CHIROPRACTIC RE-EXAM NOTE

Patient: [Name]
Date of birth: [Date]
Date of re-exam: [Date]
Initial exam: [Date of the initial exam]
Care so far: [Number of visits over how many weeks]
Chiropractor: [Name, credentials]

INTERVAL HISTORY
Patient's view: [How they feel compared with the start of care, in their words]
Pain: [Rating out of 10 today, compared with the initial exam]
Daily function: [What is easier now, and what is still limited]
Adherence: [Visits attended, home exercises done, advice followed]
New problems: [New complaints, neurological symptoms, red flags, or none]

OUTCOME MEASURES
Measure: [The named outcome measure used at the initial exam]
Scores: [Initial score, today's score, and the change]
Clinical meaning: [Whether the change is meaningful for this measure]

RE-EXAMINATION
Range of motion: [Initial and current values, by direction]
Palpation and segments: [Current tenderness, tone, and restricted segments, compared with the initial exam]
Orthopedic tests: [Each test repeated, with initial and current results]
Neurological exam: [Repeated findings, and any change]

GOAL STATUS
Short-term goals: [Each goal: met, partly met, or not met]
Long-term goals: [Each goal: met, partly met, or not met]

ASSESSMENT
Overall progress: [Improving, plateaued, or worse, with the evidence]
Diagnosis: [Unchanged, revised, or new]
Reasoning: [Why care should continue, change, taper, stop, or be referred]

PLAN
Decision: [Continue, taper, discharge, or refer]
Visit frequency: [New frequency and duration, or none after discharge]
Updated goals: [New or revised goals, with dates]
Referral: [To whom, why, how urgent, and what was sent; or not needed]
Self-management: [Home program, and when to come back]
Next re-exam: [Date or visit number, or not applicable]

Signed: [Chiropractor name, credentials, date and time]