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Date of visit
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SUBJECTIVE
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Pt presents w/ c/o:
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Pt has positional difficulty with:
• • •
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Pt has functional difficulty with
• • •
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HEP/ Self-care Compliance
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ASH Items
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Nature of condition
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Stage of condition
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PAIN
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Pain frequency
• • •
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PAIN RATING
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Verbal pain rating at present____/10
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Result
|
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Verbal pain rating at best____/10
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Result
|
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Verbal pain rating at worst____/10
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Result
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Aggravating factors
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Position of comfort
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Pain description
• • •
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%Improve since 1st tx
• • •
|
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ADL PROBLEMS
|
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ADL Problems
• • •
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Others, please specify
|
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OBJECTIVE
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Palpation & Inspection
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Test and Measure Findings:
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ELBOW ROM
|
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Extension (AROM normal 0°)
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Flexion (AROM normal 145°)
|
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Pronation (AROM normal 70°)
|
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Supination (AROM normal 85°)
|
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MUSCLE STRENGTH
|
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Triceps
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Biceps Brachii
|
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Brachooradialis
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Extensor Carpi ulnaris
|
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Extensor Carpi radialis longus
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Extensor Carpi radialis brevis
|
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Extensor digitorum
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Flexor carpi ulnaris
|
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Flexor carpi radialis
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Palmaris longus
|
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Pronator
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Supinator
|
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Neuromuscular patterns
|
Supine scan of Pelvic landmarks
• • •
|
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TODAY'S TREATMENT
|
|
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Therapeutic Exercise: (97110)
|
Total time
|
|
Note
|
Rationale for therapeutic exercise
|
|
Manual Therapy: (97140)
|
Total time
|
|
Joint Mob grade
|
Nerve glides
|
|
Note
|
Rationale for manual therapy
|
|
Neuromuscular Re-Education: (97112)
|
Total time
|
|
Note
|
|
|
NMR Rational UE,Core, LE
• • •
|
Rationale for neuromuscular re-education
|
|
Therapeutic Activities: (97530)
|
Total time
|
|
Ther act Rationale for UE or LE
• • •
|
Rationale for skilled therapeutic activities
|
|
Heat: (97010)
|
Total time
|
|
Note
|
Rationale for heat therapy
|
|
Electric Stimulation: (97014)
|
Total time
|
|
Note
|
Rationale for electrical stimulation
|
|
Ultrasound: (97035)
|
Total time
|
|
Note
|
Rationale for ultrasound
|
|
Gait Training: (97116)
|
Total time
|
|
Gait Training: level/ steps
|
Rationale for gait training
|
|
Review of HEP
|
Pt. Edu Response
• • •
|
|
HEP initiated
|
HEP advanced
|
|
Total Direct contact Hands-on Time
|
Total Treatment Time:
|
|
ASSESSMENT
|
|
|
Assessment
• • •
|
Pt has met goal for
|
|
PLAN
|
|
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Frequency
|
Duration
|
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ICD-10 CODES
|
POC: UE-gen, scap-stab, sling
|
|
Treating Provider
|
Supervising Provider
|
