Medicare Chiropractic Initial Visit Note (CMT)

Patient: [Patient name], [DOB]

Date of Service: [Date of service]

Provider: [Provider name, credentials]

Location: [Clinic location]

Visit Type: Initial Visit (Medicare CMT)

Chief Complaint

[Primary complaint as symptom + anatomical region, duration, precipitating event if applicable, and primary functional impact; patient quotation permissible] (Write as 1–2 sentences. Specify symptom and region; avoid generic terms like "pain.")

History of Present Illness

[Complaint 1 detailed HPI] (Include: mechanism of onset or trauma vs. insidious onset; symptom quality/character; onset date and total duration; intensity with numeric scale if available; frequency and timing pattern; precise location with radiation/referral pattern; aggravating and relieving factors; prior treatments and response; functional impact on ADLs, work, and/or recreation. Details must support causal relationship to documented subluxation level(s).)

[Complaint 2 detailed HPI] (Include only if multiple complaints. Follow same structure in separate paragraph.)

Past History

• Pertinent Medical/Surgical History: [Relevant conditions and surgeries] (Omit non-relevant items; if asked but unknown, document "not reported.")
• Prior Injuries: [Relevant prior injuries or episodes with relevance to current presentation]
• Medications: [Current medications / none reported]
• Allergies: [Allergies / NKDA]
• Social/Occupational Factors: [Occupation, activity level, ergonomics, relevant hobbies or sports]
• Prior Imaging: [Type, date, and relevance / none reported] (Note source and availability if applicable.)
• Prior Conservative Care: [Chiropractic, PT, home care, injections, other treatments with response] (Include only if relevant.)

Red Flag Screening

• Constitutional symptoms: [Negative / Positive with details and action taken]
• Progressive neurologic deficits: [Negative / Positive with details and action taken]
• Bowel/bladder changes or saddle anesthesia: [Negative / Positive with details and action taken]
• Fracture/malignancy risk factors: [Negative / Positive with details and action taken]
• Cervical vascular risk: [Negative / Positive with details and action taken / Not applicable] (Include for cervical complaints.)

Physical Examination

(Document clinician-observed and measured findings only. Do not document tests not performed; if an expected test is omitted due to contraindication, state the reason.)

• General Observations: [Gait, posture, guarded movements] (Include only if clinically relevant.)
• Inspection: [Postural findings, deformity, edema, discoloration, scars focused to involved regions]
• Palpation: [Static and motion palpation findings by region/level; tenderness, tone, trigger points, joint end-feel]
• Range of Motion: [Quantified ROM by region with pain provocation and quality of motion; specify active vs. passive]
• Neurologic: [Sensation by dermatome, strength by myotome with grades, DTRs, upper motor neuron signs if indicated]
• Orthopedic Tests: [Named tests with positive/negative results and side/region] (List only tests performed.)

Subluxation Demonstration

(Complete one pathway. Do not infer findings from patient complaints; document direct observations or imaging.)

Imaging Pathway

(Complete if imaging used to demonstrate subluxation.)

• Imaging Type and Region: [Modality and anatomical region(s)]
• Source and Date: [In-house / External], [Date performed] (If external, note that report/images are on file.)
• Findings: [Statement that imaging demonstrates spinal subluxation at specified level(s) with brief supporting descriptors]
• Identified Level(s): [Precise vertebral level(s)]

P.A.R.T. Physical Examination Pathway

(Complete if imaging not used. Document findings by involved spinal level. At least 2 of 4 elements required; at least one must be A or R. Repeat block for each involved level. Omit elements not present.)

• Level: [Spinal level]
• P (Pain/Tenderness): [Location, quality, and method of assessment]
• A (Asymmetry/Misalignment): [Segmental malposition/asymmetry and method used]
• R (Range of Motion Abnormality): [Restriction or hypermobility, planes involved, and method]
• T (Tissue Tone/Texture Abnormality): [Hypertonicity, spasm, edema, or texture change]

Summary: [Confirm which P.A.R.T. criteria are met at which level(s)] (Example: "Subluxation demonstrated at C5-C6 via A + R findings.")

Assessment

• Primary Diagnosis: [Spinal subluxation or segmental dysfunction with precise level(s)]
• Secondary Diagnosis(es):
  • [Neuromusculoskeletal diagnosis with anatomical correlation to subluxation level(s)]
  • [Additional diagnosis if applicable]

Symptom-to-Level Linkage: [1–2 sentences explaining how symptoms correlate with documented subluxation level(s) and how CMT is expected to address the dysfunction]

Clinical Status: [Acute / Chronic / Acute exacerbation of chronic], onset [date], [brief prognosis statement]

Plan of Care

• Date of Initial Treatment: [Date if CMT performed today / To be determined at first manipulation]
• Treatment Frequency and Duration: [Specific frequency and time-limited or visit-limited endpoint]
• Functional Goals: (Include at least 2–3 measurable goals. Do not omit; if goals cannot be established today, document reason and plan to establish at follow-up.)
  • [Functional goal 1 with target metric and timeframe]
  • [Functional goal 2 with target metric and timeframe]
  • [Functional goal 3 with target metric and timeframe]
• Objective Measures to Track Progress: [Pain scale, ROM measurements, functional tests, disability indices]
• Planned Interventions: [Anticipated CMT regions and technique approach; home exercise/self-management recommendations]
• Referral or Co-management: [Referral target and reason / None indicated]
• Patient Education and Consent: [Risks, benefits, and alternatives discussed; consent obtained]

Treatment Performed Today

(Include only if CMT performed at initial visit. Omit entire section if no manipulation performed.)

• Regions Manipulated: [Cervical / Thoracic / Lumbar / Pelvic / Sacral]
• Segmental Levels Adjusted: [Specific levels]
• Technique and Approach: [Technique name(s), patient position, contacts]
• Patient Tolerance and Immediate Response: [Change in pain/ROM/function; adverse symptoms or none]
• Post-Treatment Instructions: [Activity guidance, home care, warning signs requiring urgent evaluation]

Active/Corrective Care Statement

[Statement confirming active/corrective care with expectation of measurable functional improvement] (Include only if documentation supports measurable improvement expectations; omit for maintenance care.)

Signature

Provider Signature: [Signature]

Printed Name and Credentials: [Provider name, credentials]

Date/Time Signed: [Date and time]

(Provider must authenticate entry if prepared by scribe or AI drafting tool.)