OMT & Auricular Acupuncture Procedure Note

Patient was assessed and determined by physician to be good candidate for trial of [checkbox name="OMT-BFA" value="Osteopathic Manipulative Treatment|Auricular Acupuncture"].[conditional field="OMT-BFA" condition="(OMT-BFA).is('Osteopathic Manipulative Treatment')"]

OSTEOPATHIC MANIPULATIVE TREATMENT

INDICATIONS/COUNSELING:
-Patient verbally consented and agreed to proceed with OMT
-Discussed the following risks & benefits of the procedure: making their MSK pain worse, making no difference to their pain, prolonged soreness after the procedure, and rare risk of vertebral artery dissection from cervical HVLA (if that particular modality used).
-Discussed alternatives to procedure which include: [checkbox value="continuing rest|continuing home stretches|continuing physical therapy|waiting to see if pain self-resolves"].

PHYSICAL EXAM (OSTEOPATHIC):
[checkbox memo="Cervical ICD10 M99.01" name="Cerv" value=""][/conditional][conditional field="Cerv" condition="(Cerv).is('')"]-Cervical: [select value="L|R|B/L"] paraspinal [select value="muscle spasm|tenderness to palpation"] and somatic dysfunction over segments- [checkbox value="L OA|R OA|C2|C3|C4|C5|C6|C7"]
[/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Osteopathic Manipulative Treatment')"][checkbox memo="Thoracic ICD10 M99.02" name="Thor" value=""][/conditional][conditional field="Thor" condition="(Thor).is('')"]-Thoracic: [select value="L|R|B/L"] paraspinal [select value="muscle spasm|tenderness to palpation"] and somatic dysfunction over vertebral segments- [checkbox value="T1|T2|T3|T4|T5|T6|T7|T8|T9|T10|T11|T12"]
[/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Osteopathic Manipulative Treatment')"][checkbox memo="Lumbar ICD10 M99.03" name="Lumb" value=""][/conditional][conditional field="Lumb" condition="(Lumb).is('')"]-Lumbar: [select value="L|R|B/L"] paraspinal [select value="muscle spasm|tenderness to palpation"] and somatic dysfunction over vertebral segments- [checkbox value="L1|L2|L3|L4|L5"]
[/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Osteopathic Manipulative Treatment')"][checkbox memo="Sacral ICD10 M99.04" name="Sacr" value=""][/conditional][conditional field="Sacr" condition="(Sacr).is('')"]-Sacral: [checkbox memo="Torsion" name="tors" value=""][/conditional][conditional field="tors" condition="(tors).is('')"][select value="forward|backward"] sacral torsion on [select value= "L|R"] axis, [/conditional][conditional field="Sacr" condition="(Sacr).is('')"][checkbox memo="spasm/tenderness" name="sacttp" value=""][/conditional][conditional field="sacttp" condition="(sacttp).is('')"] [select value="muscle spasm|tenderness to palpation"] of [select value="R|L|B/L"] sacral sulcus[/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Osteopathic Manipulative Treatment')"][checkbox memo="Pelvis/Inom ICD10 M99.05" name="Pelv" value=""][/conditional][conditional field="Pelv" condition="(Pelv).is('')"]
-Pelvis/Inominates: [checkbox memo="shear" name="shear" value=""][/conditional][conditional field="shear" condition="(shear).is('')"][select value="L|R"] [select value="superior|inferior"] inominate shear,[/conditional][conditional field="Pelv" condition="(Pelv).is('')"][checkbox memo="rotation" name="rot" value=""][/conditional][conditional field="rot" condition="(rot).is('')"] [select value="L|R"] [select value="anterior|posterior"] inominate rotation[/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Osteopathic Manipulative Treatment')"]

