|
Subjective
|
|
|
Chief Complaint
|
Time In
|
|
VAS______/10
|
Radiation to:
|
|
Duration
|
Quality
• • •
|
|
Objective
|
|
|
Musculoskeletal Exam
|
|
|
ROM
• • •
|
|
|
Motor
|
|
|
Lower Extremity
|
|
|
left______/5
|
right______/5
|
|
Upper Extremity
|
|
|
left______/5
|
right______/5
|
|
Sensory
|
Reflexes
|
|
Orthopedic Test(s)
|
Other
|
|
Assessment
|
|
|
ICD-10 Diagnosis
• • •
|
|
|
Additional Diagnoses
|
|
|
Plan
|
|
|
Modalities/Procedures
|
|
|
Therapeutic exercises
|
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
Neuromuscular re-education
|
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
Massage
|
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
EMS
|
Heat
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
Ultrasound
|
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
Trigger Point/Myofacial release
|
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
Traction
|
|
|
Initials
|
Area(s) treated
|
|
Time (minutes)
|
Rationale
|
|
Manipulation
|
|
|
Initials
|
Area(s) treated
|
|
Other
|
Other
|
|
Initials
|
Area(s) treated
|
|
Time
|
Rationale
|
|
Progress after TX
|
|
|
VAS______/10
|
Radiation to:
|
|
Duration
|
ROM/Mm Tone
|
|
Treatment tolerance/compliance
|
Recommendations
|
|
Referrals
|
|
|
Provider
|
|
|
Please read and sign below
|
Time Out
|
