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Workers Comp #
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Date of Onset
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History/Subjective
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Initial Comments
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Area of pain
• • •
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Onset
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Mechanism of Injury
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Palliative
• • •
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Provocative
• • •
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Tingling/Numbness
• • •
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Denies Numbness/Tingling
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VAS
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Nature of Pain
• • •
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Other Doctors
• • •
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Denies other care before today.
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History of Illness
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Night sweats / Unexplained Weight Loss
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Sleep
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Other comments
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Objective
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Objective Findings
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Observation:
• • •
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C/S
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Palpation:
• • •
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Tender Facets
• • •
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Orthopedic / Provocative Testing
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Spurling's Sign
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Hoffman's Sign
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Cervical ROM:
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Flexion
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With Pain?
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Extension
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With Pain?
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Rt. Rot
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With Pain?
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Lt. Rot
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With Pain?
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Lt.Lat. Flex
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With Pain?
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Rt.Lat. Flex
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With Pain?
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Cervical Spinal listings
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Occiput
• • •
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C1
• • •
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C2
• • •
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C3
• • •
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C4
• • •
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C5
• • •
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C6
• • •
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C7
• • •
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Cervical Spine Orthopedic Tests
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Cervical Compression Test
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Cervical Distraction
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Shoulder Depression Test
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U.E. myotomes
|
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Left C5 shoulder abduction
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Rt.
|
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Left C6 elbow flexion/wrist extension
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Rt.
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Left C7 elbow extension/wrist flexion
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Rt.
|
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Left C8 finger flexion
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Rt.
|
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Left T1 finger abduction
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Rt.
|
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Light touch
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C5
|
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C6
|
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C7
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Comment
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C8
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Comment
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T1
|
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Thoracic:
|
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Visual:
|
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Adams Sign
|
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Spinous Percussion
|
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Palpation
• • •
|
|
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Tender Facets
• • •
|
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Thoracic Spinal listings
|
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T1
• • •
|
|
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T2
• • •
|
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T3
• • •
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T4
• • •
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T5
• • •
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T6
• • •
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T7
• • •
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T8
• • •
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T9
• • •
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T10
• • •
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T11
• • •
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L/S:
|
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Gait
• • •
|
|
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Palpation
• • •
|
|
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Palpation (Spasm)
• • •
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Palpation (Trigger Points)
• • •
|
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Tender Facets
• • •
|
|
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Lumbar AROM:
|
|
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Flexion
|
With Pain?
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Extension
|
With pain?
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Lt. Rot
|
With pain?
|
|
Rt. Rot
|
With pain?
|
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Lt. Lat. Flex
|
With pain?
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Rt. Lat. Flex
|
With pain?
|
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Lumbar Spinal Listings
|
|
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L1
• • •
|
|
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L2
• • •
|
|
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L3
• • •
|
|
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L4
• • •
|
|
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L5
• • •
|
|
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Pelvis
|
|
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Pelvis - Left Illium
• • •
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Pelvis - Right Illium
• • •
|
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Lumbar Spine Orthopedic Tests
|
|
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SLR
|
With Pain?
• • •
|
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Well Leg Raise
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With Pain?
• • •
|
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Toe Walk
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With Pain?
• • •
|
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Heel Walk
|
With Pain?
• • •
|
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Shoulder Exam
|
|
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Palpation
|
|
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Shoulder Orthopedic Exams
|
|
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Impingement:
• • •
|
|
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Speed's Test:
• • •
|
|
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O'Briens Test:
• • •
|
|
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Yergason's Test:
• • •
|
|
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Empty Can
• • •
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|
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L.E. Myotomes
|
|
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L2/3
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Rt.
|
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Left L3/4
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Rt.
|
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Left L4/L5
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Rt.
|
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L5
|
Rt.
|
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S1 Lt
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Rt.
|
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DTRs
|
|
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Lt C5
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Rt
|
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Lt. C6
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Rt.
|
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Lt. C7
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Rt.
|
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L4 Lt.
|
Rt.
|
|
S1 Lt.
|
Rt.
