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Service Disclaimer
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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Subjective
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Subjective Complaint
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Other
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Patient Medical History
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Past Medical History Freewrite
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Past Surgical History
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Past Surgical History Freewrite
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Social History
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Other
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Family has a history of the following
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Other
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Medications
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Allergies
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Other
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Review of systems
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ROS other
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Patient Height
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Patient Weight
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General Wellness Assessment
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Onset
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Aggravating Factors
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Duration
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Impact on Quality of Life and Functional Impairment
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Medical Necessity Justification
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Objective Findings
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Image Standing from Front
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Image Standing from Back
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Image Tip-Toes from Back
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Image of Bottom of Both Feet
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Image of Top of both feet
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Gait Analysis
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Other
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Muskuloskeletal
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Other
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Vascular
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Other
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Dermatologic- Skin Exam
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Other
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Neurologic
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Other
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Additional Imaging Reviewed
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Other
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Assessment
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Assessment/ Diagnoses
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Additional Assessment/ Plan
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Plan
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Treatment Plan
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Conservative Treatment Measures
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Vascular Referral Yes / No
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PATIENT c/o
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RIGHT LEG
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LEFT LEG
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Additional Patient CC
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SEVERITY OF DISCOMFORT
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LOCATION
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Patient is significantly concerned due to
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Patient states symptoms started
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DIAGNOSTIC TESTS
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Diagnostic examinations performed
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Results: see attached LEVI report
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Ultrasound Report
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Ultrasound Report
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SEVERE FUNCTIONAL INCOMPETENCE OF
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RIGHT GSV
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RIGHT SSV
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LEFT GSV
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LEFT SSV
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Chronic Venous Insufficiency 187.2: Dermatitis (eczematous) L30.9 stasis 187.2 Eczema (acute) (chronic) (erythematous) (fissum)
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No indication or visualization of Deep Vein Thrombosis noted via ultrasound assessment
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Indication or visualization of Deep Vein Thrombosis noted via ultrasound assessment
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Patient states currently uses 20-30 mmHg compression stockings without any relief
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187.323 – Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity Chronic venous hypertension wi
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187.003- Postthrombotic syndrome without complications of bilateral lower extremity. Postthrombotic syndrome w/o complications o
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L81.0 Postinflammatory hyperpigmentation Hyperpigmentation (darkening) skin, after inflammation; Post-inflammatory hyperpigmenta
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PATIENT DIAGNOSIS
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Patient diagnosis codes
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HPI Note
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Plan Considerations
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