|
Date of visit
|
|
|
Referred by
|
Treating Dx
|
|
Note service type
• • •
|
Note visit type
|
|
History
|
|
|
SUBJECTIVE
|
|
|
Recent subjective finding
|
Short term goals
|
|
Long term goals
|
Latest exacerbation date
|
|
Reason for exacerbation
|
|
|
GENERAL HEALTH QUESTIONS
|
|
|
Personal health rating: "At the present time, would you say that your health is___________
|
|
|
ONSET
|
|
|
Approximate date of onset
|
|
|
OR
|
|
|
Exact onset date
|
Cause of current episode
|
|
Recent symptom trend
|
Surgery date
|
|
How much have your symptoms interfered with your daily activities?
|
|
|
ASH Items
|
|
|
Treatment start date (initial eval date)
|
Stage of condition
|
|
Nature of condition
|
|
|
VITAL SIGNS
|
|
|
Height
|
Weight
|
|
Blood pressure
|
|
|
Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
|
|
|
PAIN
|
|
|
Pain frequency
• • •
|
|
|
PAIN RATING
|
|
|
Verbal pain rating at present____/10
|
Result
|
|
Note
|
|
|
Verbal pain rating at best____/10
|
Result
|
|
Note
|
|
|
Verbal pain rating at worst____/10
|
Result
|
|
Note
|
|
|
Aggravating factors
|
Position of comfort
|
|
SPINAL SYMPTOM RATING
|
|
|
Neck disability index
|
Result
|
|
Note
|
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
|
|
ORTHOPEDIC TESTS
|
|
|
Sharp Purser test
|
Note
|
|
Anterior Shear Test
|
Note
|
|
Axial manual traction - Result
|
Note
|
|
Cervical compression test - Result
|
Note
|
|
Cervical distraction test - Result
|
Note
|
|
Valsalva maneuver - Result
|
Note
|
|
VBAI - Result
|
Note
|
|
Other orthopedic tests
|
|
|
CERVICAL ROM
|
|
|
Cervical extension (AROM normal 45°) - current
|
|
|
Cervical flexion (AROM normal 45°) - current
|
|
|
Cervical left lateral flexion (AROM normal 45°) - current
|
|
|
Cervical right lateral flexion (AROM normal 45°) - current
|
|
|
Cervical left rotation (AROM normal 80°) - current
|
|
|
Cervical right rotation (AROM normal 80°) - current
|
|
|
MUSCLE STRENGTH
|
|
|
Cervical flexors
|
Cervical extensors
|
|
Deltoid
|
Lower trapezius
|
|
Elbow extension
|
Elbow flexion
|
|
Infraspinatus
|
Subscapularis
|
|
Serratus anterior
|
Neuromuscular patterns
|
|
TREATMENT
|
|
|
TODAY'S TREATMENT
|
|
|
Therapeutic Exercise: (97110)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Manual Therapy: (97140)
|
Total time
|
|
Note
|
Rationale for manual therapy
|
|
Neuromuscular Re-Education: (97112)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Therapeutic Activities: (97530)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ice: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Electric Stimulation: (97014)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ultrasound: (97035)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Gait Training: (97116)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Review of HEP
|
Notes
|
|
TAPINGS
• • •
|
|
|
PLAN
|
|
|
PLAN OF CARE
|
|
|
Frequency
|
Duration
|
|
Treatment
• • •
|
Discharge note
|
|
ICD-10 CODES
|
|
|
Medicare Functional Limitation
|
|
|
Code Category
• • •
|
Code Status
• • •
|
|
Treating Provider
|
Supervising Provider
|
