Outpatient Health Summary

Patients Name
Date of Birth
Marital Status:
M
Significant Others:

Sex
S

Family
History:

Employment
Tobacco

Phone Numbers:
DNR Status:
Resuscitate?
Next of Kin:

Religion:
Social
History:

wak SOS version 5:091102b

Date

Update:
Home
Work
Yes

Occupation

Qualifications:

Education

ETOH

M
F

No

Drugs
Siblings

Sex Hx
Others:

Past Medical History

CPT#

Start Date

Problem / Diagnosis

Medications

Start

Stop

Allergies, Adverse Drug Reactions:

Health Maintenance
Parameter

Dates

DPT/DT/TD
OPV
MMR
HIB
Influenza
Hepatitis
PPD/Tine
Pneumovax
H&P
Eye exam
Dental exam
PAP smear
Mammogram
Urinalysis
Hemoccult
Cholesterol
Sigmoidoscopy
Others
Funded by a grant from the Bureau of Research. 2002 American Academy of Osteopathy.
Designed to coordinate with the Established Outpatient Osteopathic SOAP Note Form. Recommended by American Association of Colleges of Osteopathic Medicine.

Past Surgical History

Date

Type

Consultants

Outpatient Osteopathic SOS History/Exam Form

Patients Name _______________________________

wak SOS version 5:091102b

Office of:
For office
use only:

Date________________

HISTORY

(See Outpatient Health Summary Form for details of history)

Patients Pain Analog Scale: Not done

NO PAIN

WORST POSSIBLE PAIN

CC

E l e m e n t s

History of Present Illness

Status of 3 chronic

Location

Quality

Severity

_______________________

Duration

_______________________

Timing

_______________________

Context

Modifying factors

Assoc. Signs and Sx

OR

or inactive conditions

Review of Systems (Only ask / record those systems pertinent for this encounter.) Not done

Level: ROS

Constitutional (Wt loss, etc.)

Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin, breast)
Neurological
Psychiatric
Endocrine
Hematologic/lymphatic
Allergic/immunologic

Past Medical, Family, Social History

Past History / Trauma

Family History
Social History

II

None

III

1 system pertinent
to the problem

IV
V

2-9 systems
10 systems

Level: PFSH
II
None

III
IV 1 history area

2 history areas
V

Not done

Overall History = Average of HPI, ROS or PFSH:

Level: HPI
II
1-3 elements reviewed

III
IV 4 elements OR status

V of 3 chronic conditions

II

( 1-3 HPI )

III

( 1-3 HPI, 1 ROS )

IV

(4+ HPI, 2-9 ROS, 1 PFSH)

(4+ HPI, 10+ ROS, 2+ PFSH)

Signature of transcriber: ______________________________

Signature of examiner: ___________________________________

Funded by a grant from the Bureau of Research. 2002 American Academy of Osteopathy.
Designed to coordinate with the Established Outpatient Osteopathic SOAP Note Form. Recommended by American Association of Colleges of Osteopathic Medicine.

(Page 1 of 3)

Outpatient Osteopathic SOS Musculoskeletal Exam Form

wak SOS version 5:091102b

Not done
Patients Name ______________________
Date ________
Sex: Male
Female
Age _____
* Vital Signs (3 of 7)
Wt. ____________
Ht. ______________
Temp. _________
Reg.
Pt. position for recording BP:
Resp. ____
Pulse ____
Irreg.
Standing________ Sitting________ Lying__________
* Gait and Station:
Notes
Body

Endo.
Type:
Posture:
Excl.
Gait: Symmetrical

Meso.
Fair

Ecto.

Poor

Asymmetrical
I
N

Ant./Post. Spinal Curves:

Cervical Lordosis


Thoracic Kyphosis


Lumbar Lordosis


I = increased; N = normal; D = decreased

*1

*2

*3
*4
*5
*6

Skin:
Head / neck
Trunk

N

Reflexes:
Biceps L
R
Triceps L
R
Brachio- L
Radialis R

0

Methods Used For

Examination
All T
A
R

L. upper extremity
R. upper extremity
1

T

2

3

4

Patella

Horizontal Planes


Ab

L
R
Achilles L
R
Babinski L
R

Key to the
Severity Scale
Region
Evaluated
Head and Face
Neck
Thoracic T1-4
T5-9
T10-12
Ribs
Lumbar
Sacrum / Pelvis
Pelvis / Innom.
Abd ./ Other
Upper
R
Extremity L
Lower
R
Extremity L

Signature of transcriber: ________________________

* Gen. Appearance:

D

Ab

For office
use only:

Scoliosis (Lateral Spinal Curves):

None
Sitting

Functional
Standing

Mild
Prone/Supine

Moderate
Unable to Examine

Severe

Right: 1/8
Short leg?
Equal
Left: 1/8
N

Office of:

