ChiroExam AP part

Assessment:
Patient is of [select name="ASSHealth" value="Good|decent|average|poor"] health and is expected to have [select name="ASSProg" value="Good|decent|average|poor"] prognosis.
Factors that affect prognosis[checkbox name="ASSAffect" value="Pre-existing conditions(diabetes,etc|Sedentary lifestyle|compliance|availability of the patient|severity of condition|age"]

They patient has seen  [checkbox name="improvement" value="does not apply as it is 1st visit|30%|50%"] Improvement with the current plan 

Plan:

Chiropractic Manipulative therapy of the following levels [checkbox name="Fixations" value="C1|c2|C3|C4|C5|C6|C7|C8|T1|L1|L2|L3|L4|L5|S1"] was performed. The clinical reasoning being to improve range of motion and decrease pain.

Chiropractic Manipulative therapy of the following extremities [checkbox name="EXT" value="Shoulders|Hips|wrists|elbows"] was performed. The clinical reasoning being to improve range of motion and decrease pain

Modalities such as [checkbox name="modalities" value="Unsupervised ESTIM|Exercises|Massage|Mechanical traction of affected area"] were performed to decrease pain 

The patient is to come [select name="freq" value="1|2|3"] times a week for the next [select name="freq2" value="2|3|4|5|6"] weeks at which point a re-evaluation will be done to determine the next plan. 

The patient has a short term goal of : [select name="STG" value="decrease pain by 2 on VAS scale in 2 weeks|Increase ROM slightly in 2 weeks|decrease pain and increase rom slightly in 2 weeks"]

The patient has a long term goal of : [select name="LTG" value="decrease pain by 4-5 on VAS scale in 4-6 weeks|Increase ROM to almost pre injury levels in 4-6 weeks|decrease pain and increase rom completely in 4-6 weeks|return to pre injury levels|do ADLS without pain"]

Diagnosis Codes:
[checkbox name="DDX" value="M54.12 Cervical Radiculopathy||M54.16 Lumbar Radiculopathy| M54.2 Cervicalgia|M54.50 Lumbar Pain|M54.6 Thoracic pain| M62.830 muscle spasm of back|M25.511 Right shoulder pain|M25.512 Left Shoulder Pain|M25.551 Pain in right hip|M25.552 Pain in left hip|Other"] 
Other: [text name="otherddx" default=]

CPT Codes done in visit:
[checkbox name="CPTs" value="99203|98940|98943|97012|G0283|97014"]
Assessment:
Patient is of health and is expected to have prognosis.
Factors that affect prognosis

They patient has seen Improvement with the current plan

Plan:

Chiropractic Manipulative therapy of the following levels was performed. The clinical reasoning being to improve range of motion and decrease pain.

Chiropractic Manipulative therapy of the following extremities was performed. The clinical reasoning being to improve range of motion and decrease pain

Modalities such as were performed to decrease pain

The patient is to come times a week for the next weeks at which point a re-evaluation will be done to determine the next plan.

The patient has a short term goal of :

The patient has a long term goal of :

Diagnosis Codes:

Other:

CPT Codes done in visit:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.93, 14 form elements, 124 boilerplate words, 1 text boxes, 7 checkboxes, 6 drop downs, 57 total clicks
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