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Exam Type:
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No Accident:
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Date of Accident:
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Body parts injured:
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Accident Info:
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Subjective:
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Main Problem:
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Main Problem Dictation:
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Pain Level:
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Pain Level Change:
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Site of Pain:
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Pain Description:
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Onset:
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ONSET NO INJURY
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Duration:
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Current Meds:.
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Heartburn:
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On blood thinners:
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Increased Pain:
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Decreased Pain:
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Radiating/Paresthesia:
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Radiating/Paresthesia Area:
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Catching:
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Range of Motion:
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No Pre-existing:
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Pre-existing condition:
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Aggravation:
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Objective:
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Exam deferred to next visit.
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Swelling:
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Swelling Site:
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Ecchymosis:
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Ecchymosis Site:
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1st carpal-metacarpal joint:
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Grind test for DJD 1 st C-MC Joint:
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Exam 1st ray colateral ligament:
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Exam of the 1st ray radial side
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Exam of 1st ray ulnar side:
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No triggering:
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Yes triggering
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Neurovascular:
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Supination:
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Pronation:.
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Tinel:
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Phalen:
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Elbow Tinel:
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Range of Motion Wrist:
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Range of Motion Fingers:
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Ulnar Deviation:
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Radial Deviation:
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Elbow Tender:
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Radial Head Tender:
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X-Ray:
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X-ray Results:
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Xray Dictation:
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MRI REVIEWED:
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MRI DICTATION:
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Correlation:
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Assessment:
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Assessment:
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Assessment Dictation:
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2ndry to MVA:
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Accident aggravated PP:
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2ndry to slip & fall:
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Slip & fall aggravated PP:
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Surgery Discussion:
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Plan:
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Return Appointment:
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Work Status/School Status:
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Stressed home/formal PT:
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No Work::
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PT 1X Visit:
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Reinstructed in home PT:
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Counseled in smoking:
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Durable Medical Goods:
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Disposition:
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Patient currently in Pain Management:
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WT DISCUSSION AGREED/DECLINED:
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Heartburn:
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KASPER:
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Medications:
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Cautioned Medications:
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Continue meds other source:
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C & I blood thinners:
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Patient is released:
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No Meds:
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Final Discharge Options:
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