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Subjective:
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Initial Comments
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Primary complaint
• • •
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Mechanism of Injury (T)
|
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Date of Onset
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quantify the Onset
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VAS
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Nature of Pain
• • •
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Denies radiating symptoms
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Radiating symptoms are (T)
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Relief
• • •
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Provocative
• • •
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Frequency
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Timing
• • •
|
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No other care before toay.
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Other Healthcare Providers
• • •
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Night sweats / Unexplained Weight Loss
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Sleep
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Other comments
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Disability index % (T)
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History of Illness
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|
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Secondary complaint
• • •
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Onset (T)
|
|
VAS
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Mechanism of Injury
|
|
Relief
• • •
|
Provocative
• • •
|
|
Denies radiating symptoms
|
Radiating symptoms are
|
|
Frequency
|
Timing
• • •
|
|
History of Illness
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Other comments
|
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Disability index % (T)
|
|
|
3rd complaint ALL (T)
|
Disability index % (T)
|
|
4th complaint (T)
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Disability index % (T)
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|
|
|
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Objective
|
|
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DTR normal
|
DTR not normal
• • •
|
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Gait
• • •
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Distress/tired
• • •
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C/S
|
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Muscle spasms
• • •
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muscle tendernes
• • •
|
|
fluid motion
• • •
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Pain?
• • •
|
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Cervical ROM
• • •
|
Pain?
• • •
|
|
Posture/observation
• • •
|
Trigger points location (T)
|
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Comment
|
|
|
Cervical Spine Orthopedic Tests
|
Max cervical compression
• • •
|
|
Shoulder depressor
• • •
|
Cervical distraction
• • •
|
|
Cervical compression
• • •
|
Dekleyn's
• • •
|
|
Bakody's
• • •
|
upper extermity sensory exam
• • •
|
|
Upper extremity strength
• • •
|
Comment
|
|
Other Orthopedics (T)
|
|
|
Thoracic:
|
Thoracic posture
• • •
|
|
fluid motion
• • •
|
Pain?
• • •
|
|
Muscle spasms
• • •
|
muscle tendernes
• • •
|
|
Rib motion
• • •
|
Adams Sign
|
|
Soto Halls
• • •
|
Trigger points location (T)
|
|
Comment
|
Other Orthopedics (T)
|
|
L/S:
|
|
|
Dorsolumbar ROM
• • •
|
Pain?
• • •
|
|
Lower extremity strength
• • •
|
Pain?
• • •
|
|
muscle spasms
• • •
|
pain?
• • •
|
|
leg length (short)
|
Sensory exam
• • •
|
|
Posture
• • •
|
Trigger points location (T)
|
|
Pelvis
• • •
|
Comment
|
|
Lumbar Spine Orthopedic Tests
|
Trendelenburg
|
|
SLR
• • •
|
radiating with SLR
• • •
|
|
Slump test
• • •
|
FABERE's
• • •
|
|
Toe Walk
|
Heel Walk
|
|
Yeomans
|
Kemps test
• • •
|
|
Other Orthopedics(T)
|
|
|
Shoulder Exam
|
Observation
• • •
|
|
Shoulder ROM
• • •
|
Muscle palpation
• • •
|
|
Upper extremity strength
• • •
|
upper extermity sensory exam
• • •
|
|
Shoulder orthopedic exams
|
|
|
Speeds Test
• • •
|
Empty Can
• • •
|
|
Dawburns Test
• • •
|
Hawkin's - Kennedy
• • •
|
|
Yergason's Test
• • •
|
Other orthopedic tests (T)
|
|
Elbow/Wrist/Hand
|
|
|
Observation:
• • •
|
Palpation of muscles
• • •
|
|
Elbow ROM and pain
• • •
|
Hand/finger ROM and pain
• • •
|
|
Wrist ROM
• • •
|
Wrist pain
• • •
|
|
Elbow Orthopedics
• • •
|
Other Orthopedics (T)
|
|
Knee/Ankle/Foot
|
|
|
Observation:
• • •
|
Palpation (Spasm)
• • •
|
|
Ankle ROM
• • •
|
ankle pain?
• • •
|
|
Knee ROM and pain
• • •
|
Foot/toes ROM and pain
• • •
|
|
Knee Orthopedics
• • •
|
Ankle Orthopedics
• • •
|
|
Other comments (T)
|
Other Orthopedics (T)
|
|
|
|
|
ASSESSMENT
• • •
|
prognosis fair/poor
• • •
|
|
ST Goals:______
|
LT goals
|
|
Comments
|
|
|
|
|
|
PLAN
• • •
|
|
|
T/S:____
• • •
|
C/S:____
• • •
|
|
L/S:____
• • •
|
SI
• • •
|
|
extremity adj type it out
|
|
|
Ice
|
Kinesio Tape
• • •
|
|
IASTM Area
• • •
|
IASTM time
|
|
Therapeutic Exercise: Areas___
• • •
|
Therapeutic Stretches
• • •
|
|
Treatment plan
• • •
|
Follow up on
• • •
|
|
Change in treatment plan
|
Treated by:
|
|
Chiropractic Adjustments 98940
• • •
|
Chiropractic Adjustments 98941
• • •
|
|
Extraspinal Adjustments 98943
• • •
|
Records reviewed
• • •
|
|
Therapeutic Exercise 97110
• • •
|
Radiology
• • •
|
|
Supplies
• • •
|
Cold/Hot Pack 97010
• • •
|
|
Acupuncture 97810
• • •
|
Laboratory
• • •
|
|
Electrical Stim Unattended G0283
• • •
|
Manual Therapy Techniques 97140
• • •
|
