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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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Treatment start date (initial eval date)
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Stage of condition
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Nature 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
• • •
|
Others, please specify
|
|
OBJECTIVE
|
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Palpation & Inspection
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Supine scan of Pelvic landmarks
• • •
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Test and Measurements:
|
Test and Measure Score:
|
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CERVICAL ROM
|
|
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Cervical extension (AROM normal 45°) - current
|
|
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Cervical flexion (AROM normal 45°) - current
|
|
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Cervical left lateral flexion (AROM normal 45°) - current
|
|
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Cervical right lateral flexion (AROM normal 45°) - current
|
|
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Cervical left rotation (AROM normal 80°) - current
|
|
|
Cervical right rotation (AROM normal 80°) - current
|
|
|
MUSCLE STRENGTH
|
|
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Cervical flexors
|
Cervical extensors
|
|
Deltoid
|
Lower trapezius
|
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Elbow extension
|
Elbow flexion
|
|
Neck Side Bender
|
Neck Rotator
|
|
Serratus anterior
|
Neuromuscular patterns
|
|
TODAY'S TREATMENT
|
|
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Therapeutic Exercise: (97110)
|
Total time
|
|
Ther Ex Spine Rationale (General/Flexibility):
|
Ther Ex Spine & Extremity Rationale (LB+LE/ CS+UE):
|
|
Note
|
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
|
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
|
|
Body Mechanics Assessment
|
Computer Ergonomic Assessment
|
|
Total Direct contact Hands-on Time
|
Total Treatment Time:
|
|
ASSESSMENT
|
|
|
Assessment
• • •
|
Pt has met goal for
|
|
PLAN
|
|
|
Frequency
|
Duration
|
|
ICD-10 CODES
|
POC: C-sp, T-sp, LBP
|
|
Treating Provider
|
Supervising Provider
|
