|
Note Type
|
|
|
Subjective
|
|
|
Subjective report
|
|
|
CC/ HPI
|
|
|
Problem 1 (P1)
|
Mechanism of Injury
|
|
Date of Injury
|
Quality
|
|
Current pain:_/10
|
Worst pain: _/10
|
|
Best pain: _/10
|
Exacerbating factors
|
|
Easing factors
|
Pattern
|
|
Prior level of function
|
Patient identified goals
|
|
Problem 2 (P2)
|
|
|
Problem 2 (P2)
|
Mechanism of Injury
|
|
Date of Injury
|
Quality
|
|
Current pain:_/10
|
Worst pain: _/10
|
|
Best pain: _/10
|
Exacerbating factors
|
|
Easing factors
|
Pattern
|
|
Prior level of function
|
Patient identified goal
|
|
Problem 3 (P3)
|
|
|
Problem 3 (P3)
|
Mechanism of Injury
|
|
Date of Injury
|
Quality
|
|
Current pain:_/10
|
Worst pain: _/10
|
|
Best pain: _/10
|
Exacerbating factors
|
|
Easing factors
|
Pattern
|
|
Prior level of function
|
Patient identified goal
|
|
Outcome Measure
|
|
|
FOTO score: _/100
|
|
|
Medical history
|
|
|
Medical history reviewed with patient
|
Medical history comments
|
|
Yellow flags
|
|
|
Red Flags
|
|
|
Objective
|
|
|
Objective Tests & Measures
|
|
|
Observation
|
|
|
Sitting posture
|
Standing posture
|
|
Sit > Stand Transfer
|
Gait
|
|
Toe walk
|
Heel walk
|
|
Single Limb Stance
|
Stair Navigation
|
|
Squat
|
Running
|
|
Additional Observation
|
|
|
Neurological Screen
|
|
|
Sensation
|
|
|
Light touch sensation:
|
Sharp/ dull:
|
|
Reflexes
|
|
|
C5
|
C6
|
|
C7
|
L3-L4
|
|
L5-S1
|
Babinksi
|
|
Clonus
|
Hoffman's Test
|
|
Inverted Supinator Sign
|
|
|
Cranial Nerve Exam
|
Cranial Nerve Exam Tested and Intact
|
|
CN I: Olfactory
|
CN II: Optic
|
|
CN III: Oculomotor
|
CN IV: Trochlear
|
|
CN V: Trigeminal
|
CN VI: Abducens
|
|
CN VII: Facial
|
CN VII: Vestibulocochlear
|
|
CN IX: Glossopharyngeal
|
CN X: Vagus
|
|
CN XI: Accessory
|
CN XII: Hypoglossal
|
|
Cranial Nerve Exam Comments
|
|
|
Upper Quarter Examination
|
|
|
Cervical Screen
|
Cervical Spine Cleared
|
|
Cervical Palpation Characteristics
|
|
|
Cervical Observation
|
|
|
Cervical ROM
|
|
|
Flexion
|
|
|
Extension
|
|
|
L Rotation
|
R Rotation
|
|
L Sidebend
|
R Sidebend
|
|
Cervical Retraction
|
|
|
Cervical Protraction
|
|
|
Cevical MMT: 0-5/5
|
|
|
Flexion
|
|
|
Extension
|
|
|
L Rotation
|
R Rotation
|
|
L Sidebend
|
R Sidebend
|
|
Cervical Retraction
|
|
|
Cervical Protraction
|
|
|
Cervical Special Tests
|
|
|
Spurling's Test
|
Distraction Test
|
|
Sharps Purser Test
|
ULTT Median Nerve
|
|
ULTT Radial Nerve
|
ULTT Ulnar Nerve
|
|
ULTT Musculocutaneous Nerve
|
Cervical Rotation Lateral Flexion Test
|
|
Sharp-Purser Test
|
Alar Ligament Test
|
|
Transverse Ligament Test
|
Additional Cervical Special Tests
|
|
Cervical Segmental Assessment
|
|
|
CPA/ UPA
|
Side Glides
|
|
Antlanto-occipital Joint
|
Atlantoaxial Joint
|
|
1st Rib
|
Other Cervical Segmental Assessment
|
|
Cervical Spine Additional Tests & Measures
|
|
|
Cervical Additional Tests & Measures
|
|
|
Thoracic Spine/ Ribs Screen
|
Thoracic Spine Cleared
|
|
Thoracic Spine/ Ribs Palpation Characteristics
|
|
|
Thoracic Spine/ Ribs Observation
|
|
|
Thoracic ROM
|
|
|
Flexion
|
|
|
Extension
|
|
|
L Rotation
|
R Rotation
|
|
