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Body Region
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Note Visit Type
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Note Service Type
• • •
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SUBJECTIVE
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Recent Subjective Finding
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History
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Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
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Personal health rating: "At the present time, would you say that your health is___________
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PAIN
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Approximate date of onset
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Type of Pain
• • •
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Verbal pain rating at present____/10
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Pain frequency
• • •
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Verbal pain rating at worst____/10
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Verbal pain rating at best____/10
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Aggravating factors
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Relieving Factors
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How much have your symptoms interfered with your daily activities?
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OR
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Exact onset date
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Cause of current episode
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Recent symptom trend
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Surgery date
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ASH Items
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Treatment start date (initial eval date)
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Stage of condition
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Nature of condition
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OBJECTIVE
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Palpation & Inspection
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VITAL SIGNS
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Height
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Weight
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Blood pressure
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OUTCOME MEASURE TOOLS
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Note
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ADL PROBLEMS
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ADL Problems
• • •
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Others, please specify
|
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ORTHOPEDIC TESTS
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Special test
|
|
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ACTIVE & PASSIVE ROM
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MUSCLE STRENGTH
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ASSESSMENT
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Clinical Impression
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Short term goals
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Long term goals
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TODAY'S TREATMENT
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Durable Medical Equipment: (Back Brace L0648)
|
Rationale for Back Brace dispensed with fitting and instruction (98960 - 15 mins)
|
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Durable Medical Equipment: (TENS Unit E0730)
|
Rationale for TENS Unit dispensed with electrode placement, frequency and duration instruction (98960 - 15 mins)
|
|
Therapeutic Exercise: (97110)
|
|
|
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Manual Therapy: (97140)
|
Total time
|
|
Note
|
Rationale for manual therapy
|
|
Neuromuscular Re-Education: (97112)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Therapeutic Activities: (97530)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
|
|
|
Ice: (97010)
|
Total time
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Electric Stimulation: (97014)
|
|
|
|
Total time
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Ultrasound: (97035)
|
Total time
|
|
Note
|
|
|
|
Rationale for skilled therapeutic exercise
|
|
Gait Training: (97116)
|
Total time
|
|
|
|
|
Note
|
Rationale for skilled therapeutic exercise
|
|
Review of HEP
|
Notes
|
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TAPINGS
• • •
|
|
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PLAN OF CARE
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|
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Frequency
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Duration
|
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Treatment
• • •
|
Discharge note
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ICD-10 CODES
|
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Medicare Functional Limitation
|
|
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Code Category
• • •
|
Code Status
• • •
|
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Treating Provider
|
Supervising Provider
|
