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Referring Doctor
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Chief Complaint
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Chief complaint
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History of Present Condition
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History of Present Condition
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Onset/Timing
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pain scale
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comment
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Quality
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Aggravating factor
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ambulation
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Past medical history
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Past medical history
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Past Surgical History
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Past Surgical History
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Comment
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Diagnostic Testing / Imaging
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X-ray
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CT
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MRI
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Current pain medication
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Current pain medication
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comment
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Observation
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Posture
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Gait
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Assistive device
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Range of Motion
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UE ROM
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Shoulder Flexion ( Left)
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Shoulder Flexion ( Right )
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Shoulder extension (Left)
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Shoulder extension (Right)
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Shoulder Abduction ( Left)
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Shoulder Abduction ( Right )
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Shoulder adduction (Left)
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Shoulder adduction (Right)
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Shoulder Internal rotation ( Left )
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Shoulder Internal rotation ( Right )
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Shoulder external rotation ( Left )
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Shoulder external rotation ( Right )
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Elbow Flexion ( Left )
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Elbow Flexion ( Right )
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Elbow Extension ( Left)
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Elbow Extension ( Right)
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Wrist Flexion ( Left )
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Wrist Flexion ( Right )
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Wrist Extension ( Left )
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Wrist Extension ( Right )
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Wrist Ulnar deviation ( Left )
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Wrist Ulnar deviation ( Right )
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Wrist radial deviation ( Left)
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Wrist radial deviation ( Right )
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Neck flexion
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Neck extension
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Neck side bending ( Left )
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Neck side bending ( Right )
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Neck rotation ( Left )
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Neck rotation ( Right )
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LE ROM
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Trunk flexion
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Trunk extension
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Trunk side bending ( Right )
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Trunk side bending ( Left )
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Trunk rotation ( Right )
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Trunk rotation ( Left )
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Hip Flexion ( Right )
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Hip Flexion ( Left )
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Hip extension ( Right )
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Hip extension ( Left )
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Hip abduction ( Right )
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Hip abduction ( Left )
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Hip adduction (Right )
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Hip adduction (Left )
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Hip internal rotation ( Right )
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Hip internal rotation ( Left)
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Hip external rotation ( Right )
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Hip external rotation ( Left )
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Knee Flexion ( Right )
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Knee Flexion ( Left )
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Knee extension ( Right )
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Knee extension ( Left)
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Ankle dorsiflexion ( Right )
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Ankle dorsiflexion ( Left )
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Ankle plantar flexion ( Right )
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Ankle plantar flexion ( Left)
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Ankle eversion ( Right )
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Ankle eversion ( Left )
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Ankle inversion (Right )
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Ankle inversion (Left )
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Manual Muscle Test
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UE MMT
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Right upper Trapezius
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Left Upper Trapezius
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Right middle Trapezius
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Left middle Trapezius
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Right lower Trapezius
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Left lower Trapezius
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Right levator scapular
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Left levator scapular
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Neck flexors
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Neck extensors
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Right deltoid
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Left deltoid
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Right Latissimus dorsi
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Left Latissimus dorsi
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Right Pectorals
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Left Pectorals
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Right Supraspinatus
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Left Supraspinatus
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Right Infraspinatus/ Teres minor
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Left Infraspinatus/ Teres minor
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Right subscapularis
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Left subscapularis
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Right rhomboid
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Left rhomboid
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Right Biceps
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Left Biceps
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Right Triceps
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Left Triceps
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Right Wrist extensors
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Left Wrist extensors
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Right Wrist flexors
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Left Wrist flexors
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LE MMT
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Right illiopsoas
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Left illiopsoas
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Quadratus lumborum
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Rectus abdominis
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Right Gluteus maximus
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Left Gluteus maximus
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Right Gluteus medius
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Left Gluteus medius
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Right Quads
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Left Quads
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Right Hamstrings
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Left Hamstrings
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Right adductors
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Left adductors
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Right anterior tibialis
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Left anterior tibialis
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Right posterior tibialis
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Left posterior tibialis
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Right Gastrocnemius
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Left Gastrocnemius
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Right peroneals
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Left peroneals
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Right extensor hallucis
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Left extensor hallucis
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Right flexor hallucis
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Left flexor hallucis
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Assessment
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Patient education
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patient education
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Following
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Rehab Potential
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Patient problems
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Limitation Problem 1
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Pain Problem 2
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strength problem 3
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strength problem-where
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LOM problem
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LOM problem- where
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Rehab Goals
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Short Term Goals
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Short Term Goals - Pain (%)
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Short Term Goals - Pain (scale)
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Short Term Goals - Pain 2 ( where )
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Short Term Goals - ROM ( %)
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Short Term Goals - ROM 2-where
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Short Term Goals - MMT(%)
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Short Term Goals - MMT (where)
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Short Term Goals - MMT (scale)
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Long Term Goals
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Long term goal 1 (%)
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Long term goal 2(%)
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Long term goal 2
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Long Term Goals 3 - Pain (%)
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Long Term Goals 3 - Pain (where)
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Long Term Goals 4 - MMT & ROM (%)
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Long Term Goals 4 - MMT & ROM (where)
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Long Term Goals 4 - MMT & ROM (UE or LE)
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PLAN OF CARE
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Frequency
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Duration
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Plan : Begin Plan as Outlined
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Procedures
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CPT- Physical therapy Evaluation (97161) where
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CPT- Physical therapy Re-evaluation (97164) where
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CPT-Manual Therapy(97140) minute
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CPT-Manual Therapy(97140) -where
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CPT- Manual Therapy (97140)-what
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CPT- Therapeutic Exercise (97110) minute
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CPT- Therapeutic Exercise (97110) -where
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CPT- Therapeutic Exercise (97110)-what
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CPT-Neuromuscular reeducation (97112) minute
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CPT-Neuromuscular reeducatio (97112) -where
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CPT- Therapeutic Activities (97530) minute
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CPT-Therapeutic activities (97530)-where
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CPT- Self care /home management training (97535) minute
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CPT- Electirc Stim(97014/G0283) where
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CPT- Electirc Stim(97032) where
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CPT- Ultrasound(97035) where
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CPT- Mechanical traction (97012)
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Medical certification
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my care
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