L Sidebend
|
R Sidebend
|
|
Thoracic Segmental Assessment
|
|
|
CPA/ UPA
|
Other Thoracic Segmental Assessment
|
|
Rib Mobility Assessment
|
|
|
Rib Mobility Assessment
|
|
|
Thoracic/ Ribs Additional Tests & Measures
|
|
|
Additional Tests & Measures
|
|
|
Shoulder Screen
|
Shoulders Cleared
|
|
Shoulder Palpation Characteristics
|
|
|
Shoulder Observation
|
|
|
Scapular Dyskinesis
|
|
|
Scapular Dyskinesis Present
|
Scapular Dyskinesis Comments
|
|
Shoulder ROM
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Internal Rotation
|
R Internal Rotation
|
|
L External Rotation
|
R External Rotation
|
|
Apley's Scatch Test
|
|
|
Flexion, Abduction and ER
|
|
|
Extension, Adduction and IR
|
|
|
Shoulder MMT: 0-5/5
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Internal Rotation
|
R Internal Rotation
|
|
L External Rotation
|
R External Rotation
|
|
Shoulder Special Tests
|
|
|
Drop Arm Sign
|
Painful Arc Sign
|
|
Infraspinatus Test
|
Empty Can Test
|
|
Hawkin's Kennedy Test
|
Neer's Test
|
|
Compression Rotation Test
|
O'Brien's Test
|
|
Yergason's Test
|
Biceps Load Test II
|
|
Speed's Test
|
Horizontal Adduction Test
|
|
AC Shear Test
|
Roos Test
|
|
Adson's Test
|
Wright's Test
|
|
Additional Special Tests
|
|
|
Shoulder Joint Play Assessment
|
|
|
Glenohumeral Joint
|
Acromioclavicular Joint
|
|
Sternoclavicular Joint
|
Scapulothoracic joint
|
|
Other Shoulder Joint Play Assessment
|
|
|
Shoulder Additional Tests & Measures
|
|
|
Shoulder Additional Tests & Measures
|
|
|
Elbow Screen
|
Elbows cleared
|
|
Elbow Palpation Characteristics
|
|
|
Elbow Observation
|
|
|
Elbow Girth
|
|
|
Elbow ROM
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Pronation
|
R Pronation
|
|
L Supination
|
R Supination
|
|
Elbow MMT: 0-5/5
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Pronation
|
R Pronation
|
|
L Supination
|
R Supination
|
|
Elbow Special Tests
|
|
|
Varus Stress Test
|
Valgus Stress Test
|
|
Mill's Test
|
Cozen's Test
|
|
Maudsley's Test
|
Golfer's Elbow Test
|
|
Ulnar Nerve Compression Test
|
Other Elbow Special Tests
|
|
Elbow Joint Play Assessment
|
|
|
Humeroulnar Joint
|
Humeroradial Joint
|
|
Proximal Radioulnar Joint
|
Other Elbow Joint Play Assessment
|
|
Elbow Additional Tests & Measures
|
|
|
Elbow Additional Tests & Measures
|
|
|
Wrist/ Hand Screen
|
Wrists and Hands Cleared
|
|
Wrist/ Hand Palation Characterisitics
|
|
|
Wrist/ Hand Observation
|
|
|
Wrist ROM
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Ulnar Deviation
|
R Ulnar Deviation
|
|
L Radial Deviation
|
R Radial Deviation
|
|
Thumb ROM
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
L CMC Jt Palmar Abduction
|
R CMC Jt Palmar Abduction
|
|
L CMC Jt Palmar Adduction
|
R CMC Jt Palmar Adduction
|
|
L CMC Jt Radial Abduction
|
R CMC Jt Radial Abduction
|
|
L CMC Jt Radial Adduction
|
R CMC Jt Radial Adduction
|
|
L IP Jt Flexion
|
R IP Jt Flexion
|
|
L IP Jt Extension
|
R IP Jt Extension
|
|
Finger ROM
|
Digit Measured:
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
L PIP Flexion
|
R PIP Flexion
|
|
L PIP Extension
|
