|
Date of visit
|
|
|
SUBJECTIVE
|
|
|
Pt presents w/ c/o:
|
Pt has positional difficulty with:
• • •
|
|
Pt has functional difficulty with
• • •
|
HEP/ Self-care Compliance
|
|
ASH Items
|
|
|
Nature of condition
|
Stage of condition
|
|
PAIN
|
Pain frequency
• • •
|
|
PAIN RATING
|
|
|
Verbal pain rating at present____/10
|
Result
|
|
Verbal pain rating at best____/10
|
Result
|
|
Verbal pain rating at worst____/10
|
Result
|
|
Aggravating factors
|
Position of comfort
|
|
Pain description
• • •
|
%Improve since 1st tx
• • •
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
Supine scan of Pelvic landmarks
• • •
|
|
Test and Measurements:
|
Test and Measure Score:
|
|
SHOULDER ROM
|
|
|
Flexion (AROM normal 180°)
|
|
|
Extension (AROM normal 60°)
|
|
|
Abduction (AROM normal 180°)
|
|
|
Adduction (AROM normal 60°)
|
|
|
Internal Rotation (AROM normal 80°)
|
|
|
External Rotation (AROM normal 90°)
|
|
|
MUSCLE STRENGTH
|
|
|
Subscapularis
|
Teres minor
|
|
Deltoid
|
Lower trapezius
|
|
Latissimus Dorsi
|
Biceps Brachii(Long head)
|
|
Infraspinatus
|
Supraspinatus
|
|
Serratus anterior
|
Pectoralis major
|
|
Rhomboids
|
Neuromuscular patterns
|
|
TODAY'S TREATMENT
|
|
|
Therapeutic Exercise: (97110)
|
Total time
|
|
Note
|
|
|
Ther Ex UE Rationale (gen/scap/sling):
|
Rationale for therapeutic exercise
|
|
Manual Therapy: (97140)
|
Total time
|
|
Joint Mob grade
|
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
|
Rationale for gait training
|
|
HEP initiated
|
HEP advanced
|
|
Total Direct contact Hands-on Time
|
Total Treatment Time:
|
|
ASSESSMENT
|
|
|
Assessment
• • •
|
Pt has met goal for
|
|
PLAN
|
|
|
Frequency
|
Duration
|
|
ICD-10 CODES
|
POC: UE-gen, scap-stab, sling
|
|
Treating Provider
|
Supervising Provider
|
