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(SPECIAL NOTE: This is an unedited SOAP Note. In other words, this is how it looked after it was created by the Report Master Program, without any additional editing.)


Re: Mr. Prone  Accident  -  Visit Date: Wednesday, October 11, 2006

Date of Injury/Onset:  August 1, 2006

Mr. Accident presented himself at our office on October 11, 2006 for treatment of his complaints arising from a motor vehicle accident that he was involved in on August 1, 2006. 

SUBJECTIVE COMPLAINTS:
An assessment of Mr. Accident's current signs and symptoms was performed today.  His neck pain has improved quite a bit since we last saw him.  It was 6 on the 1 to 10 Pain Scale.  His daily activities are seriously affected by this symptom.  He stated that his left hip pain has experienced slight improvement.  On the 1 to 10 scale today, this complaint was rated at 5.  The patient's daily activities are somewhat affected by this symptom.  The patient stated that he is sleeping well.

OBJECTIVE EVALUATION:
Passive ranges of motion of the cervical spine were found to be decreased to a slight degree, with pain. 

Palpation Evaluation:  Paraspinal Studies: Cervical region palpation revealed the following:  moderate pain, and articular fixations at C1.  Palpation revealed the following:  slight pain and tenderness, and mild edema of the left hip. 

ASSESSMENT/TREATMENT:
Today's Modalities & Procedures:  The following procedures were performed and/or recommended today:  Cervical region modalities consisted of chiropractic adjustment to C1.  Additional modalities consisted of chiropractic adjustment, and EMS (97014) to the left hip.  The above was for the purpose of decreasing pain and decreasing spasms. 

Today's Assessment:  Mr. Accident is progressing slower than expected.  His progress is being limited by work activities.  The patient is not yet at MMI and is presently receiving medically necessary therapeutic care.  Minor improvement in the patient's condition has occurred since his last visit. 

Prognosis:  At this time, Mr. Accident's prognosis is good.  His case is somewhat complicated, but continued improvement is expected, despite permanent residuals being a possibility. 

FUTURE CARE PLAN:
Present Care Phase:  Currently, we have the patient in a relief phase of care. 

Future Treatment Plan:  Our recommended future care plan for this patient consists of moist heat therapy, EMS (electrical muscle stimulation) and chiropractic adjustments three times a week for four weeks. 

Goals of Treatment Plan:  The preceding treatment plan has the goal of increasing strength, returning the patient to his pre-accident status and increasing flexibility.