AI Scribe for Chiropractors

DAILY VISIT SOAP — VISIT 8 of 12

Patient: John D.
DOB: 1972 (53 y/o male)
Date: Today, 2:15 PM
Provider: Dr. M. Reyes, DC — Lic #DC-99887
Care Plan: Active care, Medicare beneficiary, visit 8 of 12 (recert at visit 12).
Primary Dx: M54.5 — Low back pain
Secondary Dx: M99.03 — Segmental and somatic dysfunction, lumbar region
Subluxation listing: L5 PRI-S (posterior, right, inferior — superior segment notation per Gonstead)

SUBJECTIVE:
Pt presents for visit 8 of 12 in active care plan for chronic mechanical low back pain. Reports overall improvement since starting care 3 weeks ago. VAS pain today 3/10 (was 7/10 at initial exam). Most painful with prolonged sitting at desk after lunch. Denies radicular symptoms, bowel/bladder changes, saddle anesthesia, night pain, fever, or unintentional weight loss (red flags negative).
Functional: Reports being able to lift his 35-lb toddler again without sharp pain. Sleep improved — only 1 night of disrupted sleep this week (was 5–6 nights at intake). Returned to walking dog 30 min/day.
Since last visit (Tuesday): No new injuries, falls, or aggravations. Performed home exercises 4 of 4 prescribed days. Took 1 dose of acetaminophen 500 mg yesterday after long drive.
Functional outcome: Modified Oswestry Disability Index 18% (was 38% at intake).

OBJECTIVE — PART EXAM:
P (Pain on palpation): Tenderness +2/4 at L4–L5 right paraspinal, +1/4 at L5–S1 right, +1/4 at right SI joint. (Was +3/4 throughout at intake.)
A (Asymmetry / misalignment): Posterior pelvic asymmetry — R PSIS measures 3 mm inferior to L. Lumbar lordosis mildly increased on visual inspection. L5 segment palpates with posterior, right, inferior listing.
R (Range of motion):
- Lumbar flexion: 50° (was 30° at intake; normal ~60°)
- Lumbar extension: 20° (was 10°; normal ~25°)
- Right lateral flexion: 22° (was 12°)
- Left lateral flexion: 25° (was 18°)
- Rotation R/L: 30° / 32° (was 18° / 20°)
- End-range pain only at extension and right lateral flexion.
T (Tissue tone): Right lumbar paraspinals hypertonic +2/4, with palpable taut bands at L4 level. Left paraspinals normal tone. Right QL mildly tight. Improvement noted from initial visit.

Orthopedic re-tests:
- Kemp test (R): mild discomfort, no radiation (was positive with radiation at intake).
- SLR (R/L): 80° / 85°, negative bilaterally.
- Patrick/FABER: negative bilaterally.
- Heel/toe walk: intact.
DTRs: L4 (patellar) and S1 (Achilles) +2 bilaterally. Sensation L1–S1 dermatomes intact.

ADJUSTMENT PERFORMED:
- L5–S1: Diversified, side-posture, P-A with rotational component, right side down. Audible release. Tolerated well.
- Right SI joint: Diversified, side-posture, ASIS push contact. Audible release.
- T12–L1: Diversified, prone, bilateral hypothenar P-A. Audible release.

MODALITIES:
- Cryotherapy (97010): 12 minutes to lumbar region post-adjustment.
- Therapeutic exercise (97110, 8 min): supervised glute bridges 3x10, dead bug 3x10, and bird dog 3x8.
Total face-to-face skilled time: 22 minutes.

ASSESSMENT:
Pt continues to make objective and subjective progress in active chiropractic care for chronic mechanical LBP with lumbar segmental dysfunction. Pain reduced 57% from intake (VAS 7 → 3/10), Oswestry improved from 38% to 18% (clinically meaningful change >10%), lumbar flexion ROM improved 67%. Functional gains in lifting, sleep, and ambulation support continued necessity of skilled chiropractic care. Pt remains symptomatic and not at maximum therapeutic improvement — active care is medically necessary.

PLAN:
- Continue current care plan: 4 visits remaining of authorized 12-visit plan.
- Frequency reduced to 2x/week given clinical progress.
- Re-evaluation scheduled at visit 12 (in 2 weeks). Recertification of plan if continued progress; otherwise transition to maintenance care or discharge.
- Home program updated: progress glute bridges to single-leg, add bird-dog hold 10 sec, continue daily walking 30+ min.
- Patient education: ergonomic review of desk station, sitting posture cues, lumbar support cushion recommendation.
- Will monitor for any sign of plateau; if reached, will transition appropriately.

CERTIFICATION STATEMENT:
This patient continues to demonstrate measurable functional improvement and remains under active chiropractic care for a documented neuromusculoskeletal condition. Skilled chiropractic services remain medically necessary at this time per the established Plan of Care.

Provider signature: M. Reyes, DC — electronically signed