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TELE-HEALTH
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Tele-Health used
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Referral
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In-House Referral
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Outside Referrals
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Direct Access
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Referring Provider
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Note Type
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Visit #:
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Next Progress Note:
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Subjective
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Subjective report
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CC/ HPI
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Problem 1 (P1)
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Mechanism of Injury
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Date of Injury
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Quality
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Current pain:_/10
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Worst pain: _/10
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Best pain: _/10
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Exacerbating factors
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Easing factors
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Pattern
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Prior level of function
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Patient identified goals
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Problem 2 (P2)
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Problem 2 (P2)
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Mechanism of Injury
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Date of Injury
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Quality
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Current pain:_/10
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Worst pain: _/10
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Best pain: _/10
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Exacerbating factors
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Easing factors
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Pattern
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Prior level of function
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Patient identified goal
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Problem 3 (P3)
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Problem 3 (P3)
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Mechanism of Injury
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Date of Injury
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Quality
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Current pain:_/10
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Worst pain: _/10
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Best pain: _/10
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Exacerbating factors
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Easing factors
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Pattern
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Prior level of function
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Patient identified goal
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Outcome Measure
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Outcome Measure
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Medical history
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Medical history reviewed with patient
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Medical history comments
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Yellow flags
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Red Flags
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Objective
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Objective Tests & Measures
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Observation
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Sitting posture
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Standing posture
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Sit > Stand Transfer
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Gait
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Toe walk
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Heel walk
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Single Limb Stance
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Stair Navigation
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Squat
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Running
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Additional Observation
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Neurological Screen
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Sensation
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Light touch sensation:
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Sharp/ dull:
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Reflexes
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C5
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C6
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C7
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L3-L4
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L5-S1
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Babinksi
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Clonus
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Hoffman's Test
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Inverted Supinator Sign
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Cranial Nerve Exam
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Cranial Nerve Exam Tested and Intact
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CN I: Olfactory
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CN II: Optic
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CN III: Oculomotor
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CN IV: Trochlear
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CN V: Trigeminal
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CN VI: Abducens
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CN VII: Facial
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CN VII: Vestibulocochlear
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CN IX: Glossopharyngeal
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CN X: Vagus
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CN XI: Accessory
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CN XII: Hypoglossal
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Cranial Nerve Exam Comments
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Upper Quarter Examination
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Cervical Screen
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Cervical Spine Cleared
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Cervical Palpation Characteristics
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Cervical Observation
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Cervical ROM
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Flexion
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Extension
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L Rotation
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R Rotation
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L Sidebend
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R Sidebend
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Cervical Retraction
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Cervical Protraction
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Cevical MMT: 0-5/5
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Flexion
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Extension
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L Rotation
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R Rotation
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L Sidebend
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R Sidebend
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Cervical Retraction
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Cervical Protraction
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Cervical Special Tests
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Spurling's Test
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Distraction Test
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Sharps Purser Test
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ULTT Median Nerve
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ULTT Radial Nerve
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ULTT Ulnar Nerve
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ULTT Musculocutaneous Nerve
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Cervical Rotation Lateral Flexion Test
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Sharp-Purser Test
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Alar Ligament Test
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Transverse Ligament Test
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Additional Cervical Special Tests
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Cervical Segmental Assessment
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CPA/ UPA
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Side Glides
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Antlanto-occipital Joint
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Atlantoaxial Joint
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1st Rib
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Other Cervical Segmental Assessment
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Cervical Spine Additional Tests & Measures
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Cervical Additional Tests & Measures
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Thoracic Spine/ Ribs Screen
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Thoracic Spine Cleared
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Thoracic Spine/ Ribs Palpation Characteristics
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Thoracic Spine/ Ribs Observation
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Thoracic ROM
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Flexion
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Extension
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L Rotation
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R Rotation
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L Sidebend
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R Sidebend
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Thoracic Segmental Assessment
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CPA/ UPA
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Other Thoracic Segmental Assessment
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Rib Mobility Assessment
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Rib Mobility Assessment
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Thoracic/ Ribs Additional Tests & Measures
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Additional Tests & Measures
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Shoulder Screen
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Shoulders Cleared
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Shoulder Palpation Characteristics
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Shoulder Observation
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Scapular Dyskinesis
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Scapular Dyskinesis Present
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Scapular Dyskinesis Comments
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Shoulder ROM
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Internal Rotation
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R Internal Rotation
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L External Rotation
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R External Rotation
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Apley's Scatch Test
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Flexion, Abduction and ER
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Extension, Adduction and IR
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Shoulder MMT: 0-5/5
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Internal Rotation
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R Internal Rotation
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L External Rotation
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R External Rotation
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Shoulder Special Tests
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Drop Arm Sign
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Painful Arc Sign
