|
Date of visit
|
|
|
ASH Items
|
|
|
Treatment start date (initial eval date)
|
Stage of condition
|
|
Nature of condition
|
|
|
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
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
|
|
ANKLE ROM
|
|
|
Plantar flexion (AROM normal 45°)
|
|
|
Dorsiflexion (AROM normal 20°) - current
|
|
|
Inversion (AROM normal 20°)
|
|
|
Eversion (AROM normal 45°)
|
|
|
MUSCLE STRENGTH
|
|
|
GCM
|
Tibialis Anterior
|
|
Peroneus
|
Extensor hallucis Longus
|
|
Flexor Digitorum Longus
|
Flexor Hallucis Longus
|
|
Tibialis Posterior
|
Extensor Digitorum Longus
|
|
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
|
|
|
Frequency
|
Duration
|
|
ICD-10 CODES
|
Code Category
• • •
|
|
Treating Provider
|
Supervising Provider
|
