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labs
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Labs
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Radiology
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Radiology
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Braces fitted
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Braces ordered
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Medical necessity
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PT Recommendations
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PT Recommendation Comments
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Home Health
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Home health comments
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Referrals
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Referral Comments
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Education
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Education Comments
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Diet
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Diet Comments
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General Instructions
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General Instruction Comments
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post op care
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cast removal
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Cast application
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Work Status
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RTW NO RESTRICTIONS
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RTW Date
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TTD
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TTD Appointment Date
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RTW with Restrictions
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RTW Date
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No Lifting
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No lifting over____ lbs
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No Repetitive squatting/kneeling
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No repetitive climbing/walking uneven surface
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No prolonged walking/sitting/standing
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Minutes per hour
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No repetitive reaching over shoulder
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Which Upper Extremity
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No Keyboarding
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No repetitive bending, stooping, twisting
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No repetitive finger, hand or wrist motion
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Which Arm
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No repetitive power grip
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Which Upper Extremity
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Sedentary Work Only
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Other
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office injections
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Right Knee joint Injection
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Left Knee joint Injection:
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Right Shoulder joint Injection:
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Left Shoulder Injection:
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Right Shoulder bursa Injection:
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Left Shoulder bursa Injection:
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Right hip joint Injection:
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Left hip joint Injection:
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Right hip bursa Injection:
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Left hip bursa Injection:
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Right carpal tunnel injection
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Left carpal tunnel injection
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Right DeQuervaines injection
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Left DeQuervaines injection
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right knee synvisc
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Left knee synvisc
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Medication
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Lot Number
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Exp. Date
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number injection
• • •
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pt brought meds
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fluoroscopic time
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follow up
• • •
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Dr. David Robins
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