Osteopathic Structural Exam Note (TART/Somatic Dysfunction)

Documents osteopathic structural examination findings using the TART framework (Tissue texture, Asymmetry, Restriction, Tenderness) organized by body region. Supports somatic dysfunction diagnosis and OMT billing by link…

Document Type

clinical note / Progress Note

Specialties

Osteopathic Doctor

Created by Augustun

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Osteopathic Structural Exam (TART)

Date: [encounter date]

Provider: [name and credentials]

Reason for Exam: [evaluation for somatic dysfunction contributing to chief complaint / pre-OMT assessment / follow-up structural exam / other: specify]

Exam Scope: [screening / focused / comprehensive] in [standing / seated / supine / prone]

Exam Approach

[Brief statement of method used: observation, palpation, static and dynamic motion testing] (Note any limitations affecting the exam such as pain-limited ROM, positioning restrictions, or time constraints. If any TART component was not assessed, state which and why.)

Regional Findings

(For each region examined: if somatic dysfunction is present, document TART findings and segmental/positional diagnosis when applicable. If no dysfunction found, state "Examined—TART negative." Omit regions not examined, or note "Not examined" with brief reason if clinically relevant. Do not auto-populate normal findings for regions not actually examined.)

Head: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [tissue texture]; A: [asymmetry]; R: [restriction: plane, barrier, quality]; Tnd: [tenderness]. [Segmental/positional diagnosis if applicable]
Cervical: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Thoracic: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Ribs: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Lumbar: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Sacrum: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Pelvis/Innominate: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Upper Extremity (R/L): [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Lower Extremity (R/L): [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]
Abdomen/Viscera: [Examined—TART negative / Not examined / Somatic dysfunction present:]
T: [..]; A: [..]; R: [..]; Tnd: [..]. [Segmental/positional diagnosis if applicable]

Somatic Dysfunction Summary

(List only regions with diagnosed somatic dysfunction, most clinically significant first. Include only regions with supporting TART documentation above.)

[Region]: [Key TART features] — [Segmental/positional diagnosis if applicable]

Total regions with somatic dysfunction: [count]

Interval change: [improved / unchanged / worse] (Include only for follow-up exams with comparable reassessment.)

Post-intervention reassessment: [changes in tenderness, ROM, tissue texture] (Include only if reassessment performed this encounter.)

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