R PIP Extenson
|
|
L DIP Flexion
|
R DIP Flexion
|
|
L DIP Extension
|
R DIP Extenson
|
|
Wrist MMT: 0-5/5
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Ulnar Deviation:
|
R Ulnar Deviation
|
|
L Radial Deviation
|
R Radial Deviation
|
|
Thumb MMT: 0-5/5
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
L Opposition
|
R Opposition
|
|
Finger MMT: 0-5/5
|
Digit Measured
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
Grip Strength
|
|
|
Qualitative
|
Quantitative
|
|
Pinch Strength
|
|
|
Qualitative
|
Lateral Pinch
|
|
3 Jaw Chuck
|
Tip to Tip
|
|
Wrist/ Hand Special Tests
|
|
|
Adson's Test
|
Allen Test
|
|
Bunnell's Sign
|
Carpal Compression Test
|
|
Clunk Test
|
Finkelstein Test
|
|
Froment's Sign
|
Phalen's Sign
|
|
Watson's Sign
|
Wright's Test
|
|
TFCC Test
|
Other Wrist/ Hand Special Tests
|
|
Wrist Joint Play Assessment
|
|
|
Radiocarpal joint
|
Midcarpal joint
|
|
Intercarpal Joint
|
Ulnocarpal Joint
|
|
Distal Radioulnar Joint
|
Other Joint Play Assessment
|
|
Thumb/ Finger Joint Play Assessment
|
|
|
CMC Joint
|
MCP Joint
|
|
IP Joint
|
PIP Joint
|
|
DIP Joint
|
Other Joint Play Assessment
|
|
Wrist/ Hand Additional Tests & Measures
|
|
|
Wrist/ Hand Additional Tests & Measures
|
|
|
Lower Quarter Examination
|
|
|
Lumbopelvic Screen
|
Lumbar Spine Cleared
|
|
Lumbar Palpation Characteristics
|
|
|
Lumbar Observation
|
|
|
Lumbar ROM
|
|
|
Flexion
|
|
|
Extension
|
|
|
L Rotation
|
R Rotation
|
|
L Sidebend
|
R Sidebend:
|
|
Lumbar Repeated Movements
|
|
|
Flexion
|
|
|
Extension
|
|
|
L Side Glide
|
R Side Glide
|
|
Lumbar Special Tests
|
|
|
Quadrant test
|
SLR test
|
|
Slump test
|
Femoral nerve test
|
|
Prone Instability Test
|
Thigh Thrust SIJ Provocation Test
|
|
Distraction Provocation SIJ Test
|
Gaenslen's Provocation SIJ Test
|
|
Compression Provocation SIJ Test
|
Sacral Thrust Provocation SIJ Test
|
|
Other Special Tests of the Lumbar Spine
|
|
|
Lumbar Segmental Assessment
|
|
|
CPA/ UPA
|
SI Joint
|
|
Other Segmental Assessment
|
|
|
Lumbar Additional Tests & Measures
|
|
|
Lumbar Additional Tests & Measures
|
|
|
Hip Screen
|
Hips Cleared
|
|
Hip Palpation Characteristics
|
|
|
Hip Observation
|
|
|
Hip ROM
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
L Internal Rotation
|
R Internal Rotation
|
|
L External Rotation
|
R External Rotation
|
|
Hip MMT: 0-5/5
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
L Internal Rotation
|
R Internal Rotation
|
|
L External Rotation
|
R External Rotation
|
|
Hip Special Tests
|
|
|
FADIR test
|
Scour test
|
|
FABER test
|
Thomas test
|
|
90/ 90 test
|
Prone knee bend
|
|
Other Special Tests of Hip
|
|
|
Hip Accessory Motion
|
|
|
Femoralacetabular Joint
|
Other Accessory Motion
|
|
Hip Additional Tests and Measures
|
|
|
Hip Additional Tests & Measures
|
|
|
Knee Screen
|
Knee Cleared
|
|
Knee Palpation Characteristics
|
|
|
Knee Observation
|
|
|
Knee Girth
|
|
|
Knee ROM
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
Knee MMT: 0-5/5
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
Knee Special Tests
|
|
|
Lachman's Test
|
