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Workers Comp #
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Date of Onset
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History/Subjective
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Initial Comments
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Area of pain
• • •
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Onset
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Mechanism of Injury
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Palliative
• • •
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Provocative
• • •
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Tingling/Numbness
• • •
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Denies Numbness/Tingling
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VAS
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Nature of Pain
• • •
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Other Doctors
• • •
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Denies other care before today.
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History of Illness
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Night sweats / Unexplained Weight Loss
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Sleep
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Other comments
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Objective
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Objective Findings
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Observation:
• • •
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C/S
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Palpation:
• • •
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Tender Facets
• • •
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Orthopedic / Provocative Testing
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Spurling's Sign
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Hoffman's Sign
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Cervical ROM:
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Flexion
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With Pain?
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Extension
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With Pain?
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Rt. Rot
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With Pain?
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Lt. Rot
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With Pain?
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Lt.Lat. Flex
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With Pain?
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Rt.Lat. Flex
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With Pain?
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Cervical Compression Test
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Cervical Distraction
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Shoulder Depression Test
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U.E. myotomes
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Left C5 shoulder abduction
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Rt.
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Left C6 elbow flexion/wrist extension
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Rt.
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Left C7 elbow extension/wrist flexion
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Rt.
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Left C8 finger flexion
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Rt.
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Left T1 finger abduction
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Rt.
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Light touch
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C5
|
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C6
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C7
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Comment
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C8
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Comment
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T1
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Thoracic:
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Visual:
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Adams Sign
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Spinous Percussion
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Palpation
• • •
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Tender Facets
• • •
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L/S:
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Gait
• • •
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Palpation
• • •
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Palpation (Spasm)
• • •
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Palpation (Trigger Points)
• • •
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Tender Facets
• • •
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Lumbar AROM:
|
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Flexion
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With Pain?
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Extension
|
With pain?
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Lt. Rot
|
With pain?
|
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Rt. Rot
|
With pain?
|
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Lt. Lat. Flex
|
With pain?
|
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Rt. Lat. Flex
|
With pain?
|
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Pelvis
|
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Pelvis - Left Illium
• • •
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Pelvis - Right Illium
• • •
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Lumbar Spine Orthopedic Tests
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SLR
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With Pain?
• • •
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Well Leg Raise
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With Pain?
• • •
|
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Toe Walk
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With Pain?
• • •
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Heel Walk
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With Pain?
• • •
|
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Shoulder Exam
|
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Palpation
|
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Shoulder Orthopedic Exams
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Impingement:
• • •
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Speed's Test:
• • •
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O'Briens Test:
• • •
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Yergason's Test:
• • •
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Empty Can
• • •
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Elbow/Wrist/Hand
|
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Observation:
• • •
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Palpation (Spasm)
• • •
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Palpation (Trigger Points)
• • •
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Elbow/Wrist/Hand AROM
|
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Right Elbow Extension
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Right Elbow Flexion
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Left Elbow Extension
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Left Elbow Flexion
|
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Lateral Epicondylitis - Resist Wrist Extension:
• • •
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Medial Epicondylitis - Resist Wrist Extension:
• • •
|
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Right Forearm Pronation
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Right Forearm Supination
|
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Left Forearm Pronation
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Left Forearm Supination
|
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Right Wrist Extension
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Right Wrist Flexion
|
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Left Wrist Extension
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Left Wrist Flexion
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Grip Strength Testing: Dynamometer
• • •
|
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Comments
|
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Knee/Ankle/Foot
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Observation:
• • •
|
|
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Palpation (Spasm)
• • •
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Palpation (Trigger Points)
• • •
|
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Knee/Ankle/Foot AROM
|
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Right Knee Extension
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Right Knee Flexion
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Left Knee Extension
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Left Knee Flexion
|
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Special Testing Knee:
|
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Drawer Test:
• • •
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Lachman Test:
• • •
|
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Apley Grind Test:
• • •
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McMurray Test:
• • •
|
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Patellar Test:
• • •
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Medial Stress Test:
• • •
|
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Lateral Stress Test:
• • •
|
|
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Right Ankle Dorsiflexion
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Right Ankle Plantar Flexion
|
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Left Ankle Dorsiflexion
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Left Ankle Plantar Flexion
|
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Head Injuries:
|
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Cerebellar Testing:
• • •
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Intention Tremor
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Dysmetria
|
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Comments
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Assessment
|
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Diagnosis
• • •
|
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Comments on DX
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Prognosis
• • •
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Comments
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Allowed Conditions:
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Allowed Conditions (Other)
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Treatment Recommendations
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Physical Therapy / Aquatic Therapy Recommendations/ Acupuncture Recommendations
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Physical Therapy
• • •
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Frequency
• • •
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Medically Necessary
|
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Aquatic Therapy
|
|
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Frequency
• • •
|
|
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Massage Therapy
|
|
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Frequency
• • •
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Medically Necessary
|
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Chiropractic Therapy
|
|
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Modality Requested
• • •
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Medically Necessary
|
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Frequency
• • •
|
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Acupuncture
• • •
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Medically Necessary
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Frequency
• • •
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Durable Medical Equipment
|
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Supplies
• • •
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Medically Necessary
|
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Comments
|
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Imaging Recommendations
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Radiology - MRI, X-Rays, CT Scans..ETC
• • •
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Medically Necessary
|
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Comments
|
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Consult Recommendations
|
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Pain Management Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
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Orthopedic Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
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Orthopedic Surgical Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
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Neurology Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
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Neurosurgery Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
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Psychological Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
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Neuropsych Consultation
• • •
|
Medically Necessary
|
|
Comments
|
|
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Psychiatric Consult
• • •
|
Medically Necessary
|
|
Comments
|
|
|
EMG/NVC Testing
|
|
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Diagnostic Testing
• • •
|
Medically Necessary
|
|
Comments
|
|
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Other Recommendations
|
|
|
Functional Capacity Exam (FCE)
|
Voc Rehab
|
|
Visit Recommendation and Plan
|
|
|
Plan
|
|
|
Medication Reviewed
|
Comments
|
|
Medications Prescribed at Today's visit
|
|
|
Medications Prescribed
• • •
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Medication is Medically Necessary and Appropriate for the Allowed Conditions in the claim
|
|
Medications
|
|
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Records reviewed
• • •
|
|
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Imaging/Diagnostic Testing Review Notes
|
|
|
Office visit consisted of the following:
• • •
|
|
|
Comments
|
|
