COMLEX-II PE and SOAP notes

[MedicineMan99]

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I have a few questions about the SOAP notes on COMLEX-II:

Let's say you performed OMT. Where do you document that you actually performed the OMT vs. when you would perform the OMT but didn't? Do you write in the plan "I performed lumbar soft tissue techniques" or "Will perform lumbar soft tissue techniques" respectively in the Plan?

Also, did you only do a OMT structural exam when you performed OMT?

Thanks!

 

[Bitsy]

You document performed OMT under the plan..."performed muscle energy to lumbar back with improvement in pain and range of motion upon reassessment" (or something like that). Make sure to document your structural findings under the objective part of your SOAP note if you did one. If you think a patient needs OMT or presents with musculoskeletal complaint (back pain, knee injury, etc), perform structural exam and OMT!! I think I performed OMT on 3-5 patients. The only reasons you should document recommending OMT instead of performing it is if you leave the room and forget to do it...."recommend OMT to lumbar back area" or if you think the patients needs HVLA (can't do that on the PE). In general, just use another technique such as muscle energy versus just recommending HVLA. Oh, and you would put the recommendation of OMT under the plan.

 

[DD214_DOC]

I didn't write it out that way. I just put under plan, "OMT: paraspinal inhibition lumbar spine" or something like that.