Osteopathic Manipulative Treatment: New Patient Example

Source: http://www.md-do.org/omm.htm

SOAP Note - New Patient Example

S
A patient complains of low back pain that began 3 days ago after he lifted a heavy object. Cannot straighten up when walking. Pain with change of position. Denies radiation of pain; it stays along the low back and waistline. Denies areas of numbness. Comfortable when lying down. Aspirin helps some. Has used heat with some help. No prior history of back pain or injury. Denies allergies. Medical/surgical history is unremarkable.

O

Tenderness noted over lumbar and sacral regions
Inability to extend lumbar spine when standing
Flexion posture when standing
Muscle spasms noted in paraspinals of the lumbar region
Decreased range of motion of lumbar spine and sacrum was noted on active and passive motion testing
Neurological exam normal
A
1. Lumbosacral sprain. 846.0

2. Somatic dysfunction - lumbar, sacral 739.3 and 739.4

P
1. OMT (appropriate techniques used*), applied to the lumbar and sacral regions

2. Continue aspirin

3. No lifting, bending or twisting

4. Follow up in two days to reevaluate patient progress



CODING FOR THIS CASE

Evaluation/management; new patient 99203-25

OMT two body regions; lumbar/sacral 98925

*See AOA Glossary of Osteopathic Terminology for appropriate techniques.