OMT Follow-Up Visit Note (Planned Treatment, No Separate E/M)

Date/Time: [Date and time of encounter]

Patient: [Patient name and identifier]

Clinician: [Clinician name and credentials]

Visit Type: Planned OMT follow-up, no separate E/M

Episode/Target Complaint: [Target complaint for OMT treatment series]

(Use this template only for planned OMT follow-up within an existing OMT episode. If a new complaint, substantial interval change, medication management, new diagnostic workup, or material treatment plan revision occurred, document with a separate E/M note instead.)

Interval Subjective

[Interval trajectory since last OMT, functional impact, patient-reported response to prior session including benefit duration and any soreness or adverse effects, red-flag screen if clinically indicated, pain score if mentioned, home program adherence if mentioned] (Combine into 1–3 sentences. Include only items explicitly stated. Do not include a full review of systems.)

Osteopathic Structural Exam

[Focused safety exam findings] (Include only if performed, such as brief neuro screen for radicular symptoms. Include vitals only if clinically relevant to treatment safety.)

• [Region]: [TART findings: tenderness, asymmetry, restriction, tissue texture]; [Segmental diagnosis if applicable]
• [Region]: [TART findings]; [Segmental diagnosis if applicable]
• [Region examined but not treated]: [Reason: resolved / contraindication / patient preference]

(Include only regions evaluated today. Do not auto-populate normal findings for regions not examined.)

Assessment

• [Somatic dysfunction diagnosis by region treated]
• [Associated clinical condition and functional limitation] (Optional)
• [Rationale for treating compensatory regions] (Include only if applicable)

[Patient trajectory within current OMT episode: improving / plateaued / worsening]

OMT Procedure

Indication: [Link to diagnosed somatic dysfunction, symptoms, and functional goals; note planned follow-up in ongoing series]

Consent: [Risks, benefits, and alternatives discussed; verbal consent obtained / prior consent reviewed and reaffirmed] (Always document)

Safety Screen: [Pertinent negatives or precautions for techniques used; relevant risk factors such as osteoporosis, anticoagulation, pregnancy, recent trauma, neurologic deficit; higher-risk technique considered but deferred if applicable] (Always document)

Treatment:

• [Region]: [Technique(s)]; [Patient position]; [Segmental targets if relevant]
• [Region]: [Technique(s)]; [Patient position]; [Segmental targets if relevant]

Response: [Patient tolerance]; [Adverse events if any]; [Immediate patient-reported or clinician-observed response]; [Post-treatment reassessment findings if performed] (Do not imply improvement without explicit report. State "response not assessed" if not evaluated.)

Plan

• Home program: [Stretches / exercises / ergonomics / activity modifications with frequency and duration] (Confirm continuation if unchanged, or detail updates)
• Return precautions: [Region-appropriate red flags that should prompt urgent evaluation]
• [Next visit timeframe and goals] (Include only if discussed)

Signature: [Clinician name, credentials, date/time]

(This focused OMT template intentionally excludes full HPI, ROS, and multi-system physical exam to avoid documentation that could be misread as a separately billable E/M service. Omit fields entirely when information was not obtained, except Consent and Safety Screen which should always be documented. Do not infer symptom improvement or absence of red flags without explicit documentation.)