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Place of Service
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Chief Complaint
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Picture
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Picture
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Home Visit
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Assisted Living
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Reason for Home Visit
• • •
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Other
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Initial Visit
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Subsequent visit
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Medications Reviewed
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HPI
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HPI
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Chief Complant
• • •
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Anatomy
• • •
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Specific Complaints
• • •
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Anatomy
• • •
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Exacerbates
• • •
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Exacerbates Comments
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Relief
• • •
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Relief Comments
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Onset
• • •
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Onset Comments
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Pain Scale
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HPI 2
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Secondary Complaint
• • •
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Anatomy
• • •
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Specific Complaints
• • •
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Exacerbates Comments
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Relief
• • •
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Relief Comments
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Onset
• • •
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Onset Comments
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Pain Scale
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F/U Visit
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F/U visit
• • •
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Anatomy
• • •
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F/U for Freewrite
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Anatomy
• • •
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Patient Comments
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Anatomy
• • •
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Exacerbates
• • •
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Exacerbates Comments
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Relief
• • •
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Relief Comments
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Onset
• • •
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Onset Comments
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Pain Scale
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Treatment progress
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Additional Info
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Routine Footcare
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Nails
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Nails Non Ambulatory
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Nails and Calluses
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Anatomy
• • •
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Nails and Calluses Non Ambulatory
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Anatomy
• • •
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Corns
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Anatomy
• • •
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Heel Callus
• • •
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Treatment progress
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CLASS C (1 CL B, 2 CL C)
• • •
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PMH
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Medical History
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Past Medical History
• • •
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Past Medical History Freewrite
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Past Surgical History
• • •
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Comments
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Family Medical History
• • •
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Family Medical History Freewrite
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Social History
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No Alcohol No Smoking
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Alcohol
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Smoking
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Other substances
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Smoking Status (from vitals)
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Review of Systems
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Review of Systems
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ROS Normal
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ROS Neuropathy
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ROS Arthritis
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ROS PVD
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ROS Arthritis + PVD
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ROS Neuropathy + PVD
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Objective
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Gait Exam
• • •
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Vascular Exam
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Vascular Exam
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Vascular Normal B
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Vascular Non Palpable B
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Vascular DP No PT B
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Vascular Diminished B
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Posterior Tibial Lt
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Posterior Tibial Rt
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Dorsalis Pedis Lt
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Dorsalis Pedis Rt
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CFT
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CLASS A FINDINGS (1)
• • •
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CLASS B FINDINGS (2)
• • •
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Dermatological Exam
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Callus-Bilateral
• • •
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Corns - Bilateral
• • •
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IPK BILAT
• • •
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Callus
• • •
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Corns
• • •
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IPK
• • •
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Edema
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Location
• • •
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Tinea Dry
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Tinea Web
• • •
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Xerosis B
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Dermatitis
• • •
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Verucca
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Location
• • •
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Ecchymosis
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Location
• • •
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Hematoma
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Location
• • •
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Cellulitis
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Location
• • •
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Abscess/Paronychia
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Location
• • •
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Foreign Body
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Location
• • •
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Ulcers
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Ulcers
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Ulcer Stage 1 (skin intact)
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Location
• • •
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Ulcer Stage 2(epidermis/dermis)
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Location
• • •
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Ulcer Stage 3 (Sub Q)
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Location
• • •
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Ulcer Stage 4 (bone, muscle)
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Location
• • •
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Ulcer Infx.?
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Ulcer length
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Ulcer width
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Ulcer depth
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%granulation%necrotic
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Picture
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Picture #2
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Nail Exam
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Nail Exam
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Dermatological Nail Exam:
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Normal Nail Exam:
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Mycotic Nails ALL (1)
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Mycotic Nails ALL (2)
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Mycotic Nails
• • •
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Non Dystrophic nails
• • •
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Ingrown
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Nail Anatomy
• • •
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Paronychia
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Nail Anatomy
• • •
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Subungual Hematoma
• • •
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Orthopedic Exam
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Orthopedic Exam:
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Ankle Sprain
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Arthritis
• • •
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Bunion
• • •
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Hallux Limitus
• • •
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Hammer toe
• • •
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Mallet toe
• • •
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MPJ Contraction (Metatarsalgia)
• • •
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Pes Cavus
• • •
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Pes Planus
• • •
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Plantar Fasciitis
• • •
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Posterior Calcaneal Bursitis
• • •
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Tailor's Bunion
• • •
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Tendiniitis
• • •
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Location
• • •
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Fracture
• • •
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Location
• • •
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Range of Motion
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Normal ROM
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ROM Mild Decreased
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ROM Mod Decreased
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ROM Severe Decreased
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ROM Ankle
• • •
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ROM MPJ's
• • •
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Neurological Exam
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Neurological Exam:
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Neuro Normal
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Neuro Abnormal
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Epiciritic Senastion
• • •
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Ankle Reflexes
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Mulder's sign
• • •
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Positive Tinels sign
• • •
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