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Plan/Prescription for Treatment
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Ordering Physical Therapy?
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Ordering Diagnostic Tests?
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Type of Study #1
• • •
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Region of body studied #1
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Type of Study #2
• • •
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Region of body studied #2
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Comments on Diagnostic Tests
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Changing Medications?
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Medications prescribed today:
• • •
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List medications you are stopping. (optional)
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Starting opiates? (check "ON" if risks discussed)
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Stopping NSAIDs due to GI/Renal/CV risks?
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Comments on Medications
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Ordering Referral?
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Select Referrals
• • •
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Reason for referrals
• • •
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Comments on Referrals
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Intramuscular injection
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Diagnosis _1
• • •
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Comments on Diagnosis
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Informed consent
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Type of Cleansing Agent _4
• • •
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Needle size? _5
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Steroid Concentration _7
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Type of Steroid _8
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Volume of Injectate _9
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Location of Injections _10
• • •
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After care
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Lot Number
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Ordering Injection?
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Side of Procedure
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Name of Procedure
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Select all levels (for Spine Procedures Only)
• • •
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When was procedure performed/scheduled?
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Comments on Injections
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Follow-up with Provider
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When to schedule MD/PA follow-up visit for re-eval (4 weeks is routine)
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Reason for Follow-up (if "as needed follow-up" choose "if symptoms worsen")
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Follow up with which Provider
• • •
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Ultrasound Evaluation
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Body Region
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Limited or Complete
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Provider
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Indication
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Discussions with Patient
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Types of Discussions
• • •
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Discharge Plan therapy included
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Discharge Plan No therapy
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Visit summary
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Work Note Provided
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Work note
• • •
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Work restrictions
• • •
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Work note extra
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EMC
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