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Vital Sign
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vital sign comment
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Height
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Weight
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Temp
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Blood Pressure
/
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Pulse
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Chief Complaint
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Chief Complaint
• • •
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History Of Injury / Causation
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History of Injury
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ROS
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Musculoskeletal
• • •
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Musculoskeletal [-]
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MSK Comments
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Neurological [-]
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Neurological
• • •
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Neuro Comments
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History of Present Complaint
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areas of complaints
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Location
• • •
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Location Comments
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Quality
• • •
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Quality Comments
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Severity
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Severity Comments
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Modifying Factors
• • •
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Modifying Factors Comments
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Physical Examination
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Extremities WNL
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Extrem Comments
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Orthopedic Evals
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Lt. Shoulder
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Rt. Shoulder
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Tenderness
• • •
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Observation
• • •
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Pos. Orthos
• • •
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Ranges of Motion
• • •
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Neg Ortho
• • •
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Lt. Elbow
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Right Elbow
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Tenderness
• • •
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Observation
• • •
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Ranges of Motion
• • •
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Pos. Orthos
• • •
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Neg Ortho
• • •
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Right Wrist
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Left Wrist
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Tenderness
• • •
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Observation
• • •
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Ranges of Motion
• • •
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Orthos
• • •
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Extremity Abnormal
• • •
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Right Hand/Fingers
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Left Hand/Fingers
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Tenderness
• • •
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Observation
• • •
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Ranges of Motion
• • •
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Orthos
• • •
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Reflexes
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UE Reflex bilateral
• • •
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UE Reflex Left
• • •
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UE Reflex Right
• • •
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Dermatomes
|
dermatomes
• • •
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Muscle Testing Brief
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Muscle Testing result
• • •
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Xray performed
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Xray findings
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Assessment and Plan
|
assessment
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PT recommendations
• • •
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PT Recommendation Comments
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Referrals
• • •
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Referral Comments
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