Chiropractic Soap Note Template

							                                    CLI 650

                         Introduction to Clinic II
                                  Spring 2009


Trimester Credit Hours: 0.5
Trimester Contact Hours: 15
Lecture Hours/Week: 0
Trimester Lecture Hours: 0
Lab Hours/Week: 1
Trimester Lab Hours: 15
Course Prerequisites: Intro to Clinic I

Meeting times: Lab A: Thursday’s @ 8:30, Room 3080
               Lab B: Thursday’s @ 9:30, Room 3080

Course Instructor:
Nathan Bailey, DC

Phone: 913-234-0776 (ext. 1776)
E-mail: nathan.bailey@cleveland.edu
Office Location: 1173 Overland Park Campus
Office hours: By appointment (Tuesday and Thursday only)

Course Co-instructors: Drs. Debra Denno and James Bond

Course Description: This laboratory course presents a review of clinic
procedures, with emphasis on assessment and rationale for choice of technique
and treatment plan, utilizing the techniques covered in Cleveland Comprehensive
Methods.


Required Text: Current edition of the CCCKC Clinic Policies and Procedures
Manual, and course notes.


Attendance: Attendance is required at all times. Attendance is taken every class
session and students are responsible for all assignments and requirements
whether or not they are in attendance. Course credit will be given only if the
student is present at least ninety percent of the time completes the course with a
passing grade. Should absences exceed ten percent of the scheduled class time
the student will be dismissed from the class with the grade of “XF”.


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Class Participation: Class participation is mandatory. This includes gowns and or
shorts for patients who are treated in class.

Evaluation: The final grade will be determined by two assignments, a quiz,
attendance and technique/documentation evaluations. Each of these 5 criteria is
outlined below with their assigned points.

      Assignment # 1                       65 points
      Assignment # 2                       85 points
      Quiz (Phases of Care Definitions)    14 points
      Technique/documentation evaluations 36 points (see “Intro to Clinic
      _________________________________Evaluation” form below) _____
      Maximum total points                200 points



      Grading Scale:

      180- 200 points (90%-100%)        A
      160- 179 points (80%-89%)         B
      140- 159 points (70%-79%)         C
      120- 139 points (60%-69%)         D
      Less than 120 points (0%-59%)     F

Assignments 1 and 2:
      Assignments 1 and 2 will be take home assignments where you will be
      asked a series of questions based on a case study. The questions will
      contain basic science and clinical science questions. Assignment 2 will be
      comprehensive containing not only basic science and clinically oriented
      questions but also documentation oriented questions.
      In accordance with academic policy, all students must obtain a
      minimum score of 70% on the comprehensive final assignment
      (Assignment/Case study #2) in order to successfully pass this
      course regardless of the grade or cumulative points earned before
      going into said final. If the student passed the final assignment by
      70%, the final grade is base on the following grading scale.

Assignment/Evaluation Schedule

Assignment #1: Case study 1 due March 5th, more information will accompany
case study.

Assignment #2: Case study 2 due April 9th, more information with case study.
This will be comprehensive.

      Intro to Clinic Technique/documentation evaluations


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      Students will be graded on the performance of chiropractic assessments
      (static and motion palpation), and chiropractic adjustments. They will also
      be evaluated on the quality of SOAP note documentation. The categories
      and points per category on the “Intro to Clinic evaluation form” will serve
      as the standard template when instructors evaluate students. To keep
      parity in the grading process, each student should be evaluated by each
      instructor at least once during the semester. The student’s highest
      three grades from this form will count towards the student’s final
      grade. It is expected students will perform more than three “treatments”
      during the course of the semester in order to maximize the student’s
      “hands-on” experience and increase proficiency. It should be noted that
      when instructors grade students in these categories, each instructor will
      weigh the students experience level into the total grade on any given
      evaluation form.


                      Intro to Clinic Evaluation Receipt
Intern Name____________________Intern #________
Patient #_____________
                                                                       Grade
“S” Note                       0             1             2        A = 10 - 12
“OAP” Note                     0             1             2        B=8-9
Static/Kinetic Palp            0             1             2        C=6-7
Tissue Pull                    0             1             2        No Credit = 5
Set Up/LOD                     0             1             2        or below
Thrust                         0             1             2
Grading Key               Unacceptable   Acceptable     Excellent        Total



Comments:_________________________________________________
___________________________________________________________
______________________________

Clinician ___________________________ Date __________




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Examinations:
A student who arrives late to an examination will only be allowed to sit for the
exam if no other student has already completed it. Additional time is not available
to students who arrive late.
There will be no early examinations given to students.
Random seating arrangements may be made for scheduled examinations. It is
the responsibility of the student to be present and on time so the seating can be
quickly accomplished.


