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Date of visit
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Referred by
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Treating Dx
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Note service type
• • •
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Note visit type
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History
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SUBJECTIVE
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Pt presents w/ c/o:
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Recent subjective finding
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Pt has functional difficulty with:
• • •
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Pt has positional difficulty with:
• • •
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Short term goals
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Long term goals
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Reason for exacerbation
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Latest exacerbation date
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GENERAL HEALTH QUESTIONS
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Personal health rating: "At the present time, would you say that your health is___________
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ONSET
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Approximate date of onset
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Cause of current episode
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Recent symptom trend
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Surgery date
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How much have your symptoms interfered with your daily activities?
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ASH Items
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Treatment start date (initial eval date)
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Stage of condition
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Nature of condition
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VITAL SIGNS
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Height
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Weight
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Blood pressure
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Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
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PAIN
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Pain frequency
• • •
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Pain description
• • •
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Verbal pain rating at present____/10
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Result
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Verbal pain rating at best____/10
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Result
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Verbal pain rating at worst____/10
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Result
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Aggravating factors
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Position of comfort
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WRIST AND HAND SYMPTOM RATING
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DASH
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Result
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ADL PROBLEMS
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ADL Problems
• • •
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Others, please specify
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OBJECTIVE
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Palpation & Inspection
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Supine scan of Pelvic landmarks
• • •
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Test and Measurements:
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Test and Measure Score:
|
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ORTHOPEDIC TESTS
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Phalen Test
|
Note
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Tinnel Sign
|
Note
|
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Ulnar nerve test
|
Note
|
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Froment's sign
|
Note
|
|
Finkelstein Test
|
Note
|
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Sharpey's Test(TFCC)
|
Note
|
|
Other orthopedic tests
|
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WRIST ROM
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Extension (AROM normal 70°)
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Flexion (AROM normal 75°)
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Radial deviation (AROM normal 20°)
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Ulnar deviation(AROM normal 25°)
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MUSCLE STRENGTH
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Extensor carpi ulnaris
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Extensor carpi radialis longus
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Extensor carpi radialis brevis
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Extensor digitorum
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Elbow extension
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Flexor carpi ulnaris
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Flexor carpi radialis
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Palmaris longus
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Abductor pollicis longus
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Flexor pollicis brevis
|
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Opponens pollicis
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Neuromuscular patterns
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TREATMENT
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|
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Therapeutic Exercise: (97110)
|
Total time
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|
Note
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Rationale for therapeutic exercise
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Ther Ex LE Rationale (General/NWB):
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Ther Ex LE Rationale (Decond/Condit/ADLs):
|
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Manual Therapy: (97140)
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Total time
|
|
Joint Mob grade
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Nerve glides
|
|
Note
|
Rationale for manual therapy
|
|
Neuromuscular Re-Education: (97112)
|
Total time
|
|
Note
|
|
|
NMR Rational UE,Core, LE
• • •
|
Rationale for Neuromuscular Re-education
|
|
Therapeutic Activities: (97530)
|
Total time
|
|
Note
|
Rationale for therapeutic activities
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for heat therapy
|
|
Electric Stimulation: (97014)
|
Total time
|
|
Note
|
Rationale for electrical stimulation
|
|
Ultrasound: (97035)
|
Total time
|
|
Note
|
Rationale for ultrasound
|
|
Gait Training: (97116)
|
Total time
|
|
Gait Training: level/ steps
|
Gait Training: Free Text
|
|
Note
|
Rationale for gait training
|
|
HEP initiated
|
HEP advanced
|
|
Body Mechanics Assessment
|
Computer Ergonomic Assessment
|
|
PLAN OF CARE
|
|
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POC: Balance, Gait, Pain
|
POC: LE-gen, LE-adv, LE-NWB, TKE
|
|
POC: LB/LE-strength, Spine-mobility, Core-sports
|
POC: Balance, Gait, Pain
|
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Frequency
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Duration
|
|
Treatment
• • •
|
Discharge note
|
|
ICD-10 CODES
|
|
|
Medicare Functional Limitation
|
|
|
Code Category
• • •
|
Code Status
• • •
|
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Treating Provider
|
Supervising Provider
|
