Complete chiropractic re-examination template for periodic progress assessments. Document treatment effectiveness and justify continued care.
A chiropractic progress note (also called a re-examination, re-eval, or periodic exam) is a comprehensive assessment performed at regular intervals during a course of care. It documents the patient's response to treatment, compares current status to baseline findings, evaluates progress toward goals, and determines whether continued care is indicated.
Progress notes are essential for several reasons:
A comprehensive progress note compares current findings to baseline and demonstrates the effectiveness of treatment. Each section provides evidence for continued care decisions.
Overview of care provided since the initial evaluation or last re-exam, including number of visits, treatments performed, and patient compliance. This establishes the context for evaluating outcomes.
Patient's report of improvement, including changes in pain levels, functional abilities, and quality of life. Document in the patient's own words when possible, with specific comparisons to initial presentation.
Current examination findings with direct comparison to initial evaluation. Include ROM, orthopedic tests, neurological exam, palpation findings, and subluxation assessment using the same measurements for valid comparison.
Standardized functional outcome questionnaires (NDI, ODI, etc.) with scores compared to baseline. These provide objective, validated measures of functional improvement.
Clinical interpretation of progress toward goals, treatment effectiveness, and remaining impairments. This section demonstrates your clinical reasoning for continued care recommendations.
Revised plan based on re-examination findings, including modified goals, adjusted frequency, new interventions if indicated, and timeline for next re-evaluation or discharge.
Below is a comprehensive chiropractic re-examination template. Use this for periodic progress assessments or let SOAP Note Buddy auto-generate progress notes in your EHR.
| Pain Measure | Initial Evaluation | Current | Change |
|---|---|---|---|
| Pain at Rest | [0-10] | [0-10] | [Improved/Same/Worse by X] |
| Pain at Worst | [0-10] | [0-10] | [Improved/Same/Worse by X] |
| Pain with Activity | [0-10] | [0-10] | [Improved/Same/Worse by X] |
| Motion | Initial | Current | Normal | Change |
|---|---|---|---|---|
| Cervical Flexion | [deg] | [deg] | 50 | [+/- deg] |
| Cervical Extension | [deg] | [deg] | 60 | [+/- deg] |
| Cervical Rotation R | [deg] | [deg] | 80 | [+/- deg] |
| Cervical Rotation L | [deg] | [deg] | 80 | [+/- deg] |
| Lumbar Flexion | [deg] | [deg] | 90 | [+/- deg] |
| Lumbar Extension | [deg] | [deg] | 30 | [+/- deg] |
Progress notes are critical for justifying continued care and avoiding insurance denials. Here's how to write effective re-examinations.
The entire purpose of a progress note is comparison. Every finding should be presented alongside the initial evaluation finding. "Pain is 4/10" is less compelling than "Pain reduced from 7/10 at initial evaluation to 4/10 currently, a 43% improvement."
For valid comparison, re-test using the same methods as the initial evaluation. If you measured cervical rotation with a goniometer at IE, use a goniometer at re-exam. If you used the NDI outcome measure, use the NDI again.
Insurance companies care most about functional outcomes. "ROM improved 15 degrees" is less compelling than "Patient can now drive 45 minutes without pain, compared to 10 minutes at initial evaluation, allowing return to work commute."
Don't assume the reader will understand why more treatment is needed. Explicitly state: "Remaining impairments require continued skilled chiropractic treatment because..." This addresses the medical necessity question directly.
If the patient isn't improving, document why and what you're changing. "Patient showing slower than expected progress due to physical work demands. Modifying treatment to include more stabilization exercises and consulting with employer regarding modified duties."
Progress notes require comparing current findings to historical data - exactly what AI is good at. Instead of flipping between charts and manually creating comparison tables, let AI handle the heavy lifting.
SOAP Note Buddy tracks your patient's history and automatically generates progress notes that compare current findings to baseline, calculate improvement percentages, and document progress toward goals.
A progress note that takes 20-30 minutes manually can be generated in 2-3 minutes with AI assistance.
Try Free for 3 DaysRe-examinations should be performed every 12 visits or 30 days, whichever comes first. This is a common payer requirement. Re-exams should also be performed when there is a significant change in the patient's condition (improvement or decline), when modifying the treatment plan significantly, or when the patient reaches a treatment milestone.
A chiropractic progress note should include treatment summary (visits since last evaluation), subjective progress (patient-reported improvement, pain levels), objective re-examination (ROM, palpation, subluxation status compared to baseline), outcome measures with score comparisons, assessment of progress toward goals, and an updated treatment plan with continued care justification.
Justify continued care by documenting: (1) measurable improvement since initial evaluation, (2) remaining impairments that require skilled chiropractic treatment, (3) expected additional improvement with continued care, (4) functional goals not yet achieved, and (5) consequences of discontinuing care. If progress has plateaued, document whether MMI has been reached or if modified treatment is warranted.
Common chiropractic outcome measures include Neck Disability Index (NDI) for cervical conditions, Oswestry Disability Index (ODI) or Revised Oswestry for lumbar conditions, Roland-Morris Disability Questionnaire, Visual Analog Scale (VAS), and Numeric Pain Rating Scale (NPRS). Choose measures relevant to the patient's condition and use the same measures throughout care for valid comparison.
Document subluxation improvement by comparing current findings to initial listings. Note which subluxations have resolved, which are improving (reduced fixation, tenderness, or associated findings), and which persist. For example: "C5 PRI subluxation at IE - now showing improved mobility with only mild fixation. L4 subluxation resolved." This demonstrates treatment effectiveness.
If the patient isn't improving, document the findings honestly and explain the clinical reasoning. Consider: (1) compliance issues, (2) complicating factors (work demands, comorbidities), (3) need for treatment modification, (4) possible referral or co-management, or (5) potential maximum therapeutic benefit reached. Document your plan to address the lack of progress or transition to discharge.
Yes, re-examinations are typically billed using E/M codes (99211-99215) or the chiropractic re-evaluation code if the payer recognizes it. The level billed depends on the complexity of the re-examination performed. Check with specific payers, as some bundle re-exam fees into CMT visits. Always document the medical necessity for the re-examination.
AI documentation tools like SOAP Note Buddy can dramatically speed up progress notes by automatically comparing current findings to baseline, calculating improvement percentages, tracking progress toward goals, and generating compliant medical necessity language. This turns a 20-30 minute task into a 2-3 minute review process.
Let AI handle the comparisons and calculations. Try SOAP Note Buddy free for 3 days.
Start Your Free Trial