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Diagnosis
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Chief Complaint
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Interval History
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Interval History
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PHYSICAL EXAM
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Vitals
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General WNL
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General Comments
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Lumbar Spine - Normal
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Lumbar Spine Comments
• • •
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Neurological Exam - Motor Normal
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Motor Exam comments
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Neurological Exam - As Listed Below
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Right Iliopsoas Grade
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Left Iliopsoas Grade
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Right Quadriceps Grade
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Left Quadriceps Grade
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Right Tibialis Anterior Grade
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Left Tibialis Anterior Grade
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Right EHL Grade
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Left EHL Grade
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Right Gastrocnemius Grade
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Left Gastrocnemius Grade
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Right Peroneal Grade
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Left Peroneal Grade
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Sensory Exam normal
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Sensory Exam As Indicated Below
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Sensory Exam comments
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Sensory Exam RLE
• • •
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Sensory Exam LLE
• • •
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Other pertinent exam findings
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Imaging
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XR
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CT Scan
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MRI
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Labs/Other Studies
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ASSESSMENT
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ASSESSMENT (Comments)
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PLAN:
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PLAN: Physical Therapy
• • •
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PLAN: Labs
• • •
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PLAN: Radiology
• • •
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PLAN: Referrals
• • •
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PLAN: Neurodiagnostics
• • •
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PLAN: General Instructions
• • •
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ACDF
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Cervical Posterior Decompression and Fusion
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Laminoplasty
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XLIF
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Lumbar Disecectomy
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Lumbar Decompression
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Lumbar Posterior Fusion
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Lumbar Decomrpression/PSF
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ALIF
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BMP
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FOLLOW-UP
• • •
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Total time spent
• • •
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SALUTATION
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