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Soft Tissue Shoulder Disorders Care Pathway

Date of last update: September, 2024

1. Record Keeping

Record keeping serves as a recall aid for the clinician of their interaction with the patient. It should concisely “tell the story” of the patient, and accurately reflect those interactions. Record-keeping requirements may be established by your jurisdiction’s standards of practice. These standards should be adhered to when maintaining your clinical records.

Subjective: Document the patient's reported symptoms, feelings, and feedback at each visit.

Objective: Record observable and measurable data such as physical examination findings and outcome measures.

Assessment: Provide a clinical assessment based on the subjective and objective data. Affirm or revise the diagnosis. Information about the patient's progress towards their goals could be recorded here.

Plan: Outline the treatment plan, any adjustments made, advice or other additional interventions or referrals. Any care or plan of care should reasonably be supported by the documented patient “story”. Timeline for follow-up and re-evaluation could be recorded here.

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

All content and media on the Canadian Chiropractic Guideline Initiative (CCGI) website is created and published online for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. Always seek the guidance of a qualified health professional with questions, concerns or management regarding your health.

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