Osteopath-Vorlage
Osteopath Initial Consult
Eine professionelle Osteopath-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
The Osteopath Initial Consult template is designed for osteopathic practitioners to document comprehensive initial assessments of patients presenting with musculoskeletal complaints. This template includes sections for detailing the presenting complaint, complaint history, past medical history, goals, assessment findings, diagnosis, treatment, and treatment plan. It is ideal for osteopaths to capture detailed patient information, ensuring a thorough understanding of the patient's condition and facilitating effective treatment planning. This template is particularly useful for documenting initial consultations, helping osteopaths provide tailored care and track patient progress over time.
Vorlagenvorschau
Initial Consultation
Practitioner: Thomas Kelly
Created: 1 November 2024, 10:00 AM
Last updated: 1 November 2024, 10:30 AM
Presenting Complaint:
S: Localised pain in the lower back, right side
Q: Dull and throbbing
I: 7/10 at worst, currently 5/10
R: Pain radiates to the right hip
T: Intermittent, worse in the morning
AGG: Sitting for long periods, bending forward
REL: Lying flat, applying heat
Complaint History:
ONSET: 2 months ago
MOI: Lifting a heavy box
CHRONO: Worsened over the past month
PREV TTT: Physiotherapy sessions, chiropractic adjustments
PREV INVEST/IMAGING: MRI scan showing mild disc bulge
Past Medical History:
PREV EPS: Similar episode 1 year ago
ACC/INJ: None
ILLNESSES: Hypertension
MEDN: Lisinopril 10mg daily
OPERATIONS: Appendectomy 5 years ago
LEISURE: Regular swimming
GOALS:
SHORT: Reduce pain to 3/10 within 2 weeks
INTERMED: Improve mobility and reduce stiffness
LONG: Full recovery and return to normal activities
Assessment:
EXAMINATION: Tenderness in the lumbar region, reduced flexion
RESTRICTED: Forward bending
HT: Positive straight leg raise test
PALP: Muscle tightness in the lumbar paraspinals
SPECIAL TESTS: Negative for neurological deficits
DIAGNOSIS:
DX: Lumbar strain with mild disc bulge
WORKING DX: N/A
DDX: Sciatica, lumbar spondylosis
INVEST: None required at this time
Treatment:
ST: Soft tissue massage to lumbar region
ARTIC: Mobilisation of lumbar spine
MET: Applied to lumbar paraspinals
HVLA: None
DN: None
Treatment Plan:
TTT FREQ & DUR: Twice weekly for 4 weeks, review after
ADVICE: Avoid heavy lifting, maintain good posture
REHAB: Core strengthening exercises
Further Information:
Patient advised to monitor symptoms and report any changes.
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