SAMPLE FORMS FOR DOCUMENTATION Documentation 2011 Page Book # # SUBJECTIVE ____ _____ 1. Auto accident Fill-in History Form ----------------------------------------------------- 5-7 2. Patient History Form ----------------------------------------------------------------------- 8 667 a. Qualitative vs. quantitative ------------------------------------------------------- 9 421 2. Past Medical and Family History form -------------------------------------------------- 10 668 3. Review of Systems ------------------------------------------------------------------------- 11 669 4. Expanded History Form ------------------------------------------------------------------- 12 5. Red-Flag Questionnaires (2 versions) and the AHCPR stats on accuracy----------- 13-15 OBJECTIVE 6. Tenderness Scale ---------------------------------------------------------------------------- 16 165 7. Physical examination forms 17/19 a. Cervical ----------------------------------------------------------------------------- 17-18 670-71 b. Lumbar ------------------------------------------------------------------------------ 19-20 672-73 8. Waddell Signs (see lumbar exam form for documentation) -------------------------- 614-19 9. QFCE forms --------------------------------------------------------------------------------- 22-24 312-30 a. Strength and endurance normative data (Alaranta tests) 26 155-62 b. Horizontal Side Bridge normative data 27 c. Grip & pinch normative data (Jamar data) 28 d. & e. 3-minute step test norms (men - b, woman - c) 29 f. 3-minute step test - instructions 28 ____ _____ ASSESSMENT 10. ASSESSMENT (see the “A” or pg 2 of the PE forms) 30 648-50 a. Psychosocial Yellow Flags ------------------------------------------------------- 403-4 1. Biopsychosocial Model 439-43 30 652-59 b. Goal Setting -------------------------------------------------------------------------- 671/73 PLAN _____ 11. PLAN / Procedures ------------------------------------------------------------------------- 31-32 649-50 12. PT Log form --------------------------------------------------------------------------------- 33 660-61 13. Route slip 676-77 a. Example ----------------------------------------------------------------------------- 34-35 14. Functional Capacity Testing (discussion only*; bolded items include a form) a. Occupational Therapist referral* b. Job Demands Questionnaire --------------------------------------------------- 36-37 646-47 c. Lift / Carry tests (i.e., EPIC, PILE)* Ch 17 d. Spinal Function Sort*-------------------------------------------------------------- 345-49 e. Quantitative Functional Capacity Evaluation (QFCE) ----------------------- 312-32 (Text: Alaranta Chap 12) 155-62 (Text: Appendix QFCE Forms) 614-17 f. Static Position Tolerance Tests* 636-37 1 g. Return to Work form ------------------------------------------------------------ 38 675 DAILY SOAP NOTES 39 664-65 15. Daily Notes examples ---------------------------------------------------------------------- 40 666 16. Abbreviations of SOAP note form ------------------------------------------------------- Documentation of X-ray Findings 41 674 16. Elements ------------------------------------------------------------------------------------- a. Introductory information b. Report c. Template d. Example Re-Evaluations (Discussion only) 17. Progress notes Reevaluations Reexaminations counseling and/or coordination of care Chapter 2 18. Mechanisms of Documentation a. Dictation and transcription (Discussion: e-mail service option) b. Computer-assisted record keeping [commercial programs] c. Word processing programs 42-43 1. Macros: see examples and the table of contents for a disc ---------- 2. Boilerplate text 664-65 d. Hand-written notes (39-40) 666 1. see SOAP forms ----------------------------------------------------------- Chaps Chapter 3 5-10 19. Outcome Assessment Measurement Devices & 15 a. Pain 1. Quadruple VAS (QVAS) ------------------------------------------------ 44 511 2. Pain drawing -------------------------------------------------------------- 45 421-22 b. General Health 1. HSQ-12 and scoring template ------------------------------------------- 46-51 501-06 c. Condition-specific 1. Headache Disability Index (HDI) -------------------------------------- 52 539 2. Oswestry Low Back Disability Questionnaire (OLBDQ) ----------- 53 515 3. Neck Disability Index (NDI) -------------------------------------------- 