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Exam Type:
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No Accident:
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Date of Accident:
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Accident Info:
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Other body parts injured:
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MRI:
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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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Heartburn:
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Current Meds:
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On blood thinners:
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Maximum 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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No Prior Treatment:
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Prior Treatment Consisted of:
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Prior Treatment this accident/episode:
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Radiating/Paresthesia Area:
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Radiating/Paresthesia Arm:
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Catching:
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Grinding:
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Decreased Pain:
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Increased Pain:
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ROM Dictation:
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Range of Motion:
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PT help:
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No Pre-Existing:
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Pre-Existing Aggravation:
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Pre-existing condition:
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Home PT:
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Objective:
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ROM:
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ROM Change:
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Exam deferred to next visit:
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Sterno-Clavicular Joint:
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Acromio-Clavicular Joint:
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Long Head Biceps:
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Subluxible Humeral Head:
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Clavicle Tender?
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Tenderness:
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Trapezius Muscle Pain?
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Fear of Dislocation:
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Muscle Atrophy:
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Muscle Strength Decreased?
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Subscapular Muscle Pain?
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Thumb Pressure Pain?
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Hang up test negative:
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Hawkins Sign Test:
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Hang up test positive:
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Prior Diagnosis:
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Neer Sign Test:
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X-Rays:
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Correlation Previous Problem:
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XRAY Dictation:
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X-Ray Results:
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MRI REVIEWED:
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MRI Dictation:
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MRI RESULTS:
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Assessment:
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Assessment:
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2ndry to MVA:
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Assessment Comments:
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2ndry to slip & fall:
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Accident aggravated PP:
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Surgery Discussion:
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Slip & fall aggravated PP:.
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Plan:
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Return Appointment:
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Stressed home/formal PT:
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Work Status:
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Counseled in smoking:
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No Work:
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Disposition:
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Reinstructed in home PT:
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PT 1X Visit:
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Continue:
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Stop other meds:
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WT DISCUSSION AGREED/DECLINED:
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Durable Medical Goods:
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KASPER:
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Heartburn:
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No Meds:
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Cautioned Medication:
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Medications:
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Patient is released:
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C & I blood thinners:
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Patient currently in Pain Management:
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Final Discharge Options:
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