|
Referred by
|
Treating Dx
|
|
Note service type
• • •
|
Note visit type
|
|
History
|
|
|
SUBJECTIVE
|
|
|
Recent subjective finding
|
Short term goals
|
|
Long term goals
|
Latest exacerbation date
|
|
Reason for exacerbation
|
|
|
GENERAL HEALTH QUESTIONS
|
|
|
Personal health rating: "At the present time, would you say that your health is___________
|
|
|
ONSET
|
|
|
Approximate date of onset
|
|
|
OR
|
|
|
Exact onset date
|
Cause of current episode
|
|
Recent symptom trend
|
Surgery date
|
|
How much have your symptoms interfered with your daily activities?
|
|
|
ASH Items
|
|
|
Treatment start date (initial eval date)
|
Stage of condition
|
|
Nature of condition
|
|
|
VITAL SIGNS
|
|
|
Height / Weight
/
|
Blood pressure
|
|
Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
|
|
|
PAIN
|
|
|
Pain frequency
• • •
|
|
|
PAIN RATING
|
|
|
Verbal pain rating at present____/10
|
Result
|
|
Note
|
|
|
Verbal pain rating at best____/10
|
Result
|
|
Note
|
|
|
Verbal pain rating at worst____/10
|
Result
|
|
Note
|
|
|
Aggravating factors
|
Position of comfort
|
|
HIP SYMPTOM RANKING
|
|
|
LEFS Value
|
Result
|
|
Note
|
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
|
|
ORTHOPEDIC TESTS
|
|
|
Trendelenburg test - Result
|
Note
|
|
Ober test - Result
|
Note
|
|
Thomas test - Result
|
Note
|
|
Other orthopedic tests
|
|
|
HIP ACTIVE & PASSIVE ROM
|
|
|
Hip extension (AROM normal 30°) - current right
|
Hip extension (PROM normal 30°) - current right
|
|
Hip extension (AROM normal 30°) - current left
|
Hip extension (PROM normal 30°) - current left
|
|
|
|
|
Hip flexion (AROM normal 120°) - current right
|
Hip flexion (PROM normal 120°) - current right
|
|
Hip flexion (AROM normal 120°) - current left
|
Hip flexion (PROM normal 120°) - current left
|
|
|
|
|
Hip abduction (AROM normal 45°) - current right
|
Hip abduction (PROM normal 45°) - current right
|
|
Hip abduction (AROM normal 45°) - current left
|
Hip abduction (PROM normal 45°) - current left
|
|
|
|
|
Hip adduction (AROM normal 30°) - current right
|
Hip adduction (PROM normal 30°) - current right
|
|
Hip adduction (AROM normal 30°) - current left
|
Hip adduction (PROM normal 30°) - current left
|
|
|
|
|
Internal rotation (AROM normal 35°) - current right
|
Internal rotation (PROM normal 35°) - current right
|
|
Internal rotation (AROM normal 35°) - current left
|
Internal rotation (PROM normal 35°) - current left
|
|
|
|
|
Internal rotation (AROM normal 35°) - current right
|
Internal rotation (PROM normal 35°) - current right
|
|
Internal rotation (AROM normal 35°) - current left
|
Internal rotation (PROM normal 35°) - current left
|
|
|
|
|
External rotation (AROM normal 45°) - current right
|
External rotation (PROM normal 45°) - current right
|
|
External rotation (AROM normal 45°) - current left
|
External rotation (PROM normal 45°) - current left
|
|
|
|
|
External rotation (AROM normal 45°) - current right
|
External rotation (PROM normal 45°) - current right
|
|
External rotation (AROM normal 45°) - current left
|
External rotation (PROM normal 45°) - current left
|
|
MUSCLE STRENGTH
|
|
|
Deltoid
|
Elbow flexion
|
|
Elbow extension
|
Wrist flexion
|
|
Wrist extension
|
Finger abduction
|
|
Finger adduction
|
Pincer grasp
|
|
Lower trapezius
|
Serratus anterior
|
|
Infraspinatus
|
Subscapularis
|
|
Glut medius
|
Hip flexion
|
|
Hip extension
|
Knee flexion
|
|
Knee extension
|
Plantar flexion
|
|
Dorsiflexion
|
Ankle inversion
|
|
Ankle eversion
|
Great toe extension
|
|
Abdominals
|
VMO
|
|
Gastroc
|
Hamstrings
|
|
Hip flexors
|
Tib post
|
|
Tib ant
|
Neuromuscular patterns
|
|
TREATMENT
|
|
|
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
|