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Infraspinatus Test
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Empty Can Test
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Hawkin's Kennedy Test
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Neer's Test
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Compression Rotation Test
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O'Brien's Test
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Yergason's Test
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Biceps Load Test II
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Speed's Test
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Horizontal Adduction Test
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AC Shear Test
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Roos Test
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Adson's Test
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Wright's Test
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Additional Special Tests
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Shoulder Joint Play Assessment
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Glenohumeral Joint
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Acromioclavicular Joint
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Sternoclavicular Joint
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Scapulothoracic joint
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Other Shoulder Joint Play Assessment
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Shoulder Additional Tests & Measures
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Shoulder Additional Tests & Measures
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Elbow Screen
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Elbows cleared
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Elbow Palpation Characteristics
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Elbow Observation
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Elbow Girth
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Elbow ROM
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Pronation
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R Pronation
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L Supination
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R Supination
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Elbow MMT: 0-5/5
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Pronation
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R Pronation
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L Supination
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R Supination
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Elbow Special Tests
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Varus Stress Test
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Valgus Stress Test
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Mill's Test
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Cozen's Test
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Maudsley's Test
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Golfer's Elbow Test
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Ulnar Nerve Compression Test
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Other Elbow Special Tests
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Elbow Joint Play Assessment
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Humeroulnar Joint
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Humeroradial Joint
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Proximal Radioulnar Joint
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Other Elbow Joint Play Assessment
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Elbow Additional Tests & Measures
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Elbow Additional Tests & Measures
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Wrist/ Hand Screen
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Wrists and Hands Cleared
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Wrist/ Hand Palation Characterisitics
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Wrist/ Hand Observation
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Wrist ROM
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Ulnar Deviation
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R Ulnar Deviation
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L Radial Deviation
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R Radial Deviation
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Thumb ROM
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Adduction
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R Adduction
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L CMC Jt Palmar Abduction
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R CMC Jt Palmar Abduction
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L CMC Jt Palmar Adduction
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R CMC Jt Palmar Adduction
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L CMC Jt Radial Abduction
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R CMC Jt Radial Abduction
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L CMC Jt Radial Adduction
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R CMC Jt Radial Adduction
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L IP Jt Flexion
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R IP Jt Flexion
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L IP Jt Extension
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R IP Jt Extension
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Finger ROM
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Digit Measured:
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Adduction
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R Adduction
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L PIP Flexion
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R PIP Flexion
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L PIP Extension
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R PIP Extenson
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L DIP Flexion
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R DIP Flexion
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L DIP Extension
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R DIP Extenson
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Wrist MMT: 0-5/5
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Ulnar Deviation:
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R Ulnar Deviation
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L Radial Deviation
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R Radial Deviation
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Thumb MMT: 0-5/5
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Adduction
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R Adduction
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L Opposition
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R Opposition
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Finger MMT: 0-5/5
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Digit Measured
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Adduction
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R Adduction
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Grip Strength
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Qualitative
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Quantitative
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Pinch Strength
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Qualitative
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Lateral Pinch
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3 Jaw Chuck
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Tip to Tip
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Wrist/ Hand Special Tests
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Adson's Test
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Allen Test
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Bunnell's Sign
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Carpal Compression Test
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Clunk Test
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Finkelstein Test
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Froment's Sign
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Phalen's Sign
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Watson's Sign
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Wright's Test
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TFCC Test
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Other Wrist/ Hand Special Tests
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Wrist Joint Play Assessment
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Radiocarpal joint
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Midcarpal joint
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Intercarpal Joint
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Ulnocarpal Joint
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Distal Radioulnar Joint
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Other Joint Play Assessment
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Thumb/ Finger Joint Play Assessment
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CMC Joint
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MCP Joint
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IP Joint
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PIP Joint
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DIP Joint
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Other Joint Play Assessment
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Wrist/ Hand Additional Tests & Measures
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Wrist/ Hand Additional Tests & Measures
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Lower Quarter Examination
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Lumbopelvic Screen
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Lumbar Spine Cleared
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Lumbar Palpation Characteristics
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Lumbar Observation
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Lumbar ROM
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Flexion
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Extension
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L Rotation
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R Rotation
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L Sidebend
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R Sidebend:
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Lumbar Repeated Movements
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Flexion
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Extension
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L Side Glide
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R Side Glide
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Lumbar Special Tests
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Quadrant test
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SLR test
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Slump test
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Femoral nerve test
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Prone Instability Test
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Thigh Thrust SIJ Provocation Test
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Distraction Provocation SIJ Test
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Gaenslen's Provocation SIJ Test
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Compression Provocation SIJ Test
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Sacral Thrust Provocation SIJ Test
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Other Special Tests of the Lumbar Spine
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Lumbar Segmental Assessment
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CPA/ UPA
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SI Joint
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Other Segmental Assessment
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Lumbar Additional Tests & Measures
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Lumbar Additional Tests & Measures
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Hip Screen
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Hips Cleared
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Hip Palpation Characteristics
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Hip Observation
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Hip ROM
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Adduction
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R Adduction
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L Internal Rotation
