|
Visit Number
|
Lower Extremity Function Outcome
|
|
Body Area
• • •
|
Side
|
|
Subjective:
|
|
|
Subjective Information
|
|
|
Function
• • •
|
Patient actively participates in...
|
|
Pain Header
|
Patient says pain...
• • •
|
|
Pain- Resting
/
|
Pain- Active
/
|
|
Areas of Pain Default
|
|
|
Objective:
|
|
|
Range of Motion Default
|
|
|
Objective Notes
|
|
|
Session Treatment
|
|
|
Daily Treatment Header
|
|
|
Stretching
• • •
|
Therapeutic Exercises
• • •
|
|
Manual Treatment
• • •
|
Daily Treatment notes
|
|
HEP
|
|
|
Treatment Default
|
No Changes to HEP/TX Sheet
|
|
Assessment:
|
|
|
Tolerated Treatment Y/N
|
Assessment
|
|
HEP Update
|
|
|
Plan:
|
|
|
Short term plan/goal
|
Plan of care ST
|
|
Short term plan
• • •
|
Plan of Care LT
|
|
Long term plan/goal header
|
|
|
Long Term Goals/Plans
• • •
|
|
|
Treatment time
|
|
|
Discharge
|
|
|
Referral
|
|
