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HPI
|
|
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Location of pain
• • •
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Gradual. No recent trauma.
|
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Chronic sx. Similar to prior episodes.
|
MOI
• • •
|
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Ambulate?
• • •
|
Mod.Nonradiating.No numbness.Worse with movement
|
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No medications PTA
|
Worse with weight bearing
|
|
Additional notes
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|
|
|
|
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REVIEW OF SYSTEMS
|
|
|
MSK: (positive)
• • •
|
MSK (negative)
• • •
|
|
Neuro (positive).
• • •
|
Neuro (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
MSK: Location: *
• • •
|
|
|
MSK (positive)
• • •
|
MSK (negative)
• • •
|
|
FROM. N/T. No bruising or deformity. NVI
|
|
|
Additional
|
|
|
PE: Superficial
|
Focused exam (Systems:General: NAD. CSM intact.)
|
|
Insert PE Macro Here
|
|
|
|
|
|
MDM
|
Clinic Visit CPT CODE***
|
|
DDx: Fracture, sprain, strain, ligamentous injury, tendonitis
|
MDM Notes
|
|
Status:
|
Diagnosis:
• • •
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
Status:
|
Diagnosis:
|
|
|
|
|
Splint Procedure Attestation IF PERFORMED BY CLINICIAN
|
|
|
Location
|
Indication:
|
|
Type of Splint***
• • •
|
Material Used ****
• • •
|
|
Reduction technique
|
Post procedure films: successful reduction.
|
|
CSM intact. Pt tolerated procedure well.
|
Good alignment and positioning
|
|
Crutch training provided
|
***ORTHO SUPPLIES DISPENDSED***
• • •
|
|
Notes:
|
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Referral to:
• • •
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge Note: ERD ONLY
|
