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Nails
Calluses
Diabetic Patient
Anticoagulants/Antiplatelet drugs
Patient subjective
• • •
Subjective Free text
Objective
• • •
Objective free text
Weakly palpable pedal pulses
Non-palpable pedal pulses
Lesions present
Prior amputation
• • •
Fall risk assessment
• • •
Deformity
• • •
Plan
Homebound certification
Home/ALF New E&M
Home/ALF follow up E&M
Skilled nursing New E&M
Skilled nursing follow up E&M
Nail Debridement 11721
Nails <5
Callous debridement 1
Callus debridement 2-4
Callous debridement >5
Fall risk assesment
Plan free text:
9 week follow up
PRN follow up
Follow up free text

Facility consult Medical Form

Podiatrist

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Published: Aug. 11, 2025, 4:22 p.m.
Doctor: Dr. History Physical
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