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Pt described as:
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Chief Complaint:
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Current symptoms:
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Comments:
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diabetic or non-diabetic?
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other conditions include:
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Current treatment for foot issues:
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Comments:
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Last time patient saw PCP?
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Patient's Primary Care Provider is :
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Hazardous for non-medical foot care?
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Needs to be seen in home environment
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Right foot: Scaling
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Scaling Right Comments:
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Right foot: Fissure
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Fissure Right Comments:
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Right foot: Maceration
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Maceration Right Comments:
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Right foot: Hyperkeratotic Lesions
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Hyperkeratotic Lesions Right Comments:
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Right foot: Hair Growth
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Right foot: Skin Color
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Right foot: Skin Texture
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Left foot: Scaling
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Scaling Left Comments:
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Left foot: Fissure
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Fissure Left Comments:
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Left foot: Maceration
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Maceration Left Comments:
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Left foot: Hyperkeratotic lesions
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Hyperkeratotic Lesion Left Comments:
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Left foot: Hair Growth
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Left foot: Skin Color
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Left foot: Skin Texture
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Additional discriptions: describe here
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NAIL DISORDERS: none noted
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Painful nail on palpation
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Painful border on palpation
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Painful Border Comments:
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Nail incurvation
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Nail Incurvation Comments:
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Split/loosened from nail bed
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Nail Bed Comments:
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Discoloration
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Discoloration discription:
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Crumbly, subungual debris
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Thickened
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Thickness in mm:
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Non-dystrophic Toenails
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Toenails # thick/dystrophic w/subungual debris
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Elongated toe nails: choose all approp.
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Foot Diagram
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feet images
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VASCULAR EXAM: R Dorsalis Pedis pulse
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R Posterior Tibial pulse
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R hallux capillary filling time # seconds
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R Edema
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R Varicosities: present/absent
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R Temp. gradient anterior leg to dorsal foot:
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R claudication: present/absent
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L Dorsalis Pedis pulse:
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L Posterial Tibial:
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Left hallux capillary filling time # secs
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L Edema
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L Varicosities: present/absent
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L Temp. gradient anterior leg to dorsal foot:
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L claudication: present/absent
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Other findings: type here
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Amputation:
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Musc Skel exam: gait
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R Muscle strength dorsiflexion 0-5
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R plantarflexion 0-5
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R inversion 0-5
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R eversion 0-5
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R atrophy? present/absent
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L muscle strength dorsiflexion 0-5
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L plantarflexion 0-5
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L inversion 0-5
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L eversion 0-5
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L atrophy: present/absent
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ROM- Dorsiflexion:Right N/L/P
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Plantarflexion Right: N/L/P
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Inversion Right: N/L/P
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Eversion: Right: N/L/P
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ROM- Left Dorsiflexion: N/L/P
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Left Plantarflexion:N/L/P
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Inversion: Left N/L/P
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Eversion: Left: N/L/P
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Right ankle instability: present/absent
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Comment:
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Right Hallus valgus: present/absent
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Right Hammertoes
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Right Tailor's bunion: present/absent
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Right Claw toes 1-5
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Right Pes planus present/absent
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Left ankle instability: present/absent
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Comment:
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Left Hallus valgus: present/absent
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Left Hammertoes
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Left Tailors bunion: present/absent
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Left Claw toes 1-5
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Left Pes Planus: present/ absent
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NEURO: Right- Parasthesia- present/absent
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Right burning: present/absent
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Right light touch plantar: present/absent
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Right vibratory Sensation at 1st MPJ
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Left parasthesia: present/absent
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Left burning: present/absent
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Left light touch plantar: present/absent
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Left vibratory sensation at 1st MPJ
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Semms-Weinstein 5.07 monofilament. Turn on.
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Semms Weinstein Findings:
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Semms Weinstein Comments:
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ASSESSMENT/DIAGNOSES
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Other Assessments/ Diagnoses:
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PROCEDURES/PLANS: turn on
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Debrided (#how many) mycotic nails?
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Trimmed (# how many) non-dystrophic nails?
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Trimmed (# how many) dystrophic nails?
