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Chief Complaint
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No Change HPI
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Relevant History & Conditions
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Relevant History Comments
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Relevant Negative History & Conditions
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Relevant Negative History Comments
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Remarks
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Remark Comments
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Amputation
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Amputation Location
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Painful Lesions
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At Risk Foot Care
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EXAM
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Corns - LEFT
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Corns - RIGHT
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Callus - LEFT
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Callus - RIGHT
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IPK- LEFT
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IPK- RIGHT
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Characteristics
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Nail Pathology & Treatment
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T5
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TA
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T6
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T1
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T7
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T2
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T8
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T3
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T9
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T4
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ASSESSMENT - PAIN - Qualifying DX
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Pain in limb
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Pain in limb
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Marked limitation of ambulation
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Local infection / inflammation
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Nail dystrophy
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Corn / Callus
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Onychomycosis
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Keratoderma
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Ingrown nail
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IPK / Skin anomalies
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ASSESSMENT - At-Risk - Qualifying DX
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Dystrophic nail
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PAD / PVD
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Deformed nail
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ASO
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Onychomycosis
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DM - Type I
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DM - Type II
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Corn & Callus
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Coumadin Anticoagulation
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Class Findings - Q modifier
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Advanced Trophic Changes (3)
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CLASS A FINDINGS
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CLASS B FINDINGS (2)
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CLASS C FINDINGS
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CLASS FINDING FOR VASC COMPROMISED PATIENT
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New Field
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Pedal Pulses
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RIGHT: DP
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LEFT: DP
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RIGHT: PT
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LEFT: PT
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NAIL PLATE
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PLAN
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PLAN - Debride 2-4 Keratomas
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PLAN - Debride 1 Keratoma
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PLAN - Debride 5 or more Keratomas
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PVT - Debride 2 keratomas
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PVT - Debride 1 Keratoma
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PLAN: All Nails
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Debride Nails 6-10
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Debride Nails 1-5
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Trim Dystrophic Nails
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Trim Non-Dystrophic Nails
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Needs location and size
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Dx of Mycotic Nail
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MYCOTIC NAILS
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Clinical evidence of mycosis
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Pain due to the mycotic nail
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If left untreated
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Painful Ingrown Nails
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Paronychia / Inflammed
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Wedge Resection w/o Anesthesia
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Fungal/Deformed/Dystrophic
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Please select: 3 required
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Primary Care Doctor - Name
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UPIN
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Date Last Seen (within 6 months)
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Diagnosis of Routine Foot Care
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Systemic Conditions Justifying Routine Foot Care
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Assessment
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Plan
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Assessment
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Plan
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