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Subjective
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Patient reports _______
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Date of Onset
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MOI
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Current Pain Level
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Location
• • •
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Best Pain Level
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Worst Pain Level
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Level of function prior to injury
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Current functional deficits include:
• • •
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Additional functional limitations include:
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Overall Health
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Objective
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Observation
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Upper extremity standing posture
• • •
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Seated posture
• • •
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Overhead reaching
• • •
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Active Range of Motion
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Thoracic extension AROM
• • •
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Right shoulder scaption AROM
• • •
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Left shoulder scaption AROM
• • •
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Right shoulder external rotation at neutral AROM
• • •
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Left shoulder external rotation at neutral AROM
• • •
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Right Hand Behind Back
• • •
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Left Hand Behind Back
• • •
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Right elbow flexion AROM
• • •
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Left elbow flexion AROM
• • •
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Right elbow extension AROM
• • •
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Left elbow extension AROM
• • •
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Right wrist pronation AROM
• • •
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Left wrist pronation AROM
• • •
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Right wrist supination AROM
• • •
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Left wrist supination AROM
• • •
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Right wrist flexion AROM
• • •
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Left wrist flexion AROM
• • •
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Right wrist extension AROM
• • •
|
Left wrist extension AROM
• • •
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Right wrist ulnar deviation AROM
• • •
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Left wrist ulnar deviation AROM
• • •
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Right wrist radial deviation AROM
• • •
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Left wrist radial deviation AROM
• • •
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Passive Range of Motion
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Right elbow flexion PROM
• • •
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Left elbow flexion PROM
• • •
|
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Right elbow extension PROM
• • •
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Left elbow extension PROM
• • •
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Right wrist pronation PROM
• • •
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Left wrist pronation PROM
• • •
|
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Right wrist supination PROM
• • •
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Left wrist supination PROM
• • •
|
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Right wrist flexion PROM
• • •
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Left wrist flexion PROM
• • •
|
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Right wrist extension PROM
• • •
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Left wrist extension PROM
• • •
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Right wrist ulnar deviation PROM
• • •
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Left wrist ulnar deviation PROM
• • •
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Right wrist radial deviation PROM
• • •
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Left wrist radial deviation PROM
• • •
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Strength
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Right serratus anterior
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Left serratus anterior
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Right lower trapezius
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Left lower trapezius
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Right rhomboids
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Left rhomboids
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Right supraspinatus
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Left supraspinatus
|
|
Right infraspinatus
|
