|
Referred by
|
Treating Dx
|
|
Note service type
• • •
|
Note Visit Type
|
|
SUBJECTIVE
|
|
|
Recent subjective finding
|
History
|
|
Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
|
Personal health rating: "At the present time, would you say that your health is___________
|
|
PAIN
|
|
|
Approximate date of onset
|
Type of Pain
• • •
|
|
Verbal pain rating at present____/10
|
Pain frequency
• • •
|
|
Verbal pain rating at worst____/10
|
Verbal pain rating at best____/10
|
|
Aggravating factors
|
Relieving Factors
|
|
How much have your symptoms interfered with your daily activities?
|
|
|
OR
|
|
|
Exact onset date
|
Cause of current episode
|
|
Recent symptom trend
|
Surgery date
|
|
ASH Items
|
|
|
Treatment start date (initial eval date)
|
Stage of condition
|
|
Nature of condition
|
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
|
|
VITAL SIGNS
|
|
|
Height
|
Weight
|
|
Blood pressure
|
|
|
OUTCOME MEASURE TOOL
|
|
|
DASH Value
|
Note
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
ORTHOPEDIC TESTS
|
|
|
Yergason test - Result
|
Note
|
|
Drop arm test - Result
|
Note
|
|
Apprehension test - Result
|
Note
|
|
Hawkins-Kennedy Test - Result
|
Note
|
|
Other orthopedic tests
|
|
|
SHOULDER ACTIVE & PASSIVE ROM
|
|
|
L Shoulder extension (AROM normal 60°)
|
R Shoulder extension (AROM normal 60°)
|
|
L Shoulder extension (PROM normal 65°)
|
R Shoulder extension (PROM normal 65°)
|
|
L Shoulder flexion (AROM normal 180°)
|
R Shoulder flexion (AROM normal 180°)
|
|
L Shoulder flexion (PROM normal 180°)
|
R Shoulder flexion (PROM normal 180°)
|
|
L Shoulder abduction (AROM normal 180°)
|
R Shoulder abduction (AROM normal 180°)
|
|
L Shoulder abduction (PROM normal 180°)
|
R Shoulder abduction (PROM normal 180°)
|
|
L External rotation (AROM normal 90°)
|
R External rotation (AROM normal 90°)
|
|
L External rotation (PROM normal 90°)
|
R External rotation (PROM normal 90°)
|
|
L Internal rotation (AROM normal 70°)
|
R Internal rotation (AROM normal 70°)
|
|
L Internal rotation (PROM normal 70°)
|
R Internal rotation (PROM normal 70°)
|
|
L Horizontal abduction (AROM normal 45°)
|
R Horizontal abduction (AROM normal 45°)
|
|
L Horizontal abduction (PROM normal 45°)
|
Horizontal abduction (PROM normal 45°) - current right
|
|
L Horizontal adduction (AROM normal 135°)
|
R Horizontal adduction (AROM normal 135°)
|
|
L Horizontal adduction (PROM normal 135°)
|
R Horizontal adduction (PROM normal 135°)
|
|
MUSCLE STRENGTH
|
|
|
L Flexion
|
R Flexion
|
|
L Extension
|
R Extension
|
|
L Abduction
|
R Abduction
|
|
L Adduction
|
R Adduction
|
|
L External Rotation
|
R External Rotation
|
|
L Internal Rotation
|
R Internal Rotation
|
|
Others:
|
|
|
ASSESSMENT
|
|
|
Short term goals
|
Long term goals
|
|
TREATMENT
|
|
|
Therapeutic Exercise: (97110)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Manual Therapy: (97140)
|
Total time
|
|
Note
|
Rationale for manual therapy
|
|
Neuromuscular Re-Education: (97112)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Therapeutic Activities: (97530)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ice: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Electric Stimulation: (97014)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ultrasound: (97035)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Review of HEP
|
Notes
|
|
TAPINGS
• • •
|
|
|
PLAN
|
|
|
PLAN OF CARE
|
|
|
Frequency
|
Duration
|
|
Treatment
• • •
|
Discharge note
|
|
ICD-10 CODES
|
|
|
Medicare Functional Limitation
|
|
|
Code Category
• • •
|
Code Status
• • •
|
|
Treating Provider
|
Supervising Provider
|
