OMT Procedure Note

Date/Time: [date and time]   Location: [clinic/location]   Clinician: [name, credentials]

Procedure Performed

Osteopathic Manipulative Treatment (OMT) was performed. [Planned OMT follow-up visit / OMT performed during a problem-focused visit / visit type not documented]

Indication

[Presenting symptom or functional complaint] linked to somatic dysfunction in [targeted region(s)/segment(s)]. Clinical intent: [reduce pain / improve range of motion / improve function / decrease tissue hypertonicity / other]. [Ongoing care rationale if applicable: progress / flare / persistent limitation]. (If indication details are unavailable, state "Indication not documented.")

Consent

Risks, benefits, and alternatives were discussed; the patient consented to proceed. [verbal / written / consent type not documented]

Pre-Treatment Structural Exam

(Document somatic dysfunction findings for each body region to be treated. Use standard 10-region names: Head, Cervical, Thoracic, Lumbar, Sacral, Pelvic, Rib cage, Upper extremity, Lower extremity, Abdomen/viscera. Include segmental/landmark description when feasible and at least one TART element. If a TART element was not assessed, state "not assessed." Do not list a region unless dysfunction findings support it.)

• [Region]: [Segment/landmark if applicable] — [TART findings: tenderness location, asymmetry description, restriction of motion, tissue texture abnormality; state "not assessed" for any element not evaluated]
• [Region]: [Segment/landmark if applicable] — [TART findings]
• (Add additional regions as indicated.)

OMT Procedure Details

(Group techniques by region. If compensatory regions were treated beyond the primary symptomatic area, briefly state rationale such as biomechanical linkage. If technique for any region is unknown, state "Technique not documented.")

• [Region]: [Technique(s): soft tissue / myofascial release / muscle energy / counterstrain / HVLA / articulatory / cranial / lymphatic / balanced ligamentous / other]. [Rationale if compensatory region]
• [Region]: [Technique(s)]. [Rationale if compensatory region]
• (Add additional regions as treated.)

Total regions treated: [number]

Immediate Response

(Document tolerance and at least one pre-to-post comparison. If no measurable improvement, state "No immediate change.")

• Tolerance: [tolerated well / limited by pain or guarding / other]
• Pre/Post comparison: [Pain: pre __/10 → post __/10] [ROM: pre description → post description] [Palpatory/TART change: description] (Include at least one measurable comparison.)
• Overall immediate effect: [improved / no immediate change / worsened]
• Adverse events: [No adverse events / specify]

Post-OMT Instructions and Follow-Up

• Post-procedure expectations: [possible transient soreness / hydration guidance / activity modification / other]
• Home program: [heat/ice / targeted stretches / breathing exercises / ergonomics / none provided]
• Return precautions: [worsening pain / new neurologic symptoms / region-specific warnings]
• Follow-up: [interval] — [OMT follow-up / reassessment / not documented]