|
|
|
|
Reason for Visit:
|
|
|
Reason for Visit
|
DOA
|
|
SUBJECTIVE:
|
Comments:
|
|
OBJECTIVE:
|
Comments:
|
|
ASSESSMENT
• • •
|
|
|
|
Comments:
|
|
Continue Prescribed Treatment Plan
|
|
|
Treatment:
|
|
|
99212: OUTPATIENT VISIT EST
• • •
|
Chiropractic Adjustments 98940
• • •
|
|
Chiropractic Adjustments 98941
• • •
|
Chiropractic Adjustments 98942
• • •
|
|
Extraspinal Adjustments 98943
• • •
|
Activator Technique
• • •
|
|
Man. Therapy (97140) Technique
• • •
|
Technique Notes
|
|
Unit
|
Region
• • •
|
|
Start time
|
End time
|
|
ADL Self Care(97535)
|
Notes
|
|
Unit
|
Start time
|
|
End time
|
Region
• • •
|
|
Ultrasound(97035)
|
Notes
|
|
Unit
|
Start time
|
|
End time
|
Region
• • •
|
|
EMS(G0283)
|
Notes
|
|
Unit
|
Start time
|
|
End time
|
Region
• • •
|
|
Traction(97012)
|
Notes
|
|
Unit
|
Start time
|
|
End time
|
Region
• • •
|
|
Hot/Cold(97010)
|
Notes
|
|
Unit
|
Start time
|
|
End time
|
Region
• • •
|
|
(NMR) Neuro-Muscular Re-Education(97112)
• • •
|
Notes
|
|
Unit
|
Start time
|
|
End time
|
Region
• • •
|
|
Therapeutic Exercises(97110)
• • •
|
Notes
|
|
Unit
|
Region
• • •
|
|
Start time
|
End time
|
|
Therapeutic Activities 97530:
• • •
|
Notes
|
|
Unit
|
Region
• • •
|
|
Start time
|
End time
|
|
Patient Signature
|
|
|
PATIENT SIGNATURE
|
CONFIRMATION
|
|
Modify Frequency to
|
Modify Length of Frequency to
|
|
Provider notes
|
|
