Assessment
- The patient is diagnosed with a cervical strain with associated muscle spasm. The clinical impression indicates that the patient’s symptoms are consistent with this diagnosis, likely exacerbated by poor posture and prolonged computer use. Functionally, the patient has significant limitations in neck mobility and experiences pain during prolonged sitting. Since the last visit, the patient reports a slight reduction in pain but continues to experience stiffness.
- The prognosis is positive, with the expectation that continued chiropractic care will enable the patient to reduce pain and improve mobility within 4-6 weeks. The short-term goal is to reduce the patient’s pain to a level of 3 out of 10 within two weeks. The long-term goal is to restore full range of motion and strength in the neck within six weeks.
Plan Section (P)
Plan Section (P) Components
- Treatment Plan:
- Specific interventions that will be implemented to address the patient’s condition.
- Example: “Chiropractic adjustments to the cervical spine.”
- Therapeutic Exercises:
- Detailed description of the exercises prescribed, including the type, frequency, duration, and any progression plans.
- Example: “Neck strengthening exercises, 3 sets of 10 reps, twice daily.”
- Modalities:
- Any therapeutic modalities that will be used, such as heat, ultrasound, or electrical stimulation.
- Example: “Apply heat therapy to the neck for 15 minutes before exercises.”
- Patient Education:
- Information and instructions provided to the patient to help them manage their condition and prevent further injury.
- Example: “Educate the patient on proper ergonomics and posture correction techniques.”
- Home Exercise Program (HEP):
- Exercises and activities prescribed for the patient to perform at home between therapy sessions.
- Example: “Home exercise program includes stretching exercises for the neck and upper back, to be performed twice daily.”
- Referral:
- Any referrals to other healthcare professionals or specialists if necessary.
- Example: “Refer the patient to a physical therapist if no improvement is seen in four weeks.”
- Follow-Up:
- The plan for subsequent visits, including the frequency and duration of follow-up appointments.
- Example: “Schedule follow-up appointments twice a week for the next four weeks to monitor progress and adjust the treatment plan as necessary.”
Tips:
- Be specific and detailed in your treatment plan to ensure clarity and adherence.
- Tailor the plan to the individual needs and goals of the patient.
- Ensure that the patient understands their role in the treatment plan, especially for home exercises and self-care.
Example of a Plan Section for Chiropractic Care
Plan
- The treatment plan for the patient involves several key components to address their cervical strain with associated muscle spasm. The primary focus will be on chiropractic adjustments to the cervical spine. Additionally, the patient will engage in a series of neck strengthening exercises. These exercises will be performed as follows:
- Neck strengthening exercises: 3 sets of 10 repetitions, twice daily.
- To complement these exercises, heat therapy will be applied to the neck for 15 minutes prior to the exercise sessions. This will help to relax the muscles and reduce pain.
- Patient education is an essential part of the treatment plan. The patient will be educated on proper ergonomics and posture correction techniques to prevent further injury.
- The home exercise program (HEP) for the patient includes stretching exercises targeting the neck and upper back, which are to be performed twice daily.
- If no improvement is observed in the patient’s condition after four weeks, a referral will be made to a physical therapist for further evaluation.
- Follow-up appointments will be scheduled twice a week for the next four weeks to monitor the patient’s progress and make any necessary adjustments to the treatment plan.