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Other treatments
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Additional treatments/ instructions:
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Debrided # incurvated nail borders
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Injection of: (drug)
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Site of injection:
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Incised and drained: (describe)
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Dressing: describe
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Prescribed: (Rx)
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Debrided ulcer: (location)
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Debrided to level of epidermis,dermis, subQ
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Avulsed: (location)
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Comments:
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Performed matrixectomy:(location)
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Trim non-dystrophic nails CASH PAY
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Trim non-dystrophic nails, Q7
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Trim non-dystrophic nails, Q8
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Trim non-dystrophic nails, Q9
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Debride nails 5 or less, CASH PAY
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Debride nails 5 or less, Q7
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Debride nails 5 or less, Q8
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Debride nails 5 or less. Q9
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Debride nails 6 or more, CASH PAY
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Debride nails 6 or more. Q7
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Debride nails 6 or more. Q8
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Debride nails 6 or more. Q9
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Permanent ingrown removal TA
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Permanent ingrown removal T1
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Permanent ingrown removal T2
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Permanent ingrown removal T3
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Permanent ingrown removal T4
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Permanent ingrown removal T5
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Permanent ingrown removal T6
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Permanent ingrown removal T7
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Permanent ingrown removal T8
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Permanent ingrown removal T9
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PROCEDURES: Lesion Destruction
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Benign, any method, 1st
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Location:
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Benign, any method, 2-14 (add on)
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Location:
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Benign, any method, 15+ (total)
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Location:
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INCISION AND DRAINAGE
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I&D simple/single abscess
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Location:
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I&D complex/multiple abscesses
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Location:
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I&D hematoma/seroma
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Location:
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Aspirate/puncture abscess/hematoma
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I&D Post-op infection
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DEBRIDE SKIN
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Debride skin partial/full thickness
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HYPERKERATOTIC LESIONS
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Pare benign hyperkeratotic, single, Q7
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Pare benign hyperkeratotic lesion, single Q8
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Pare benign hyperkeratotic, single lesion Q9
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Pare benign hyperkeratotic, 2 thru 4. Q7
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Pare benign hyperkeratotic, 2 thru 4. Q8
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Pare benign hyperkeratotic, 2 thru 4. Q9
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Pare benign hyperkeratotic, 5+. Q7
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Pare benign hyperkeratotic, 5 or more. Q8
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Pare benign hyperkeratotic, 5 or more. Q9
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INJECTIONS
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Comments:
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Inject tendon sheath, ligament, ganglion cyst
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Comments:
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Inject tendon origin/insertion
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Location:
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Inject nerve block
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Comments:
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Injection treatment of nerve
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Location:
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Drain/inject joint/bursa, small
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Location:
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Drain/inject joint/bursa, intermediate
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DIABETIC SHOES
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Diabetic Shoes: 1 pair ordered
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Diabetic Shoes: 1 pair ordered
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Diabetic Heat mold inserts ordered: 1 pair
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Diabetic Heat mold inserts ordered: 1 pair
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Diabetic Heat mold inserts ordered: 1 pair
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PADDING AND STRAPPING
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Strap ankle
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Strap toes
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Unna boot
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TREATMENT: mycotic toenails / debridement
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TREATMENT: mycotic toenails/ trim w/ TT & M
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TREATMENT: mycotic toenails w/ TT & M
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TREATMENT: Non-dystrophic/ dystrophic toenails
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TREATMENT: Corns / Callosities
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TREATMENT:Superfic.Wound,abrasion,laceration
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TREATMENT: superficial iatrogenic lac.
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INSTRUCTIONS: Capsaicin cream
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INSTRUCTIONS: OTC Lamisil (Tinea Tx)
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INSTRUCTIONS:Gold Bond Diabetic lotion
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INSTRUCTIONS FOR EDEMA
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EDUCATION: check on
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Education:choose from drop down
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Additional Education Instructions:
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FOLLOW-UP: Check on
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Choose follow up instructions:
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BILLING CODE: turn ON
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INDEPENDENT/HOME VISIT NEW
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Moderate Complexity
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High Complexity
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Moderate complexity, HOSPICE
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High complexity, HOSPICE
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INDEPENDENT/HOME VISIT ESTABLISHED
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Moderate complexity
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High complexity
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Moderate complexity, HOSPICE
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High complexity, HOSPICE
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Assisted Living, NEW
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Moderate complexity
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High complexity
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Moderate complexity, HOSPICE
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High complexity, HOSPICE
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Assisted Living, Established
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Moderate complexity
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High complexity
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Moderate complexity, HOSPICE
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High complexity, HOSPICE
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