|
SUBJECTIVE: Patient reports
|
|
|
CC#1:
|
CHIEF COMPLAINTS: CC#1: Pain _____/10
|
|
CC#2:
|
CC#2: Pain _____/10
|
|
CC#3:
|
CC#3: Pain _____/10
|
|
Symptoms
• • •
|
Comments
|
|
Improvement %
|
regressed %
|
|
ADL's
• • •
|
Comments about ADLs
|
|
Home Care
• • •
|
Comments
|
|
OBJECTIVE
|
|
|
Cervical ROM
• • •
|
cervical ROM pain
• • •
|
|
Dorsolumbar ROM
• • •
|
Dorsolumbar ROM pain
• • •
|
|
T/S:____
• • •
|
SI
|
|
L/S:____
• • •
|
Subluxation levels: C/S:____
• • •
|
|
ext/rib hypo
• • •
|
Tenderness
|
|
Thoracic Muscle spams
• • •
|
Cervical Muscle spams
• • •
|
|
Lumbar Muscle spams
• • •
|
|
|
Posture and leg length
• • •
|
Antalgic /gait
• • •
|
|
Progress
• • •
|
Additional Assessment/orthopedics
|
|
|
|
|
ASSESSMENT
• • •
|
Phase of Care
• • •
|
|
ST Goals:______
|
LT goals
|
|
|
|
|
PLAN
• • •
|
|
|
T/S:____
• • •
|
C/S:____
• • •
|
|
L/S:____
• • •
|
SI
• • •
|
|
extremity adj type it out
|
Ice
|
|
Graston Area
• • •
|
Graston time
|
|
Therapeutic Exercise: Areas___
• • •
|
Kinesio Tape
• • •
|
|
Treatment plan
• • •
|
Change in treatment plan
|
|
Follow up on
• • •
|
|