54 537 4. Scoring method for Oswestry & NDI ---------------------------------- 55 2 5. Global Impression of Change ------------------------------------------- 56 6. Back Bournemouth Questionnaire (BBQ) ----------------------------- 57 7. Neck Bournemouth Questionnaire (NBQ ----------------------------- 58 8. Patient Specific Functional And Pain Scales -------------------------- 59 564 d. Patient satisfaction 60 1. Chiropractic Satisfaction Questionnaire ------------------------------- 560 e. Psychometric Ch 10 1. Beck's Depression Inventory -------------------------------------------- 61-62 + 21 f. Disability prediction 651-57 1. Yellow Flags Q (1st visit and Re-exam forms; scoring method) -..- 63-64 644 g. Outcomes Score Card (clean copy and completed example) ---------------- 65-66 i. PT Log ------------------------------------------------------------------------------- 67 660-61 Miscellaneous 662 20. Patient intake information ---------------------------------------------------------------- 68 a. Insurance information b. Vitamin/medication/orthotic log 69 663 21. Photocopying log --------------------------------------------------------------------------- 70-73 22. UE & LE Functional Scales -------------------------------------------------------------- 74-77 406 23. Business Associate Agreement (NEW Mandated by 2-17-2010 -------------------- 78 24. Informed Consent -------------------------------------------------------------------------- 79-80 491- 25. Appendix Forms CD ----------------------------------------------------------------------- 679 81 26. New Forms CD ----------------------------------------------------------------------------- 81 27. Recommended publications a. Order form for The Chiropractic Report (Special bonus) ---------------- b. Discussion and other recommended publications------------------------- 82-83 28. CareTrak software 84 a. Description -------------------------------------------------------------------- 406 b. SAMPLE: CareTrak brief form tracking outcomes----------------------- 29. Outcomes Assessment supplies (SGY) a. Table of Contents text: Clinical Application of Outcomes 85-86 Assessment, ed. SGY --------------------------------------------------------- b. Order form (includes a description of available materials) -------------- 87-90 3 SUBJECTIVE AUTOMOBILE ACCIDENT QUESTIONNAIRE SELECT FROM THE FOLLOWING LIST ALL THAT APPLY: ______ STOPPED/SLOWING DOWN FOR (TRAFFIC/RED LIGHT/STOP SIGN) AND WAS STRUCK IN THE REAR BY ANOTHER VEHICLE. ______ WAS PUSHED INTO THE VEHICLE IN FRONT OF HIS/HERS. ______ SLOWING DOWN TO EXECUTE A TURN AND WAS STRUCK IN THE REAR BY ANOTHER VEHICLE. ______ WAS SIDE SWIPED BY ANOTHER VEHICLE TRAVELING IN THE SAME DIRECTION. ______ ANOTHER VEHICLE TRAVELING IN THE OPPOSITE DIRECTION COLLIDED HEAD- ON WITH THE VEHICLE IN WHICH (HE/SHE) WAS RIDING. ______ ANOTHER VEHICLE RAN A (RED LIGHT/STOP SIGN) AND STRUCK (HIS/HER) VEHICLE (BROADSIDE/IN THE REAR/IN THE FRONT END). ______ THE VEHICLE IN WHICH (HE/SHE) WAS RIDING WAS STRUCK BY ANOTHER VEHICLE CAUSING IT TO (SPIN AROUND/ROLL OVER). ______ THE PATIENT WAS INVOLVED IN A MULTI-CAR COLLISION. ______ THE PATIENT WAS INVOLVED IN A MOTOR VEHICLE COLLISION. ______ THE DRIVER OF THE VEHICLE IN WHICH (HE/SHE) WAS RIDING LOST CONTROL AND (STRUCK ANOTHER VEHICLE/RAN OFF THE ROAD/STRUCK AN OBJECT). DESCRIBE________________________________________________________ ______ THE PATIENT WAS THROWN FROM THE CAR TO THE PAVEMENT. ______ THE PATIENT INJURED (HIS/HER) BACK IN A LIFTING ACCIDENT. ______ OTHER(BRIEF DESCRIPTION):__________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4 ______________________________________________________________________________ WAS THE PATIENT WEARING A SEAT BELT? ____YES ____NO (If Yes, circle: Lap, Chest, Both ) SELECT FROM THE FOLLOWING LIST ANY OBJECT WHICH THE PATIENT'S BODY STRUCK AT THE POINT OF IMPACT? ____HEAD ____FACE ____CHEST ____NECK ____BACK ____SHOULDER(S) RIGHT/LEFT ____ARM(S) RIGHT/LEFT ____LEG(S) RIGHT/LEFT ____KNEE(S) RIGHT/LEFT SELECT THE OBJECTS THAT WERE STRUCK: ____WINDSHIELD ____HEADREST ____DASHBOARD ____STEERING COLUMN ____DOOR FRAME ____BACK OF SEAT ____REAR VIEW MIRROR ____SEAT BROKE ____JARRED OR THROWN ____CANNOT REMEMBER DETAILS (DAZED) ____RENDERED UNCONSCIOUS ____OTHER:___________________________________________________________ IF THE PATIENT HAS BEEN