Anterior Drawer Test
|
|
Pivot Shift Test
|
McMurray's Test
|
|
Apley's Compression Test
|
Thessaly's Test
|
|
Varus Test
|
Valgus Test
|
|
Clarke's Test
|
Other Special Test of Knee
|
|
Knee Accessory Motion
|
|
|
Tibiofemoral joint
|
Patellofemoral Joint
|
|
Proximal Tibiofibular Joint
|
Other Knee Accessory Motion
|
|
Knee Additional Tests & Measures
|
|
|
Knee Additional Tests & Measures
|
|
|
Ankle/ Foot Screen
|
Ankle/ Foot Cleared
|
|
Ankle Palpation Characteristics
|
|
|
Ankle Observation
|
|
|
Ankle Girth
|
|
|
Ankle/ Foot ROM
|
|
|
L Dorsiflexion
|
R Dorsiflexion
|
|
L Plantarflexion
|
R Plantarflexion
|
|
L Inversion
|
R Inversion
|
|
L Eversion
|
R Eversion
|
|
L Closed Chain DF
|
R Closed Chain DF
|
|
L Great Toe Flexion
|
R Great Toe Flexion
|
|
L Great Toe Extension
|
R Great Toe Extension
|
|
L Great Toe Abduction
|
R Great Toe Abduction
|
|
L Great Toe Adduction
|
R Great Toe Adduction
|
|
Ankle/ Foot MMT: 0-5/5
|
|
|
L Dorsiflexion
|
R Dorsiflexion
|
|
L Plantarflexion
|
R Plantarflexion
|
|
L Inversion
|
R Inversion
|
|
L Eversion
|
R Eversion
|
|
L Great Toe Flexion
|
R Great Toe Flexion
|
|
L Great Toe Extension
|
R Great Toe Extension
|
|
L Great Toe Abduction
|
R Great Toe Abduction
|
|
L Great Toe Adduction
|
R Great Toe Adduction
|
|
Ankle/ Foot Special Tests
|
|
|
Anterior Drawer Test
|
Talar Tilt Test
|
|
Fibular Translation Test
|
Gap Test
|
|
Ankle Impingement Test
|
Kleiger's Test
|
|
Navicular Drop Test
|
Tinel's Sign
|
|
Windlass Test
|
Other Special Test of Ankle/ Foot
|
|
Ankle/ Foot Accessory Motion
|
|
|
Talocrural Joint
|
Talocalcaneonavicular Joint
|
|
Subtalar Joint
|
Calcaneocuboid Joint
|
|
Transverse Tarsal Joint
|
MTP Joint
|
|
IP Joint
|
Other Joint of Ankle/ Foot
|
|
Ankle/ Foot Additional Tests & Measures
|
|
|
Ankle/ Foot Additional Tests & Measures
|
|
|
Interventions Performed
|
|
|
Manual Therapy activities consisting of
|
Manual Therapy
|
|
Therapeutic Exercises consisting of
|
Therapeutic Exercise
|
|
Neuromuscular Re-education consisting of
|
Neuromuscular Re-education
|
|
Therapeutic Activities consisting of
|
Therapeutic Activities
|
|
Gait Training consisting of:
|
Gait Training consisting of:
|
|
Other Interventions included the following
|
Other interventions including:
|
|
Assessment
|
|
|
Assessment
|
|
|
Functional G Code Reporting
|
|
|
Current Status
|
|
|
Goal Status
|
|
|
D/C Status
|
|
|
G Code Rationale
|
|
|
Goals
|
|
|
Goals
|
|
|
Rehab Potential
|
|
|
Plan
|
|
|
Schedule/ Plan
|
|
|
Anticipated Treatments
|
|
|
Billing
|
|
|
Eval/ Re-eval codes
|
|
|
Initial Evalution- 97161
|
Initial Evalution- 97162
|
|
Initial Evaluation-97163
|
Re-Evaluation
|
|
Therapeutic Exercise
|
|
|
Ther Ex-1 unit
|
Ther Ex- 2 units
|
|
Ther Ex- 3 units
|
|
|
Manual Therapy
|
|
|
Manual Therapy- 1 unit
|
Manual Therapy- 2 units
|
|
Manual Therapy- 3 units
|
|
|
Neuromusclar Re-education
|
|
|
Neuro Re-ed: 1 unit
|
Neuro Re-ed: 2 units
|
|
Neuro Re-ed: 3 units
|
|
|
Gait
|
|
|
Gait: 1 unit
|
|
|
E-stim
|
|
|
E-stim
|
|
|
Self-Pay
|
|
|
Self-Pay Initial Evaluation
|
Self-Pay Daily Treatment
|