Make-up Examinations: No make-up examinations will be given unless the
student demonstrates extenuating circumstances accepted as such by the
instructor. The student must present to the instructor immediately upon missing
an examination and the student must provide appropriate documentation of an
extenuating circumstance that necessitates missing the examination. If a make-
up examination is granted, it must be completed within five days of the regularly
scheduled examination. If you miss a major examination and the instructor
allows a make-up for said missed examination, please be advised that this
make-up may be of any format.

In all cases where a make-up examination is requested, the instructor reserves
the right to assess the situation and act accordingly.


Academic Policies: The College policies regarding course withdrawals,
incompletes, etc. will be followed as described in the College Catalog.

Special Accommodations: Cleveland Chiropractic College has adopted the
definition of disability as “a physical or mental impairment that substantially limits
one or more of the major life activities of an individual, such as caring of oneself,
learning, working, performing manual tasks, walking, seeing, hearing, speaking,
and breathing.” Impairment may be “any physiological disorder or condition,
cosmetic disfigurement, anatomical loss or psychological disorder such as
retardation, organic brain syndromes, emotional or mental illness, and specific
learning disabilities.”

If you have a documented disability, which requires academic accommodations,
please see me as soon as possible during my scheduled office hours. In order to
receive accommodations in this course, I must be provided a Letter of
Accommodation from the Office of Student Services. If you have not already
done so, please register with Student Services.

Standards of Conduct: As a future doctor of chiropractic, you are expected to
adhere to the highest professional, ethical, and personal, standards of conduct.
Any activities that violate the standards of student conduct specified in the
College Catalog, Student Handbook, or Clinic Manual will form the basis of
disciplinary actions towards those involved.

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Course Objectives: This course is the second in a series of two courses
designed to familiarize the student with the Clinic protocols, continue the
transition from student to intern, and to provide clinical experience in patient
assessment and treatment procedures. In this course, the student will learn
additional clinical procedures; continue to develop patient assessment skills
delineated in the CCE Clinical Competency. This course is designed to prepare
the intern for a fluid transition into the Student Clinic.


Course Outline:

Week 1: Introduction, Review Syllabus, explain course objectives, mechanics
and requirements, Bergmann article, and Phases of Care Definitions form.

Week 2: Bergmann article Quiz, Lecture SOAP, PARTS and general
documentation protocols.

Week 3: Lecture SOAP, PARTS and general documentation protocols.
Discussion and examples, and Phases of Care Definitions form.

Weeks 4 -11: Lab SOAP documentation, treatments and Intern/ evaluations.
     (DT form overview and patient visit protocol during week 4)

Weeks 12, 13, and 14: Case studies explanation and discussion (from the two
assignments).



*** The course topics and sequence are subject to change.




Recommended references for further reading:

Yeomans SG. The Clinical Application of Outcomes Assessment. Stamford:
Appleton & Lange 2000

ACA Clinical Documentation Manual- 2005.




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Cleveland Chiropractic College
Code of Honor and Integrity

Honesty, integrity and high ethical standards are essential features of Cleveland
Chiropractic College. The honor code helps to build trust within the college
community and instills common values and principles that will extend into all
facets of personal and professional life.

As members of the Cleveland Chiropractic College community all faculty, staff
and students are bound by honor to uphold professional standards of respect,
honesty, integrity and social responsibility. We are responsible for promoting
ethical behaviors and endeavors both in and out of the classroom and will act in
a manner, which demonstrates concern for the personal dignity, rights and
freedoms of all members of the community. We pledge that we will not take
unfair advantage of any other member of the College community either by lying,
cheating or plagiarizing. We are respectful of college property and the property
of others.

I acknowledge that I am responsible for upholding the Honor Code at all times
and that failure to do so will result in disciplinary action.

________________________________                             January 6, 2009

Signature                                                    Date

Nathan D. Bailey, DC




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