|
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Elbow/Wrist/Hand
|
|
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Observation:
• • •
|
|
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Palpation (Spasm)
• • •
|
|
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Palpation (Trigger Points)
• • •
|
|
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Elbow/Wrist/Hand AROM
|
|
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Right Elbow Extension
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Right Elbow Flexion
|
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Left Elbow Extension
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Left Elbow Flexion
|
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Lateral Epicondylitis - Resist Wrist Extension:
• • •
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Medial Epicondylitis - Resist Wrist Extension:
• • •
|
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Right Forearm Pronation
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Right Forearm Supination
|
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Left Forearm Pronation
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Left Forearm Supination
|
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Right Wrist Extension
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Right Wrist Flexion
|
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Left Wrist Extension
|
Left Wrist Flexion
|
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Grip Strength Testing: Dynamometer
• • •
|
|
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Comments
|
|
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Knee/Ankle/Foot
|
|
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Observation:
• • •
|
|
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Palpation (Spasm)
• • •
|
Palpation (Trigger Points)
• • •
|
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Knee/Ankle/Foot AROM
|
|
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Right Knee Extension
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Right Knee Flexion
|
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Left Knee Extension
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Left Knee Flexion
|
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Special Testing Knee:
|
|
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Drawer Test:
• • •
|
Lachman Test:
• • •
|
|
Apley Grind Test:
• • •
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McMurray Test:
• • •
|
|
Patellar Test:
• • •
|
Medial Stress Test:
• • •
|
|
Lateral Stress Test:
• • •
|
|
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Right Ankle Dorsiflexion
|
Right Ankle Plantar Flexion
|
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Left Ankle Dorsiflexion
|
Left Ankle Plantar Flexion
|
|
Head Injuries:
|
|
|
Cerebellar Testing:
• • •
|
|
|
Intention Tremor
|
Dysmetria
|
|
Assessment
|
|
|
Diagnosis
• • •
|
|
|
Comments on DX
|
|
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Prognosis
• • •
|
|
|
Comments
|
|
|
Allowed Conditions:
|
|
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Allowed Conditions (Other)
|
|
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Plan
|
|
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Plan of Care:
|
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Passive Therapy Treatment
|
|
|
Passive Therapy Recommendations
• • •
|
|
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Medically Necessary
|
|
|
Treatment Frequency Weeks:
• • •
|
Treatment Duration week
|
|
Therapeutic Exercise 97110
• • •
|
Electrical Stim Attended 97014
• • •
|
|
Manual Therapy Techniques 97124
• • •
|
Cold/Hot Pack 97010
• • •
|
|
Ultrasound Therapy 97035
• • •
|
Mechanical Traction 97012
• • •
|
|
Physical Therapy / Aquatic Therapy Recommendations
|
|
|
Physical Therapy
• • •
|
|
|
Frequency
• • •
|
Medically Necessary
|
|
Aquatic Therapy
|
|
|
Frequency
• • •
|
Medically Necessary
|
|
Chiropractic Therapy
|
|
|
Chiropractic Therapy
• • •
|
Medically Necessary
|
|
Durable Medical Equipment
|
|
|
Supplies
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Home Health Care
|
|
|
Home Health Assistance
• • •
|
Medically Necessary
|
|
Imaging Recommendations
|
|
|
Radiology - MRI, X-Rays, CT Scans..ETC
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Consult Recommendations
|
|
|
Pain Management Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Orthopedic Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Orthopedic Surgical Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Neurology Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Neurosurgery Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Psychological Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Neuropsych Consultation
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Psychiatric Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
EMG/NVC Testing
|
|
|
Diagnostic Testing
• • •
|
Medically Necessary
|
|
Comments
|
|
|
Other Recommendations
|
|
|
Functional Capacity Exam (FCE)
|
Voc Rehab
|
|
Comments
|
Comments
|
|
Medication Reviewed
|
Comments
|
|
Medications Prescribed at Today's visit
|
|
|
Medications Prescribed
• • •
|
Medication is Medically Necessary and Appropriate for the Allowed Conditions in the claim
|
|
Records reviewed
• • •
|
|
|
Office visit consisted of the following:
• • •
|
|
|
Covid Education
|
|
|
Patient Safety Recommendations against COVID
• • •
|
|
|
Physician Statements/Comments
|
|
