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PLAN / RECOMMENDATION
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Discussed Plan of Care
• • •
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Plan (Freewrite)
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Imaging/Dx ORDER***
• • •
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Additional Diagnostic ORDER
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Lab Order
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Referral ORDER***
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Additional Referral ORDER
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Medication
• • •
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Medication (Freewrite)
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Therapy
• • •
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Therapy (Freewrite)
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Injection ORDER***
• • •
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Procedure (Freewrite)
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DECLINED Procedure / Opt Conservative
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Followup
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Followup (Freewrite)
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Co-Manage Care (Referring)
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Work Status (Special Forms CPT 99080)
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Billing CPT Code O/P Office Visit
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TRIGGER POINT INJECTIONS
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Trigger Point Injections Billing CPT Code
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TPI # of Injections
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TPI Sites
• • •
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TPI Marcaine dosage
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TPI Comments
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Education / Anticipatory Guidance
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Anticipatory Guidance
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BP Incidental Elevated
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Weight Loss
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Education
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Education (Freewrite)
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Disclosure Yes / No
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NP as Scribe Yes / No
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