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SUBJECTIVE
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◎Cheif Complaint
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◎ Progress and Response to Treatment
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◎Pain
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◎A. Description
• • •
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◎B. Pain scale
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*B. Pain scale with Movement
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SUBJECTIVE - ADDTIONAL COMMENT
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OBJECTIVE
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◎LUMBAR RANGE OF MOTION (ROM)
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◎A. Flexion
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◎B. Extension
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MUSCLE STRENGTH
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A. Flexion
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B. Extension
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OBJECTIVE - ADDTIONAL COMMENTS
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ASSESSMENT
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◎Problem List
• • •
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◎ Shor Term Goal
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◎ A. STG (Pain)
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◎ B. STG (ROM)
• • •
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◎ C. STG (Strength)
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D. STG (Balance & Mobility)
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◎ Long Term Goal
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◎ LTG - 1
• • •
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◎ LTG - 2
• • •
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ASSESSMENT - ADDITIONAL COMMENTS
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PLAN
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1 Unit TherEx
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2 Units TherEx
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1 Manual Therapy
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2 Manual Therapy
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1 Unit NeuroMuscular Education
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2 Unit NeuroMuscular Education
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1 Unit - Therapeutic activities (97530)
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2 Unit - Therapeutic activities (97530)
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3 Unit - Therapeutic activities (97530)
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4 Unit - Therapeutic activities (97530)
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Follow-Up
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*Follow-Up <RE>
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PLAN - ADDITIONAL COMMENTS
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Covering Provider
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