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R Internal Rotation
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L External Rotation
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R External Rotation
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Hip MMT: 0-5/5
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L Flexion
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R Flexion
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L Extension
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R Extension
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L Abduction
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R Abduction
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L Adduction
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R Adduction
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L Internal Rotation
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R Internal Rotation
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L External Rotation
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R External Rotation
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Hip Special Tests
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FADIR test
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Scour test
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FABER test
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Thomas test
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90/ 90 test
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Prone knee bend
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Other Special Tests of Hip
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Hip Accessory Motion
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Femoralacetabular Joint
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Other Accessory Motion
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Hip Additional Tests and Measures
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Hip Additional Tests & Measures
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Knee Screen
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Knee Cleared
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Knee Palpation Characteristics
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Knee Observation
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Knee Girth
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Knee ROM
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L Flexion
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R Flexion
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L Extension
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R Extension
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Knee MMT: 0-5/5
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L Flexion
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R Flexion
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L Extension
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R Extension
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Knee Special Tests
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Lachman's Test
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Anterior Drawer Test
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Pivot Shift Test
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McMurray's Test
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Apley's Compression Test
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Thessaly's Test
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Varus Test
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Valgus Test
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Clarke's Test
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Other Special Test of Knee
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Knee Accessory Motion
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Tibiofemoral joint
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Patellofemoral Joint
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Proximal Tibiofibular Joint
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Other Knee Accessory Motion
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Knee Additional Tests & Measures
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Knee Additional Tests & Measures
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Ankle/ Foot Screen
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Ankle/ Foot Cleared
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Ankle Palpation Characteristics
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Ankle Observation
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Ankle Girth
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Ankle/ Foot ROM
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L Dorsiflexion
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R Dorsiflexion
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L Plantarflexion
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R Plantarflexion
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L Inversion
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R Inversion
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L Eversion
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R Eversion
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L Closed Chain DF
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R Closed Chain DF
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L Great Toe Flexion
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R Great Toe Flexion
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L Great Toe Extension
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R Great Toe Extension
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L Great Toe Abduction
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R Great Toe Abduction
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L Great Toe Adduction
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R Great Toe Adduction
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Ankle/ Foot MMT: 0-5/5
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L Dorsiflexion
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R Dorsiflexion
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L Plantarflexion
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R Plantarflexion
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L Inversion
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R Inversion
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L Eversion
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R Eversion
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L Great Toe Flexion
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R Great Toe Flexion
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L Great Toe Extension
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R Great Toe Extension
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L Great Toe Abduction
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R Great Toe Abduction
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L Great Toe Adduction
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R Great Toe Adduction
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Ankle/ Foot Special Tests
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Anterior Drawer Test
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Talar Tilt Test
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Fibular Translation Test
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Gap Test
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Ankle Impingement Test
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Kleiger's Test
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Navicular Drop Test
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Tinel's Sign
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Windlass Test
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Other Special Test of Ankle/ Foot
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Ankle/ Foot Accessory Motion
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Talocrural Joint
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Talocalcaneonavicular Joint
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Subtalar Joint
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Calcaneocuboid Joint
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Transverse Tarsal Joint
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MTP Joint
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IP Joint
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Other Joint of Ankle/ Foot
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Ankle/ Foot Additional Tests & Measures
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Ankle/ Foot Additional Tests & Measures
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Interventions Performed
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Manual Therapy
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Manual Therapy
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Therapeutic Exercises
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Therapeutic Exercise
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Neuromuscular Re-education
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Neuromuscular Re-education
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Therapeutic Activities
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Therapeutic Activities
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Gait Training:
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Gait Training:
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Self Care/Home Management Training:
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Self Care/Home Management Training:
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Other Interventions:
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Other interventions:
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Assessment
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Assessment
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Goals
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Goals
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Rehab Potential
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Plan
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Schedule/ Plan
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Low Complexity
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Moderate Complexity
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High Complexity
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Anticipated Treatments
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Referring Provider Signature Line
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Referral Signature
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Billing
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Eval/ Re-eval codes
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Initial Evalution- 97161
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Initial Evalution- 97162
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Initial Evaluation-97163
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Re-Evaluation-97164
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Therapeutic Exercise
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Ther Ex-1 unit
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Ther Ex- 2 units
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Ther Ex- 3 units
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Manual Therapy
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Manual Therapy- 1 unit
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Manual Therapy- 2 units
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Manual Therapy- 3 units
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Neuromusclar Re-education
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Neuro Re-ed: 1 unit
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Neuro Re-ed: 2 units
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Neuro Re-ed: 3 units
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Therapeutic Activities
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TherAct: 1 Unit
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TherAct: 2 Unit
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Gait
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Gait: 1 unit
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Self Care/Home Management Training:
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Self Care/Home Mgmt: 1 Unit
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E-stim
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E-stim unattended
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E-stim Medicare/UHC
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Self-Pay
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Self-Pay Initial Evaluation
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Self-Pay Daily Treatment
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