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Date of visit
|
|
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Referred by
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Treating Dx
|
|
Note service type
• • •
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Note visit type
|
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SUBJECTIVE
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|
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Pt presents w/ c/o:
|
Recent subjective finding
|
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Pt has functional difficulty with:
• • •
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Pt has positional difficulty with:
• • •
|
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Short term goals
|
Long term goals
|
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Reason for exacerbation
|
Latest exacerbation date
|
|
GENERAL HEALTH QUESTIONS
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|
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Personal health rating: "At the present time, would you say that your health is___________
|
|
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ONSET
|
|
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Approximate date of onset
|
|
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Recent symptom trend
|
Cause of current episode
|
|
How much have your symptoms interfered with your daily activities?
|
Surgery date
|
|
ASH Items
|
|
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Treatment start date (initial eval date)
|
Stage of condition
|
|
Nature of condition
|
|
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VITAL SIGNS
|
|
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Height
|
Weight
|
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Blood pressure
|
|
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Medical/Social Hx &/or Co-Morbidities (that may affect recovery)
|
|
|
PAIN
|
|
|
Pain frequency
• • •
|
Pain description
• • •
|
|
Verbal pain rating at present____/10
|
Result
|
|
Verbal pain rating at best____/10
|
Result
|
|
Verbal pain rating at worst____/10
|
Result
|
|
Aggravating factors
|
Position of comfort
|
|
ANKLE SYMPTOM RATING
|
|
|
LEFS
|
Result
|
|
ADL PROBLEMS
|
|
|
ADL Problems
• • •
|
Others, please specify
|
|
OBJECTIVE
|
|
|
Palpation & Inspection
|
Supine scan of Pelvic landmarks
• • •
|
|
Test and Measurements:
|
Test and Measure Score:
|
|
ORTHOPEDIC TESTS
|
|
|
Anterior drawer test
|
Note
|
|
Talar Tilt Test
|
Note
|
|
Kleiger Test
|
Note
|
|
Thomson Test
|
Note
|
|
Other orthopedic tests
|
|
|
ANKLE ROM
|
|
|
Plantar flexion (AROM normal 45°)
|
|
|
Dorsiflexion (AROM normal 20°) - current
|
|
|
Inversion (AROM normal 20°)
|
|
|
Eversion (AROM normal 45°)
|
|
|
MUSCLE STRENGTH
|
|
|
GCM
|
Tibialis Anterior
|
|
Peroneus
|
Extensor hallucis Longus
|
|
Flexor Digitorum Longus
|
Flexor Hallucis Longus
|
|
Tibialis Posterior
|
Extensor Digitorum Longus
|
|
Neuromuscular patterns
|
|
|
TREATMENT
|
|
|
Therapeutic Exercise: (97110)
|
Total time
|
|
Ther Ex LE Rationale (General/NWB):
|
Ther Ex LE Rationale (Decond/Condit/ADLs):
|
|
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
|
|
Note
|
Rationale for 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
|
|
HEP initiated
|
HEP advanced
|
|
Body Mechanics Assessment
|
Computer Ergonomic Assessment
|
|
PLAN OF CARE
|
|
|
Frequency
|
Duration
|
|
POC: LE-gen, LE-adv, LE-NWB, TKE
|
POC: Balance, Gait, Pain
|
|
Treatment
• • •
|
Discharge note
|
|
ICD-10 CODES
|
|
|
Medicare Functional Limitation
|
|
|
Code Category
• • •
|
Code Status
• • •
|
|
Treating Provider
|
Supervising Provider
|