N

L. lower extremity
R. lower extremity
0




up
up

1

2
3








down
down

4

Ab

Motor:
C5 L
R
C6 L
R
C7 L
R
C8 L
R

1

2

3

4

Normal

*Cardiovascular
Observation normal

Palpation normal

*Lymphatics
No palpable nodes

*Neurologic and Psychiatric:
Coordination intact

Sensory intact

Mental status
Oriented:
In time

In person

In place

Good mood/ affect

Level of SOS

II
III

1-5 elements

IV

12+ elements for

musculoskeletal Exam
Perform all * elements

5

T1 L
R
L4 L
R
L5 L
R
S1 L
R

1

2

3

4

__________________________________________________

Funded by a grant from the Bureau of Research. 2002 American Academy of Osteopathy.
Designed to coordinate with the Established Outpatient Osteopathic SOAP Note Form. Recommended by American Association of Colleges of Osteopathic Medicine.

6+ elements

0 = No SD or background (BG) levels

2 = Obvious TART (esp. R and T), +/- symptoms
1 = More than BG levels, minor TART
3 = Key lesions, symptomatic, R and T stand out
Severity
Somatic Dysfunction and Other Systems
MS / SNS / PNS / LYM. / CV / RESP. / GI / FAS. / etc.
0 1
2 3
























































Signature of examiner:

(Page 2 of 3)

5

Outpatient Osteopathic Assessment and Plan Form

A

Patients Name
Dx No.

________________________________

739.0
739.1
739.2
739.8
739.3

Dx No.

All not done

Region

739.4
739.5
739.9
739.7
739.6

First visit

Y

N

Resolved

OMT

Head and Face

Neck
Thoracic T1-4
T5-9
T10-12
Ribs
Lumbar
Sacrum
Pelvis
Abdomen/Other
Upper Extremity
Lower Extremity

Written Diagnosis

ICD Code

Somatic Dysfunction of Head and Face

Somatic Dysfunction of Neck
Somatic Dysfunction of Thoracic
Somatic Dysfunction of Ribs
Somatic Dysfunction of Lumbar

Physicians evaluation of patient prior to treatment:

___________________________

Date

Written Diagnosis

ICD Code

wak SOS version 5: 5:091102b

Office of:
For office
use only:

Somatic Dysfunction of Sacrum

Somatic Dysfunction of Pelvis
Somatic Dysfunction of Abd / Other
Somatic Dysfunction of Upper Extremity
Somatic Dysfunction of Lower Extremity

Improved

Unchanged

Treatment Method
ART

BLT

CR

CS

Response

DIR

FPR

HVLA

IND

INR

LAS

Meds:

PT:

Exercise:

Other:

Worse

ME

MFR

ST

VIS

OTH

R

I

U

W

Nutrition:
Complexity / Assessment / Plan (Scoring) *Default to level 2same criteria
Problems
Self-limiting
Established problem improved / stable
Establishedworsening
Newno workup
New additional workup

Level I

Risk: (Presenting problem(x), diagnostic procedures(s), and

management options)
Minimal = Min.
Low
Moderate = Mod.
High
Minimal = Min.

1 (2 max.)
1
2
3 (1 max.)
4

Level II

Level III

Level IV

Level V

1 pt.

2 pt.

3 pt.

4 pt.

Requires 3 of above 3 (problems, risk and data).

Level I

Level II

Level III

Level IV

Level V

Min.

Low

Mod.

High

Data
Lab
Radiology
Medicine
Discuss with performing physician
Obtain records or Hx from others
Review records, discuss with physician
Visualization of tracing, specimen
Level I
Level II
Level III

1 pt.

2 pt.

Level IV

Maximum Points
1
1
1
1
1
2
2
Level V

3 pt.

4 pt.

Level of complexity = average of included areas.

Optional MethodCoding by Time

Traditional MethodCoding by Components

When majority of the encounter is counseling / coordinating, the level is determined by total time
History
Examination
Complexity /
Assessment Plan

II

III

IV

II

III

IV

Final level of service

II

III

IV

New patients (minutes)

10

15

25

40

60

OMT performed as Above:

0 areas

CPT Codes:
Other Procedures
Written Dx:
Performed:
E/M Code:
New



Write 992 plus . . .

02

03

04

Follow-up:

1-2 areas

05

IV
45

60

10

15

25

40

Dictate total time and counseling / coordinating time plus a brief description of topics discussed

>60

III
30

Final level of service

All three areas required. Average of the three equals level of service.

Minutes spent
with the patient:

II
20

Outpatient patients (minutes)

I
10

EST
...

Signature of transcriber: _________________________________

11

10

11

12

3-4 areas

12

13

Signature of examiner:

5-6 areas

14

15

Units:

7-8 areas

Consults
...

41

PRN

9-10 areas

42

43

44

45

____________________________________________

Funded by a grant from the Bureau of Research. 2002 American Academy of Osteopathy.
Designed to coordinate with the Established Outpatient Osteopathic SOAP Note Form. Recommended by American Association of Colleges of Osteopathic Medicine.

(Page 3 of 3)