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Reason for Visit:
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Reason for Visit
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DOA
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Subjective
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How do you feel today since last visit
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Patient came today to the clinic reporting:
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Objective Findings
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Examination of the patient today revealed:
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Assessment
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Notes
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Update
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Plan/ Treatment
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Continue Prescribed Treatment Plan
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Physical Therapy Treatment
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Therapeutic Exercises(97110)
• • •
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Notes
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Unit
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Region
• • •
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Start time
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End time
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Group Therapeutic Exercises(97150)
• • •
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Notes
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Unit
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Region
• • •
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Start time
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End time
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Traction(97012)
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Notes
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Unit
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Region
• • •
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Start time
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End time
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EMS(G0283)
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Notes
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Unit
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Region
• • •
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Start time
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End time
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E-stim/TENS electrodes(A4595)
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Hot/Cold(97010)
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Notes
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Unit
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Region
• • •
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Start time
|
End time
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EMS-Dolphin(97032)
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Unit
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Region
• • •
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Start time
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End time
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Therapeutic Activities/Functional training
• • •
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Notes
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Unit
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Region
• • •
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Start time
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End time
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(NMR) Neuro-Muscular Re-Education(97112)
• • •
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Notes
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Unit
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Region
• • •
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Start time
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End time
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Ultrasound(97035)
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Notes
|
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Unit
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Region
• • •
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Start time
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End time
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ADL Self Care(97535)
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Notes
|
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Unit
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Region
• • •
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Start time
|
End time
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Man. Therapy (97140) Technique
• • •
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Technique Notes
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Unit
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Region
• • •
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Start time
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End time
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PTA
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Patient Signature
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PATIENT SIGNATURE
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Patient confirmation
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Provider notes
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