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Date of visit
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SUBJECTIVE
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Pt presents w/ c/o:
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Pt has positional difficulty with:
• • •
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Pt has functional difficulty with
• • •
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HEP/ Self-care Compliance
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ASH Items
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Nature of condition
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Stage of condition
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PAIN
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Pain frequency
• • •
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PAIN RATING
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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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Pain description
• • •
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%Improve since 1st tx
• • •
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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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Knee ROM
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Knee extension (AROM normal 0°)
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Knee flexion (AROM normal 135°)
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MUSCLE STRENGTH
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Knee flexors
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Knee extensors
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IT band
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Adductors
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Hip Abductors
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Neuromuscular patterns
|
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TODAY'S TREATMENT
|
|
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Therapeutic Exercise: (97110)
|
Total time
|
|
Ther Ex LE Rationale (General/NWB):
|
Ther Ex LE Rationale (Decond/Condit/ADLs):
|
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Note
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Rationale for therapeutic exercise
|
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Manual Therapy: (97140)
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Total time
|
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Joint Mob grade
|
Nerve glides
|
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Note
|
Rationale for manual therapy
|
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Neuromuscular Re-Education: (97112)
|
Total time
|
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Note
|
|
|
NMR Rational UE,Core, LE
• • •
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Rationale for neuromuscular re-education
|
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Therapeutic Activities: (97530)
|
Total time
|
|
Note
|
Rationale for therapeutic activities
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for heat therapy
|
|
Electric Stimulation: (97014)
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Total time
|
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Note
|
Rationale for electrical stimulation
|
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Ultrasound: (97035)
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Total time
|
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Note
|
Rationale for ultrasound
|
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Gait Training: (97116)
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Total time
|
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Gait Training: level/ steps
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Rationale for gait training
|
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HEP initiated
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HEP advanced
|
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Total Direct contact Hands-on Time
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Total Treatment Time:
|
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ASSESSMENT
|
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Assessment
• • •
|
Pt has met goal for
|
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PLAN
|
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Frequency
|
Duration
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ICD-10 CODES
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POC: LE-gen, LE-adv, LE-NWB, TKE
|
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POC: LB/LE-strength, Spine-mobility, Core-sports
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POC: Balance, Gait, Pain
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Treating Provider
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Supervising Provider
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