From the Guidelines
To document ART abnormalities in a note for OMM for tight muscles in the right side of the neck, I recommend using a clear, systematic approach, as this is crucial for establishing medical necessity, tracking improvement, and communicating findings to other healthcare providers 1. When documenting ART findings, it is essential to capture the three key components of somatic dysfunction assessment in osteopathic practice: Asymmetry, Restriction of motion, and Tissue texture abnormality. The following steps should be taken:
- Document asymmetry by noting the visible or palpable differences between sides, such as "right cervical paraspinal muscles elevated compared to left"
- Document restriction of motion by describing the specific movement limitations, such as "decreased right cervical rotation and sidebending"
- Document tissue texture abnormalities by describing the quality of the tissues upon palpation, such as "hypertonicity and ropiness of right sternocleidomastoid, scalenes, and upper trapezius muscles" Additionally, it is crucial to document the specific segments affected (e.g., C2-C5) and any pain or tenderness reported by the patient during examination, as this information is vital for guiding treatment and assessing outcomes 1. By following this systematic approach, healthcare providers can ensure that their documentation is comprehensive, accurate, and effective in communicating the patient's condition and treatment needs.
From the Research
Writing ART Abnormalities in a Note for OMM
To write Active Release Technique (ART) abnormalities in a note for Osteopathic Manipulative Medicine (OMM) for tight muscles in the right side of the neck, consider the following points:
- Identify the specific muscle groups involved, such as the upper trapezius or levator scapulae muscles 2
- Note the presence of latent trigger points (LTrPs) and their location in the affected muscle groups 2
- Describe the range of motion and any restrictions in the cervical spine, such as limited lateral flexion 2
- Record the patient's pain intensity using a visual analog scale (VAS) and any changes after treatment 3, 2, 4
- Document the specific ART techniques used, such as the direction and depth of pressure, and any notable findings or responses from the patient
Key Points to Include
- Muscle group(s) involved
- Location and presence of LTrPs
- Range of motion and restrictions
- Pain intensity (VAS)
- Specific ART techniques used
- Notable findings or responses from the patient
Example Note
Example of a note for OMM using ART for tight muscles in the right side of the neck: "The patient presented with tightness in the right upper trapezius muscle, with a notable LTrP located 2 cm from the spine. The patient's cervical lateral flexion was limited to 20 degrees on the right side. The patient reported a pain intensity of 6/10 on the VAS. ART was applied to the affected area, using a deep, longitudinal stroke to release tension in the muscle. The patient reported a decrease in pain intensity to 3/10 after treatment." 2, 4