Chiropractors

He acts as a chiropractic expert specializing in pediatric orthopedics and spine management. Your task is to write a detailed and technical clinical progress report for a patient diagnosed with adolescent idiopathic scoliosis (AIS) who has been under active chiropractic care.


The report must be professionally structured to be included in the patient's medical record or to be sent to a referring physician. It begins with the patient's basic demographic data: [Patient's Full Name], [Age], [Gender], and [Date of Current Assessment]. Include a background section mentioning the initial state documented on [Initial Evaluation Date], highlighting the original Cobb Angle of [Initial Cobb Degrees] and the classification of the curve according to King or Lenke if applicable.


In the body of the report, describe in detail the findings of the current physical reassessment. It includes the results of the Adam Test, the measurement of the trunk rotation angle (ART) using the scoliometer in the zones [Curve zone: Thoracic/Lumbar/Thoracolumbar] indicating whether there were significant changes. Reports the current status of the Risser sign [Risser Grade 0-5] to determine skeletal maturity and risk of progression. Compares the most recent radiographic findings of [Current X-ray Date] with the previous ones, specifying the new Cobb Angle of [Current Cobb Degrees] and any changes in sagittal or coronal balance.


It details the treatment protocol applied to date, including [Type of Adjustments/Techniques], the use of specific stabilization exercises such as the Schroth method or SEAS, and compliance with the use of orthoses if prescribed. Analyze the objective clinical evolution: Has there been a reduction, stabilization or progression of the curve? It describes the improvement in the patient's subjective symptoms, such as pain levels, respiratory capacity or perception of body image.


It ends with a professional conclusion on the short and medium term prognosis based on bone maturity and response to treatment. Establish recommendations for the next phase of care: [Suggested frequency of visits], [Date for next x-ray check], and any necessary adjustments to the exercise plan or referral to other specialists. The tone should be strictly clinical, precise, and use standard medical terminology in chiropractic and orthopedics.

If any key information needed to fill the bracketed fields is missing, ask me the necessary questions before answering.

He acts as an expert in Chiropractic and clinical documentation with high specialization in spinal biomechanics and functional neurology. Your task is to write a professional, technical and extremely precise clinical progress note based on the last lumbar adjustment session performed on the patient. The writing must strictly follow the SOAP (Subjective, Objective, Evaluation and Plan) format, using standardized anatomical terminology and faithfully reflecting the clinical progress of the patient under chiropractic care.


It begins by analyzing the data provided for patient [Patient Name] in their [Session Number]. In the Subjective section, it describes the patient's self-perception of their current state, integrating the [VAS Pain Level] reported today versus the previous session. You should specifically mention any changes in daily functionality, sleep quality, or decrease in peripheral neurological symptoms if they existed previously, maintaining a formal and descriptive tone.


For the Objective section, detail the [Palpatory Findings] detected during the initial screening, mentioning levels of segmental restriction (e.g. L3 posterior-right), presence of hypertonicity in the paravertebral or quadratus lumborum muscles, and results of rapid screening tests such as the leg length test or the Derifield sign. Precisely specify the [Technique Used] (e.g. Diversified, Thompson Drop, Gonstead, Activator) and the correction vector applied to the [Adjusted Vertebral Segment].


In the Evaluation section, perform a clinical synthesis that correlates the intervention carried out with the immediate [Post-Adjustment Response] (e.g. release of restriction, improvement in range of motion, changes in dermatomal sensitivity). Determines whether the patient is responding according to the goals of the initial treatment plan or whether there is a plateau in recovery that requires special attention.


Finally, in the Plan section, establish directions for the next visit, including the recommended frequency and any [Lifestyle or Exercise Recommendations] instructions that have been assigned to the patient. The result must be a coherent, technical text ready to be integrated into a legal clinical history, avoiding redundancies and ensuring that each phrase adds value to the follow-up of the case.

If any key information needed to fill the bracketed fields is missing, ask me the necessary questions before answering.