Left infraspinatus
|
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Right subscapularis
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Left subscapularis
|
|
Right biceps brachii
|
Left biceps brachii
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Right triceps brachii
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Left triceps brachii
|
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Right brachioradialis
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Left brachioradialis
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Right extensor carpi radialis longus
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Left extensor carpi radialis longus
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Right extensor carpi radialis brevis
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Left extensor carpi radialis brevis
|
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Right supinator
|
Left supinator
|
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Right pronator teres
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Left pronator teres
|
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Right flexor carpi radialis
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Left flexor carpi radialis
|
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Right flexor carpi ulnaris
|
Left flexor carpi ulnaris
|
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Right grip strength at 90 degrees elbow flexion
|
Left grip strength at 90 degrees elbow flexion
|
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Joint Mobility
|
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Mid Thoracic Central PA
• • •
|
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Upper Thoracic Central PA
• • •
|
|
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Right Scapular Posterior Tipping Glide
• • •
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Left Scapular Posterior Tipping Glide
• • •
|
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Right GHJ Posterior Glide
• • •
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Left GHJ Posterior Glide
• • •
|
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Right GHJ Inferior Glide
• • •
|
Left GHJ Inferior Glide
• • •
|
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Right Humeroulnar Distraction Glide
• • •
|
Left Humeroulnar Distraction Glide
• • •
|
|
Right Humeroradial Distraction Glide
• • •
|
Left Humeroradial Distraction Glide
• • •
|
|
Right Proximal Radioulnar Anterior Glide
• • •
|
Left Proximal Radioulnar Anterior Glide
• • •
|
|
Right Proximal Radioulnar Posterior Glide
• • •
|
Left Proximal Radioulnar Posterior Glide
• • •
|
|
Right Distal Radioulnar Anterior Glide
• • •
|
Left Distal Radioulnar Anterior Glide
• • •
|
|
Right Distal Radioulnar Posterior Glide
• • •
|
Left Distal Radioulnar Posterior Glide
• • •
|
|
Special Tests
|
|
|
Vertebrobasilar Insufficiency (VBI) Test
|
|
|
Right supine pectoral length deficit test
|
Left supine pectoral length deficit test
|
|
Right scapular assist test
• • •
|
Left scapular assist test
• • •
|
|
Right painful arc test
• • •
|
Left painful arc test
• • •
|
|
Right elbow milking maneuver
|
Left elbow milking maneuver
|
|
Right elbow valgus stress test
• • •
|
Left elbow valgus stress test
• • •
|
|
Right elbow varus stress test
• • •
|
Left elbow varus stress test
• • •
|
|
Right Cozen's test
|
Left Cozen's test
|
|
Right Mills test
|
Left Mills test
|
|
Right medial epicondylalgia test
|
Left medial epicondylalgia test
|
|
Musculature tender to palpation
• • •
|
Ligament/Tendon TTP
• • •
|
|
Other objective findings
|
|
|
Neurological Exam
|
|
|
Right ULTT
• • •
|
Left ULTT
• • •
|
|
Assessment
|
|
|
Patient presents with signs and symptoms consistent with_______
|
|
|
Response to treatment
• • •
|
Rehabilitation Potential
|
|
Treatment Necessity
|
Discharge to HEP
|
|
Functional Goals
|
|
|
Functional Goals
|
Goal Status
|
|
Functional Goals
|
Goal Status
|
|
Functional Goals
|
Goal Status
|
|
Functional Goals
|
Goal Status
|
|
Functional Goals
|
Goal Status
|
|
Functional Goals
|
Goal Status
|
|
Functional Goals
|
Goal Status
|
|
Functional Goal: Patient will be able to ____
|
Goal Status
|
|
Functional Goal: Patient will be able to ____
|
Goal Status
|
|
Impairment Goals
|
|
|
Strength Goals
|
Goal Status
|
|
Strength Goals
|
Goal Status
|
|
Strength Goals
|
Goal Status
|
|
Strength Goals
|
Goal Status
|
|
Strength Goals
|
Goal Status
|
|
Strength Goals
|
Goal Status
|
|
LE ROM Goals
|
Goal Status
|
|
LE ROM Goals
|
Goal Status
|
|
LE ROM Goals
|
Goal Status
|
|
LE ROM Goals
|
Goal Status
|
|
LE ROM Goals
|
Goal Status
|
|
LE ROM Goals
|
Goal Status
|
|
Visit Treatment Procedures
|
|
|
Low Complexity Evaluation
|
Minutes
|
|
Moderate Complexity Evaluation
|
Minutes
|
|
High Complexity Evaluation
|
Minutes
|
|
Re-Evaluation
|
Minutes
|
|
Manual Units
|
Minutes
|
|
Manual (STM) performed
• • •
|
Additional Manual
|
|
Therex Units
|
Minutes
|
|
Ther-Ex performed
• • •
|
Additional Ther-ex
|
|
Neuro-ed Units
|
Minutes
|
|
Neuro-ed performed
• • •
|
Additional Neuro-ed
|
|
Ther-Act Units
|
Minutes
|
|
Ther-Act performed
• • •
|
Additional Ther-Act
|
|
Medicare E-stim
|
Minutes
|
|
Electrical stimulation location
• • •
|
|
|
Plan
|
|
|
Manual Therapy
|
TherEx
|
|
Therapeutic Activities
|
Neuro-muscular re-education
|
|
Treatment Progression
• • •
|
|
|
Frequency
|
Duration
|
|
REFERRAL SIGNATURE
|
|
