Chiropractic Soap notes V2.4

Subjective

Today , 
[date name="variable_1" default="03/01/2021"]
[text name="variable_2" default=""]
presents with a chief complaint of [text name="variable_3" default=""]
they state it began on [text name="variable_4" default=""] they state the pain is at [text name="variable_5" default=""] out of 10. 
They qualify the pain as [text name="variable_6" default=""]
They state that they have [text name="variable_7" default=""]this pain before or something similar to this type of pain.
They state that this pain [text name="variable_8" default=""] to trauma or surgery.The mechanism of injury is as follows: 
[text name="MOI" default=""] 
They state  
[checklist name="variable_1" value="numbness|tingling |radiation|none of the above"].
The radiation (if present) goes down 
[text name="variable_9" default=""].
They state that the pain gets [text name="variable_10" default=""] as the day progresses.
They state they have [text name="something" default=""] to add to these complaints

They state that they are feeling 
[checklist name="Better" value="better|the same|worse"] than last time they were in the office. 

They are 
[checklist name="satisfied" value="satisfied|unsatisfied"]with their current state and treatment plan
 
Objective

An examination of the [checkbox name="variable_2" value="Cervical Spine|Thoracic Spine|Lumbar Spine|Lower Extremity|Upper Extremity"]. Range of motion of the above was [checkbox name="variable_3" value="decreased|normal"] due to [text name="variable_11" default=""]. Deep tendon reflexes of the affected area had the following results 
[text name="variable_12" default=""], Muscle Tests of the affected area were as follows [text name="variable_13" default=""], Dermatomal examination was as follows [text name="variable_14" default=""]. Orthopedic examination was as follows [text name="variable_15" default=""]

Muscle and palpapation findings: [text name="variable_16" default=""]

Segments with hypomobility: [text name="variable_17" default=""]

Assessment:

Patient is of [text name="variable_18" default="t"] health and has a [text name="variable_19" default=""] prognosis. Factors that affect prognosis [text name="variable_20" default=""]. Patient has a diagnosis of 
[checklist name="diagnosis" value="M99.01 - Segmental and somatic dysfunction of cervical region|M99.02 - Segmental and somatic dysfunction of thoracic region|M99.03 - Segmental and somatic dysfunction of lumbar region|M79.12 - Myalgia of auxiliary muscles, head and neck|M79.18 - Myalgia, other site|M99.07 Segmental and somatic Dysfunction on Upper Extremity| M99.06 Segmental and somatic dysfunction of Lower extremity|Other(See next) "] 
[text name="variable_30" default=""]Informed consent was discussed.

Plan:
CMT of Segments in Objective section coupled with modalities as follows 
[checklist name="variable_24" value="Cupping |Supervised E-Stim 8mins |Ultrasound 5 mins|Muscle Scraping on affected region"]. Patient is to follow up within 
[text name="variable_22" default=""] days for the next [text name="variable_23" default=""] weeks in which time a re-examination will be done .

Neuromuscular retraining/Physical therapy exercises done: 
[checkbox name="variable_25" value="yes|no"]
Exercises done: 
[text name="variable_26" default=""]
Clinical reasoning for treatment:
Chiropractic manipulative therapy done to 
[checklist name="variable_27" value="decrease pain |increase range of motion|reduced inflammation"] and it is recommended to continue at the stipulated treatment plan in order to restore pre injury status within the time stipulated above. 
Modalities done to [checklist name="variable_28" value="decrease pain |increase range of motion|reduced inflammation"] and it is recommended to continue at the stipulated treatment plan in order to restore pre injury status within the time stipulated above. 
Physical therapy to done to both strengthen and stabilize affected muscles.

CPT Codes for visit:
[checklist name="CPTS" value="99203|98940|98941|98943|97032|97035|97112|97124"]