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