e.g., "Visit 4 of 8"]

Subjective

[Reason for today's visit and primary region(s) targeted; patient-reported change since last visit; current pain location, severity, and pattern; functional limitations; response to prior treatment and home program adherence; any new symptoms or red flags] (If interval history was not obtained, explicitly state the reason.)

Objective (Pre-Treatment)

[Pertinent findings for regions treated today: observation/posture, palpation findings, range of motion, joint mobility, neurologic screen if indicated, and relevant special tests] (Use brief statements; include only findings relevant to today's treatment. Label estimates clearly, e.g., "visual estimate." If no pre-treatment exam was performed, state the reason.)

Treatment

Regions Treated: [List regions with laterality and specific segments, e.g., "R cervical C4–C6; bilateral upper thoracic"]

Manual Therapy: [Technique name — target tissue/segment — grade/parameters, duration, repetitions] (List each technique performed with technique-level specificity.)

Other Modalities: [Modality name — region — key parameters and duration] (Include only if performed.)

Consent & Safety: [obtained / not obtained] (Note contraindication screening performed. If consent not obtained, state why and whether treatment was deferred.)

Time: [Timed-code minutes] | [Total treatment time] (Required for time-based billing.)

Response

Tolerance: [tolerated well / limited by pain / required modifications] (Note any adverse events or unexpected reactions and actions taken.)

Post-Treatment Reassessment: [Key outcome measures compared pre vs. post, e.g., pain score change, ROM improvement] (Do not imply improvement without documented findings. If reassessment was not performed, state the reason.)

Plan

Home Program: [Exercises or self-care instructions with dosage] (If not assigned, state so.)

Modifications & Precautions: [Activity guidance and return precautions]

Follow-up: [Next visit timing and intended focus; any referrals or plan changes with rationale]

(Omit items not applicable. Required billing elements—date, interventions, time, signature—must be documented before signing.)

Signature: [Clinician signature with credentials, date/time]

Contributors: [Assistants, supervising clinicians, AI transcription] (Include only if applicable.)