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Referred by
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Treating Dx
|
|
Note service type
• • •
|
Note visit type
|
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SUBJECTIVE
|
|
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History
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Recent subjective finding
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|
Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
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Personal health rating: "At the present time, would you say that your health is___________
|
|
PAIN
|
|
|
Approximate date of onset
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Pain frequency
• • •
|
|
Verbal pain rating at present____/10
|
How much have your symptoms interfered with your daily activities?
|
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Verbal pain rating at best____/10
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Verbal pain rating at worst____/10
|
|
Aggravating factors
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Relieving factors
|
|
OR
|
|
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Exact onset date
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Cause of current episode
|
|
Recent symptom trend
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Surgery date
|
|
ASH Items
|
|
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Treatment start date (initial eval date)
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Stage of condition
|
|
Nature of condition
|
|
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VITAL SIGNS
|
|
|
Height
|
Weight
|
|
Blood pressure
|
|
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OUTCOME MEASURE TOOL
|
|
|
DASH Value
|
Note
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
|
|
ORTHOPEDIC TESTS
|
|
|
Phalen's test - Result
|
Note
|
|
Prayer sign test - Result
|
Note
|
|
Retinacular test - Result
|
Note
|
|
Other orthopedic tests
|
|
|
WRIST/HAND ACTIVE & PASSIVE ROM
|
|
|
L Wrist extension (AROM normal 80°) - current
|
R Wrist extension (AROM normal 80°) - current
|
|
L Wrist extension (PROM normal 85°) - current
|
R Wrist extension (PROM normal 85°) - current
|
|
L Wrist flexion (AROM normal 70°) - current
|
R Wrist flexion (AROM normal 70°) - current
|
|
L Wrist flexion (PROM normal 70°) - current
|
R Wrist flexion (PROM normal 70°) - current
|
|
L Ulnar deviation (AROM normal 30°) - current
|
R Ulnar deviation (AROM normal 30°) - current
|
|
L Ulnar deviation (PROM normal 30°) - current
|
R Ulnar deviation (PROM normal 30°) - current
|
|
L Radial deviation (AROM normal 20°) - current
|
R Radial deviation (AROM normal 20°) - current
|
|
L Radial deviation (PROM normal 20°) - current
|
R Radial deviation (PROM normal 20°) - current
|
|
L Finger flexion (MCP joints) (AROM normal 90°) - current
|
R Finger flexion (MCP joints) (AROM normal 90°) - current
|
|
L Finger flexion (MCP joints) (PROM normal 90°) - current
|
R Finger flexion (MCP joints) (PROM normal 90°) - current
|
|
L Finger extension (AROM normal 30°) - current
|
R Finger extension (AROM normal 30°) - current
|
|
L Finger extension (PROM normal 30°) - current
|
R Finger extension (PROM normal 30°) - current
|
|
L Thumb abduction (AROM normal 70°) - current
|
R Thumb abduction (AROM normal 70°) - current
|
|
L Thumb abduction (PROM normal 70°) - current
|
R Thumb abduction (PROM normal 70°) - current
|
|
L Thumb adduction (AROM normal 0°) - current
|
R Thumb adduction (AROM normal 0°) - current
|
|
L Thumb adduction (PROM normal 0°) - current
|
R Thumb adduction (PROM normal 0°) - current
|
|
MUSCLE STRENGTH
|
|
|
L Wrist flexion
|
L Wrist flexion
|
|
L Wrist extension
|
L Wrist extension
|
|
L Finger adduction
|
L Finger adduction
|
|
L Finger abduction
|
L Finger abduction
|
|
L Pincer grasp
|
L Pincer grasp
|
|
Neuromuscular patterns
|
|
|
ASSESSMENT
|
|
|
Short term goals
|
Long term goals
|
|
TODAY'S 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
|
|
Gait Training: (97116)
|
Total time
|
|
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
|
