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OMM Procedure Notes

Writing clear procedure notes is important for documenting osteopathic manipulative treatment (OMT). Key components of an OMT procedure note include the date, who performed the procedure, the indications or reasons for treatment, obtaining patient consent after discussing risks and benefits, describing the specific techniques used to treat areas of somatic dysfunction, noting any complications, and post-procedure instructions. Procedure notes should document the body areas assessed and treated and may use shorthand abbreviations to describe OMT techniques efficiently in just a few sentences.

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1K views2 pages

OMM Procedure Notes

Writing clear procedure notes is important for documenting osteopathic manipulative treatment (OMT). Key components of an OMT procedure note include the date, who performed the procedure, the indications or reasons for treatment, obtaining patient consent after discussing risks and benefits, describing the specific techniques used to treat areas of somatic dysfunction, noting any complications, and post-procedure instructions. Procedure notes should document the body areas assessed and treated and may use shorthand abbreviations to describe OMT techniques efficiently in just a few sentences.

Uploaded by

Jason Wong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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OMM Procedure Notes

Writing a procedure note is an important component to providing OMT which is a medical


procedure. Procedure notes have several main components:
Date, Time, who performed the procedure (Student name/attending name)
Procedure (OMT)
Indications (Somatic Dysfunction)
Patient Consent (verbal, or written and discussion of risks and benefits)
Description of the Procedure (describe what body areas were treated with what types of
techniques)
Complications (none, or describe what complication happened)
Disposition (describe how patient was after the procedure, what they should do if any
complications happen after they leave, how they should follow-up)

For OMT this can be accomplished in several ways as evidenced by the examples below:

EXAMPLE 1
7/21/2015
Procedure: OMT performed by Napoleon Dynamite with Attending Dr. Pierce-Talsma in
attendance
Indications: Somatic Dysfunction
Consent: Risks and Benefits discussed with the patient who verbally consents to OMT today
Description:
OA sideslipped right- BLT
C3ERSr, C5ERSl, hypertonic scalenes bilat- ME and HVLA
T1SrRl, T3-6NSrRl, T7ERSl- Soft Tissue and HVLA
Right rib 1 elevated, right 4-6 exhaled- ME
L1ERSr, PL3-TP- HVLA and CS
R on R torsion- ME
Left Posterior innominate- ME
No complications during the procedure and the patient felt much better after the procedure.
Instructed to drink water and call office if signs or symptoms change or worsen.

Body areas that may be assessed, noted and billed for include:
Head
Cervical
Thoracic
Ribs
Lumbar
Sacrum
Pelvis
Upper Extremity
Lower Extremity
Abdomen
If your PE has your somatic dysfunction findings then you may utilize a note like this:

EXAMPLE 2
OMT was performed today for somatic dysfunction found on physical exam after informed
consent was obtained from the patient and risks and benefits of treatment discussed. OMT
including Soft tissue, BLT, ME, HVLA and CS were utilized in the head, neck, ribs, thorax, lumbar,
sacrum and pelvis with good effect and resolution. There were no complications to the
procedure. Patient was instructed to drink water and how best to address any post-treatment
soreness. The patient will follow-up within two weeks or will call if signs or symptoms change
or worsen.
Napoleon Dynamite- Attending Dr. Pierce-Talsma

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