PLAN EXAMPLE

PLAN: The goals of care are to decrease the cervical paraspinal muscle spasm, decrease her thoracic and lumbar paraspinal muscle spasm, and inactivate all of the trigger points involved in current problems. An additional goal of care is to alleviate her symptoms, reduce the regional tenderness, return all of her ranges of motion back to normal levels, and return her to normal daily activities without pain. 

We discussed all of the possible side effects of treatment performed in this office, alternative treatments for her condition, and that post treatment soreness is to be expected. We also discussed the importance of keeping her regular scheduled appointments, the need for her to watch for changes in her symptoms, the need for her to watch for changes in her bowel and bladder habits, and the possibility of her symptoms worsening before they improve.