|
Physical Therapy
|
|
|
Comments
|
|
|
Continuing or Reducing Therapy
|
|
|
Frequency of Therapy
|
Duration of Therapy
|
|
Comments
|
|
|
Stopping or Holding Therapy
|
|
|
Reason for holding PT
|
Comments
|
|
Home exercise handout given to patient?
|
Home Exercise Regimen
• • •
|
|
Comments
|
|
|
Discussions with Patient
|
|
|
Types of Discussions
• • •
|
|
|
Ordering Diagnostic Tests?
|
|
|
Type of Study #1
• • •
|
Region of body studied #1
|
|
Type of Study #2
• • •
|
Region of body studied #2
|
|
Type of Study #3
• • •
|
Region of body studied #3
|
|
Type of Study #4
• • •
|
Region of body studied #4
|
|
Changing Medications?
|
|
|
Medications Ordered Today
• • •
|
List medications you are stopping. (optional)
|
|
Medication Notes
|
|
|
Starting opiates? (check "ON" if risks discussed)
|
Stopping NSAIDs due to GI/Renal/CV risks?
|
|
Ordering Referral?
|
|
|
Select Referrals
• • •
|
Reason for referrals
• • •
|
|
Comments on Referrals
|
|
|
Intramuscular Injection
|
|
|
Diagnosis _1
• • •
|
Comments on Diagnosis
|
|
Informed consent
|
Type of Cleansing Agent _4
• • •
|
|
Needle size? _5
|
Steroid Concentration _7
|
|
Type of Steroid _8
|
Volume of Injectate _9
|
|
Location of Injections _10
• • •
|
After care
|
|
Lot Number
|
|
|
Schedule Injection
|
|
|
Side
|
|
|
Spinal Level (leave blank for non-spine)
• • •
|
|
|
Injection Type
|
|
|
Comments
|
|
|
Ordering Injection?
|
|
|
Recommend or gave
• • •
|
Side of Procedure
|
|
Name of Procedure
|
|
|
When was procedure performed/scheduled?
|
|
|
Comments on Injections
|
|
|
Risks Discussed?
|
|
|
Comments
|
|
|
Provider
• • •
|
|
|
Ultrasound Evaluation
|
|
|
Body Region
|
Limited or Complete
|
|
Provider
|
|
|
Indication
|
|
|
Radiographic Interpretation:
|
|
|
Side
|
|
|
Structures Visualized
• • •
|
Comments (additional structures)
|
|
Normal Structures
• • •
|
|
|
Abnormal Findings
|
|
|
Follow-up with Provider
|
|
|
When to schedule MD/PA follow-up visit for re-eval (4 weeks is routine)
|
Reason for Follow-up (if "as needed follow-up" choose "if symptoms worsen")
|
|
Follow up with which Provider
• • •
|
|
|
Discharge Plan
|
Discharge Plan No therapy
|
|
Visit summary
|
|
|
Work Note Provided
|
|
|
Work note
• • •
|
Work restrictions
• • •
|
|
Work note extra
|
|
|
Final
|
|
|
Is this the FINAL Exam?
|
|
|
How Much Therapy Completed?
|
|
|
Months, Weeks, or Sessions?
|
|
|
Where was patient First Seen?
|
Date of Accident
|
|
Comments
|
|
|
Imaging Ordered?
|
|
|
Imaging Modality
|
Body region imaged
• • •
|
|
Imaging Modality
|
Body region imaged
• • •
|
|
Imaging Modality
|
Body region imaged
• • •
|
|
Imaging Modality
|
Body region imaged
• • •
|
|
findings on imaging
|
|
|
Comments
|
|
|
Functional Limitations?
|
|
|
Describe functional impairment
|
Describe participation limitations
|
|
Comments
|
|
|
Permanent injury?
|
|
|
Mechanism of Injury
|
Comments
|
|
Comments
|
|
|
Currently at MMI?
|
|
|
MMI discharge summary
|
|