PROCEDURE
-Modalities performed: [checkbox value="HVLA|Muscle Energy|Still's Technique|Myofascial|Jones Strain-Counterstrain|Facilitated Positional Release|Articulatory|Balanced Ligamentous Tension"]
-Regions treated: [checkbox value="head|cervical|ribs|thoracic|lumbar|sacral|pelvic"]
[comment memo="CPT Codes for OMT-
-98925 - 1-2 regions treated
-98926 - 3-4 regions treated
-98927 - 5-6 regions treated
-98928 - 7-8 regions treated
-98929 - 9-10 regions treated"][/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Auricular Acupuncture')"]

AURICULAR ACUPUNCTURE

INDICATIONS/COUNSELING:
-Patient verbally consented and agreed to proceed with Auricular Acupuncture for the following reason(s): [checkbox value="MSK pain|headache|other-"] [text size="50"]
-Discussed risks & benefits of procedure which include but not limited to: making their MSK pain worse, making no difference to their pain, pain with needle insertion, drowsiness, lightheadedness or euphoria occurring during treatment or within 30min of treatments, local needle site infection, and minor bleeding at needle sites.

PHYSICAL EXAM: (in addition to above physical exam)
-Ears: [text default="Normal appearing pinna b/l, no gross deformities" size="80"]

PROCEDURE:
-[select name="Acup" value="|BFA/Active Auricular Point Protocol|HMI Auricular Trauma Protocol"] was used to identify points to be needled after being properly cleaned with Alcohol using [select name="needle" value="|ASP gold needles|Seirin needles (placed and removed after 15-20min)|Pionex needles"].
-Needles were placed in [select value="L ear|R ear|B/L ears"] based on above protocol into the following points:[/conditional][conditional field="Acup" condition="(Acup).is('HMI Auricular Trauma Protocol')"]
--(1) Hypothalamus, (2) Amygdala, (3) Hippocampus, (4) Master Cerebral, (5) Point Zero, (6) Shen Man
[checkbox value="-Location of these points was landmark-based
"][checkbox value="-Location of these points was aided by use of electrical point detector
"][checkbox value="-Low level electrical stimulation used on each of these points
"][/conditional][conditional field="Acup" condition="(Acup).is('BFA/Active Auricular Point Protocol')"]
--(1) Cingulate, (2) Thalamus, (3) Omega 2, (4) Point Zero, (5) Shen Men
[/conditional][conditional field="OMT-BFA" condition="(OMT-BFA).is('Auricular Acupuncture')"]-The patient tolerated the procedure well and was observed for several minutes following procedure with no lightheadedness/dizziness diaphoresis or other signs of neurologic reaction to the needle insertions.
-The patient was warned about possibility of drowsiness, lightheadedness or euphoria occurring during treatment or within 30min of treatments. Advised taking precautions if driving in case symptoms reoccur. Recommended avoiding heavy exertion, alcohol, undue stress for remainder of day.
[/conditional][conditional field="needle" condition="(needle).is('ASP gold needles')"]-Aftercare for ASP needles discussed, including signs and symptoms of infection, removal if in place for more than 10 days. Educated that needles often fall out on own in 5-7 days and dislodged needles are safe around the home.
[/conditional][conditional field="needle" condition="(needle).is('Pionex needles')"]-Aftercare for Pionex needles discussed, including signs and symptoms of infection, removal if in place for more than 10 days. Educated that needles often fall out on own in 5-7 days and dislodged needles are safe around the home.
[/conditional]
-Pretreatment assessment: [select value="pain-|active/passive ROM-"] [text size="50"]
-Post-treatment assessment: [select value="pain-|active/passive ROM-"] [text size="50"]
-Disposition: [checkbox value="Patient tolerated procedure well. |No immediate complications noted. |Left in stable condition."]
[textarea memo="add'l comments" memo_size="small"][conditional field="Acup" condition="(Acup).is('HMI Auricular Trauma Protocol')"]
[checkbox memo="display HMI ref" name="HMI" value=""][/conditional][conditional field="HMI" condition="(HMI).is('')"]Link to reference article for HMI ATP protocol: https://hmieducation.com/pub/publications/hmi_5429a6e797d46.pdf[/conditional]