|
PT Follow Up:
|
|
|
Subjective:
|
|
|
Subjective Free Text
|
Pt presents w/ c/o:
|
|
Pt states:
|
Pt has functional difficulty with:
• • •
|
|
Pt has positional difficulty with:
• • •
|
Current Pain Rating
• • •
|
|
Pain at best
• • •
|
Pain at worst
• • •
|
|
Pain: Constant/ Intermittent
|
Pain description
• • •
|
|
%Improve since 1st tx
• • •
|
HEP/ Self-care Compliance
|
|
Objective:
|
Objective Measures:
|
|
Objective Free Text
|
|
|
ROM
|
MMT
|
|
Test and Measurements:
|
Test and Measure Score:
|
|
Test and Measure Findings:
|
Supine scan of Pelvic landmarks
• • •
|
|
Manual Therapy
|
Interventions
|
|
Manual therapy performed
|
Manual Free Text
|
|
Manual-General
|
IASTM
|
|
STM/MFR/TpR
|
Cupping Therapy
|
|
Jt. Mobs
|
Joint Mob grade
|
|
PROM
|
Nerve glides
|
|
MWM
|
|
|
Movement Interventions Performed:
|
Movement Interventions
|
|
Therapeutic Exercises:
|
Interventions:
|
|
Ther Ex
|
Ther ex-per f/s
|
|
Movement Intervention Free Text
|
Ther Ex UE Rationale (gen/scap/sling):
|
|
Ther Ex LE Rationale (General/NWB):
|
Ther Ex LE Rationale (Decond/Condit/ADLs):
|
|
Ther Ex Spine Rationale (General/Flexibility):
|
Ther Ex Spine & Extremity Rationale (LB+LE/ CS+UE):
|
|
Exercises Advanced
|
Exercise advanced to address
|
|
|
|
|
Neuromuscular Re-education
|
Interventions:
|
|
Neuro Re-ed Performed:
|
NMR as per f/s
|
|
NMR Free Text
|
NMR Rational UE,Core, LE
• • •
|
|
MET to correct
|
MET description:
|
|
Kinesio Taping:
|
McConnell Taping
|
|
Tape location/ tech
|
|
|
Russian NMES
|
Russian Location
|
|
Therapeutic Activities:
|
Interventions:
|
|
Therapeutic Activities:
|
Ther act as per f/s
|
|
Therapeutic Activities Free Text:
|
|
|
Ther act Rationale for UE or LE
• • •
|
Ther act Gen rationale
|
|
Gait Training:
|
|
|
Gait Training: level/ steps
|
Gait Training: Free Text
|
|
Modalities:
|
Modalities
|
|
Modalities Free Text
|
Call bell
|
|
Cold pack: Location
|
Hot pack: location
|
|
Modalities Time:
|
Pt postition
|
|
w/ estim
|
Estim location
|
|
Estim Device/ Parameters
• • •
|
|
|
ETPS- location applied
|
ETPS Time:
|
|
Mechanical C/S Tx
|
C/S Tx PSI
|
|
Mechanical L/S Traction:
|
L/S Tx PSI
|
|
Traction Time:
|
Traction Free Text:
|
|
Ultrasound- PUS or CUS
|
Ultrasound- w/cm2 x time
|
|
Ultrasound location
|
|
|
Patient Education:
|
|
|
Pt. Edu Response
• • •
|
Pt ed- instructed to:
|
|
HEP initiated
|
HEP advanced
|
|
C/S AROM p METs
|
|
|
C/S Self-MET/MFR edu.
|
Traction Pt ed
|
|
Body Mechanics Assessment
|
Computer Ergonomic Assessment
|
|
Info/resource to purchase..item ..for home use.
|
Resale item purchased
|
|
for Self Care
|
for HEP
|
|
Assessment:
|
|
|
Assessment Free text
|
Assessment
• • •
|
|
Pt has met goal for
|
Communication with Supervising Therapist
|
|
Plan:
|
|
|
POC update
|
POC: Balance, Gait, Pain
|
|
POC: LE-gen, LE-adv, LE-NWB, TKE
|
POC: UE-gen, scap-stab, sling
|
|
POC: C-sp, T-sp, LBP
|
POC: LB/LE-strength, Spine-mobility, Core-sports
|
|
Re-eval next rx
|
Plan- D/C
|
|
Treatment Time:
|
|
|
Total Direct contact Hands-on Time
|
Total Treatment Time:
|
|
Total TherEx Time:
|
Total Neuro Re-Ed Time:
|
|
Total Manual Time:
|
Total TherAct Time:
|
|
Gait Training:
|
Patient Edu Time:
|
|
Total Unattended E-Stim Time
|
Total Attended E-Stim Time
|
|
Total Traction Time
|
Total Ultrasound Time
|
|
Number of Group Therapy participants
|
Group Therapy
|
|
SPTA Signature:
|
SPTA Supervision
|
|
Jeremy Signature
|
Sarah Signature
|
