Sample Treatment Plan Of Care Template
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1
2NAME/ADDRESS of CLINIC/PROVIDER
TREATMENT PLAN OF CARE
______Initial Treatment Plan
_____ Updated Treatment Plan
Date___________ Patient _______________________________ Patient DOB_______________
Diagnosis/Clinical Impression #1:
_____________________________________________________________________________
_____________________________________________________________________________
Complicated by: ________________________________________________________________
Associated with: ________________________________________________________________
Resulting in: ___________________________________________________________________
ICD
Codes:
____________________________________________________________________
Diagnosis/Clinical Impression #2:
_____________________________________________________________________________
_____________________________________________________________________________
Complicated by: ________________________________________________________________
Associated with: ________________________________________________________________
Resulting in: ___________________________________________________________________
ICD
Codes:
____________________________________________________________________
Recommended Spinal Manipulation Frequency:
Daily ___________
2 x wk ______________
1 x mo ___________
3 x wk __________
1 x wk ______________
Therapy:
Type ____________ Location ________
Frequency ________ Time ________
Type ____________ Location ________
Frequency ________ Time ________
Type_____________ Location ________
Frequency _________ Time ________
Rehab:
Cervical:
Passive ____________ Active ____________ General _____________
Lumbar:
Passive ____________ Active ____________ General _____________
Structural Support:
Cervical Pillow ______ Cervical Collar Soft ______ Firm ______
Lumbar Cushion _____ Lumbar Belt Soft ________ Firm ______
Extremity: Shoulder ____ Elbow ____ Wrist ____ Knee ____ Ankle _____ Other_____
Short Term Goals:
Reassessment ________________ week(s)/month(s)
____________ % Improvement within ______ weeks.
Long Term Goals:
____________ % Improvement
Other______________________________________________
Reports: Yes
No
Due Date _______ Type: PI WC IME Interim Insurance Special
Follow Up Procedures: Lab _______ Nutrition ________ Supports _______ Exercises_______
X-ray ______________________________________________________
RESTRICTIONS
Bed Rest _____________ Guarded Movement _____________ Athletic Activity ____________
Cervical:
Flexion ______ Extension ______ Lateral Flexion ______ Sleeping __________
Lumbar:
Sitting _____ Bending _____ Stooping _______ Lifting ______ Other ________
Other Restrictions: ______________________________________________________________
Reviewed/Prepared by: Print Name of Provider
Treatment Plan
Provider Signature ____________________________
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