|
Etiology/Px
|
Email Given
|
|
Consider Options
|
|
|
Physical Therapy
• • •
|
Physical Therapy comments
|
|
Radiology
• • •
|
Radiology comments
|
|
Referrals
|
Referrer
|
|
Education
• • •
|
Education comments
|
|
Medication Rx
• • •
|
Other Meds & comments
|
|
General Instructions
• • •
|
General Instruction comments
|
|
Knee Brace
|
Lumbar Corset
|
|
Pain Shield
|
Ankle Brace
|
|
Elbow Brace
|
At-Home Exercises
|
|
Evaluate function
|
Nonsurgical persistence
|
|
Shoulder Injection
|
|
|
Left Shoulder Injection (w/ US?)
|
Right Shoulder Injection (w/ US?)
|
|
Knee Injection
|
|
|
Left Knee Injection (w/ US?)
|
Right Knee Injection (w/ US?)
|
|
Left Ankle Injection
|
Right Ankle Injection
|
|
Cervical Trigger Point Injection
|
Lumbar Trigger Point Injection
|
|
Left Shoulder Surgery
|
Right Shoulder Surgery
|
|
Left Knee Surgery
|
Right Knee Surgery
|
|
Left Ankle Surgery
|
Right Ankle Surgery
|
|
Arthritis Disclaimer
|
Final Notes
|
|
Comp Guidelines Met
|
Comp Authorization Requested
|
|
Follow-Up
|
Location
|
|
PA/NP Attestation
|
RE MD Affirmation New York
|
|
Level 3 Visit
|
Level 4 Visit
|
|
|
RE MD Affirmation New Jersey
|
