OMT Documentation

There is no one right way to document OMT in your soap note, however there are some key
components that should be included and some errors that can be avoided. This is just one example.

Subjective:
Objective:
Include regional medical examinations and orthopedic examinations.
This is where you put your osteopathic structural exam either in a separate OSE category or under the
MSK grouping. Details of TART, if described should go here also.
The specific SD should be named here- e.g.:
Head: OA F RrSl.
Cervical: C2 RL SR E
UE: Myofascial internal rotation SD, Decreased ROM with active and passive external rotation
LE: Distal Quadriceps tenderpoint. Myofascial strain in R semitendinosus
Lumbar: AL1 TP SD
DO NOT describe treatment here. The presence of restriction or somatic dysfunction is an indication
for OMT which should be documented as a procedure in a separate procedure note elsewhere.

Assessment:
Always include your “allopathic” diagnosis first - e.g.:
1. Low back pain
2. Cervical strain
Then include SD by region. - e.g.:
3. Somatic Dysfunction Head, cervical, lumbar, UE, Other, etc. regions

Plan:
Provide your medical recommendations here. Eg:
1 Stretches prescribed to the patient: Middle scalene stretch handout, hamstring stretch handout
2 Ibuprofen 600 mg po tid
3 Ice packs at 15 min, q2h max, qid to sore areas
4 Recommend or offered OMT; Pt accepted. or Decision made to do OMT today.
See separate procedure note.
5 Follow-up in 2 weeks to evaluate progress.

The presence of somatic dysfunction is an indication for OMT which should be documented as a
procedure note. E.g.: For CPA3 please include this procedure note in the plan portion.

Procedure Note: should have 4 parts.

(1 consent and justification) Based on today’s exam the patient was found to have the above
somatic dysfunction and deemed OMT to be an appropriate treatment. Patient gave verbal consent
for the procedure.
(2 The action performed) Osteopathic manipulation was performed today utilizing HVLA to the
cervical and Lumbar regions, BLT to the head, and MFR, and counterstrain UE and LE.
(3 Response to treatment) All treatments were successful with decreased pain, tenderness,
improved symmetry and decreased restriction of motion. (note: these are TART)
(4 Complications and specific Tx based plan) The patient tolerated the procedures well and there
were no complications. If the patient is sore beyond anticipation, as discussed, the patient should
call or return for re-evaluation.