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Labs
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Lab Comments
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Radiology
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Radiology Comments
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THERAPY PERFORMED
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Therapy Ordering Provider
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Functional Report Current stat
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Functional Goal Stat
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List TX plan visit number
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Visit number only
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Pain Level
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Therapeutic exercise
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length of therapy in mins
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Vibration Plate mins only
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stand/squats/lunges
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# of stand/squat/lunges
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Steps # of Minutes only
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Steps (type performed by pt)
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How many steps performed
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NMR Vibration Plate Mins Only
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Total TX time in Mins
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Patient reports (fill in)
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Rehab Notes
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Physical Rehabilitation
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Notes
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PT ORDER FORM
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ANR DX
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Treatment goals
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TX Goal Comments
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ADL Changes (goals)
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Plan for ANR
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Frequency/Duration
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Type # per week/# of weeks tx
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Strapping
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INTERVENTIONAL POC
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Diagnostic Pain/Joint Block
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Diagnosis Other
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DME ORDERS
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DX conclusion
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Interventional Pain Procedure
• • •
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Interventional Procedure Loc.
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Injections
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