|
Care Plan:
|
|
|
Care Plan:
• • •
|
|
|
Radiology
• • •
|
Radiology Comments
|
|
PT Recommendations
|
PT Recommendation Comments
|
|
Procedures performed today
|
|
|
Interventional Procedures to be scheduled:
• • •
|
|
|
Indications for surgery:
|
|
|
Lumbar Discectomy; RT Side
• • •
|
Lumbar Discectomy; LT Side
• • •
|
|
Lumbar Discectomy Risks
• • •
|
Endoscopic Rhizotomy
• • •
|
|
Pharmacotherapeutics
|
|
|
DME
|
|
|
Referrals
|
|
|
Labs
• • •
|
Lab Comments
|
|
Education
|
Education Comments
|
|
General Instructions
• • •
|
General Instruction Comments
|
|
Additional Documentation:
|
|
|
Prolonged Services:
|
|
|
Face-to-face; 90 minutes
|
Face-to-face; 60 minutes
|
|
Non face-to-face time; 30 minutes
|
|
|
Chronic Care Management:
|
Chronic Care Management
|
|
Worker's Compensation
|
|
|
Disability Rating
|
|
|
SLU: (enter body part and percentage)
|
|
|
Need for treatment:
|
|
|
Maximum Medical Improvement:
|
|
|
Return to work:
• • •
|
|
|
Return to clinic:
|
|
|
Permanency:
|
|
