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Beginning Time
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Ending Time
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Subjective:
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Affected Areas
• • •
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Main Symptoms
• • •
|
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MOI
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Pain rating
|
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ADLs
• • •
|
Additionally, patient reports
|
|
Objective:
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|
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Cervical Posture/Observation
• • •
|
Cervical AROM
• • •
|
|
Cervical Strength
• • •
|
Tenderness
• • •
|
|
Shoulder AROM
|
UE Dermatomes
|
|
UE Myotomes
|
Deep Tendon Reflexes
• • •
|
|
Neural Tension
• • •
|
Cervical Special Tests
• • •
|
|
Flexibility
• • •
|
Additional information includes
|
|
|
|
|
Shoulder Posture/Observation
• • •
|
Shoulder AROM
• • •
|
|
Shoulder Strength
• • •
|
Shoulder Special Tests
• • •
|
|
Tenderness
• • •
|
Additional information includes
|
|
|
|
|
Elbow Observation
• • •
|
Elbow AROM
• • •
|
|
Elbow Strength
• • •
|
Elbow Special Tests
• • •
|
|
Tenderness
• • •
|
Additional information includes
|
|
|
|
|
Wrist Observation
• • •
|
Wrist Range of Motion
• • •
|
|
Wrist Strength
• • •
|
Hand Range of Motion
• • •
|
|
Hand Strength
• • •
|
Wrist Special Tests
• • •
|
|
Tenderness
• • •
|
Additional information includes
|
|
|
|
|
Lumbar Posture/Observation
• • •
|
Lumbar Range of Motion
• • •
|
|
Strength
• • •
|
LE Dermatomes
|
|
LE Myotomes
|
Neural Tension
• • •
|
|
Deep Tendon Reflexes
• • •
|
Special Tests
• • •
|
|
Tenderness
• • •
|
Flexibility
• • •
|
|
Lifting Technique
|
Gait
• • •
|
|
Additional information includes
|
|
|
|
|
|
Hip Observation
• • •
|
Hip Range of Motion
• • •
|
|
Hip Strength
• • •
|
Flexibility
• • •
|
|
Hip Special Tests
• • •
|
Tenderness
• • •
|
|
Gait
• • •
|
Additional information includes
|
|
|
|
|
Knee Observation
• • •
|
Knee Range of Motion
• • •
|
|
Strength
• • •
|
Flexibility
• • •
|
|
Knee Special Tests
• • •
|
Tenderness
• • •
|
|
Gait
• • •
|
Additional information includes
|
|
|
|
|
Ankle Observation
• • •
|
Ankle Range of Motion
• • •
|
|
Ankle Strength
• • •
|
Ankle Special Tests
• • •
|
|
Tenderness
• • •
|
Additional information includes
|
|
|
|
|
Current Mobility G-code
|
Goal Mobility G-Code
|
|
Discharge Mobility G-Code
|
Current Body Position G-code
|
|
Goal Body Position Status G-Code
|
Discharge Body Position Status G-Code
|
|
Current Carrying, Moving & Handling G-code
|
Goal Carrying, Moving, & Handling G-Code
|
|
Discharge Carrying, Handling, and Moving G-Code
|
Current Self Care G-code
|
|
Goal Self-Care G-Code
|
Discharge Self-Care G-Code
|
|
|
|
|
Therapeutic Exercise
|
Cervical AROM Exercises
|
|
Shoulder AROM Exercises
|
Elbow AROM Exercises
|
|
Wrist AROM Exercises
|
Hand AROM Exercises
|
|
Lumbar AROM Exercises
|
Hip AROM Exercises
|
|
Knee AROM Exercises
|
Ankle AROM Exercises
|
|
Core Muscle Exercises
• • •
|
Postural Exercises
• • •
|
|
Additional info for Ther Ex
|
|
|
|
|
|
Assessment:
|
|
|
Physical Therapy Diagnosis
• • •
|
Assessment
• • •
|
|
|
|
|
Plan of Care:
|
|
|
Areas to be Treated
• • •
|
Return Appointment
|
|
HEP
|
Additional HEP
|
|
|
|
|
STG 1 Pain
|
STG 2 AROM
|
|
STG 3 MMT
|
STG 4 ADL Function
|
|
STG 5 HEP
|
STG 6 RTW
|
|
STG 7 Miscellaneous
|
LTG 1 Pain
|
|
LTG 2 AROM
|
LTG 3 MMT
|
|
LTG 4 ADL Function
|
LTG 5 HEP
|
|
LTG 6 RTW
|
LTG 7 Miscellaneous
|
