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FOCUS MORE ON PATIENT CARE
Documentation
Templates
Planetrehab Incorporated
HEADQUARTERS
3 Petroleum Center
1001 W. Pinhook, Suite 113
Lafayette, LA 70503
337-261-5458
800-982-5447
MICHIGAN OFFICE
1444 Langfield
White Lake, MI 48386
www.planetrehab.com
CREATED SPECIFICALLY FOR THE PHYSICAL THERAPY & OCCUPATIONAL THERAPY INDUSTRY www.planetrehab.com.p ane .com
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EXPLANATION
This booklet contains samples of the physical therapy note templates that are in
Planetrehab when they are printed. The name of each template is in the upper right
hand corner in red. This is the name of the template in Planetrehab. It does notprint when the note is printed from Planetrehab. Likewise, the blue number in the
bottom right-hand corner is the page number for the entire booklet and does not
print. Each individual template is labeled and numbered in the footer and does
print when the note is printed.
Certain initial evaluation templates and discharge summary templates work in
conjunction. Any template labeled with a number will have a corresponding
discharge summary, with the exception of EXT: Initial Evaluation 1, EXT: Initial
Evaluation 2 and EXT: Initial Evaluation 3. For example, if you use EXT: Initial
Evaluation Ankle 1, you should use EXT: Discharge Summary Ankle 1.
The sample templates have been left mostly blank. Each sample has some patient
information and treatment report information. Also, in certain places, you will find
the words sample text where the user would type. All other text is part of the
template and will appear each time the template is used. The idea is to reduce the
amount of typing the user must do. Generally, any template labeled 2 will have
more pre-filled data that templates labeled 1.
Please keep in mind all daily templates except EXT: Daily Soap are not formatted,thus the reason they print without modification.
All templates can be modified to your needs.
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot1
Planetrehab Physical Therapy3 Petroleum Center1001 W. Pinhook Suite 113Lafayette, LA 70503800-982-5447
888-648-1554 (fax)
INITIAL EVALUATION
PATIENT INFORMATION:
Name: Kari Abbot Sex: Female DOB: 6/19/1957
Patient Code: PPT00103ICD-9-CM Code: 337.21 Reflex sympathetic dystrophy ofthe upper limb
Date of Initial Evaluation: 2/23/2010 Physician: Dr. Kristin Davis, MD
Date of Onset: 11/12/2009 Date Last Seen by Physician: 2/22/2010
EvaluationHistory: Kari Abbot is a 52 year old Female and presents with complaints of right shoulder bursitis. The patient'ssymptoms first appeared on 11/12/2004 and was diagnosed by Dr. Kristin Davis, MD and was last seen by Dr. Davis on2/22/2010.
Subjective:
Physical Demand Level:() Light() Light/Medium() Medium() Medium/Heavy() Heavy() Very Heavy
Currently Working?() Yes() No
Restricted Duty?() Yes() No
Symptom Description/Location:
Positional Tolerance:gait ()
standing ()sitting ()sleeping ()
AM Status: () better () worseMidday Status: () better () worsePM Status: () better () worse
Pain Rating:Best: ()/10 Worst: ()/10 Average: ()/10
EXT: Initial Evaluation 1
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot2
Medications:
Observation:() Rounded Shoulders() Forward Head() Dropped Shoulder (R)() Dropped Shoulder (L)() Lumbar Lordosis (increase)() Lumbar Lordosis (decrease)
() Thoracic Kyphosis (increase)() Thoracic Kyphosis (decrease)() Cervical Lordosis (increase)() Cervical Lordosis (decrease)() Rear Foot Pronation (R)() Rear Foot Pronation (L)() Rear Foot Supination (R)() Rear Foot Supination (L)
Posture:
Palpation:
Ambulation:
Mobility:
Balance:
Neurological Findings:
ROM Right Left Comments:
Strength Right Left Comments:
Joint Play/Joint Clearing:
Girth:Site () Measurement ()Site () Measurement ()Site () Measurement ()Site () Measurement ()
Flexibility:
Special Tests:
Other:
Assessment:
Rehab Potential:
Problem List:1. ()2. ()3. ()4. ()5. ()
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot3
Functional Limitations:1. ()2. ()3. ()4. ()5. ()
Plan:Frequency () Duration ()
Treatment: Therapist performed a comprehensive evaluation in order to gather information, data from measurements andidentify significant clinical findings. From this information, a complete plan of care is established. The Therapist appliedspecific manual techniques to improve the mobility of both joints and tissue. This may include joint mobilization, oscillationand passive stretching to enhance range of movement, transverse friction massage to reduce scar tissue, effleurage todecrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normal movement patterns.TOTAL TIME FOR MANUAL THERAPY: minimum of 15 minutes.
() MFR() STM() Ultrasound() Electrical Stimulation() Iontophoresis() Whirlpool() Traction() Aquatic Therapy() Phonophoresis() Neuromuscular Reeducation() Gait Training() Work Conditioning() Therapeutic Exercise() Ergonomics() Functional Capacity Eval() Education of patient family
STG in () weeks1. ()2. ()
3. ()4. ()5. ()
LTG:1. ()2. ()3. ()4. ()5. ()
Patient's Informed Consent After Initial Evaluation
I do hereby consent to the plan of care established, treatments discussed and goals set forth by the therapist at
Planetrehab Physical Therapy. I have been given the opportunity to ask questions and fully understand the plan of care atthis time. I agree with the plan for my treatment and may opt to withdraw my consent for further treatment at any time.
___________________________________________________________________________ Date ________________Patient Signature
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot4
Thank you again Dr. Davis for this referral and please call with any recommendations or questions that you may have.Your support of this practice is appreciated.
___________________________________________________________________________ Date 2/23/2010Lloyd L Braun MPT
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. The
rehabilitation potential is good.
___________________________________________________________________________ Date ________________Physician Signature
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
PHYSICAL THERAPY EVALUATION
Date of Visit: 2/23/2010
Patient Name: Kari AbbotDate of Birth: 6/19/1957Physician: Dr. Kristin Davis, MDDate of Eval: 2/23/2010Date of Onset: 11/12/2004Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb
History: Kari Abbot is a 52 year old Female presenting with complaints of right shoulder bursitis. Initial onset of symptomsappeared sample text. Previous intervention for this condition included sample text. Diagnostic Tests for this conditioninclude sample text. Currently complains of sample text pain of rated 5/10 at worst in last 48 hours. Increasedsymptoms/difficulty with sample text. Sample text seems to relieve symptoms. Sample text disturbed sleep.
C/C and/or functional loss: sample textPatient Goals: sample textPMH: sample textMedications: sample textContraindications/Precautions: sample textSocial Hx: Kari Abbot lives at home with family. Employed at sample text. Kari Abbot is a nonsmoker.
Functional Scales: Sample text where the greater/lesser scores indicates sample text.
PATIENT PROBLEMS
Posture: sample textTenderness: Grade sample text tenderness (I-IV) to palpation was appreciatedJoint Mobility: Grade sample text hypermobility/hypomobility was found at sample text segmentsFlexibility: sample textStrength: sample textNeurologic Findings: Deep Tendon Reflexes of sample text were sample text, pinwheel sensation to sample textdermatomes was sample text, myotomes of sample text was found to be sample text.Nerve Tensioning Tests: Seated Laseque Tests, SLR, Well Leg SLR (crossover sign), Bowstring, and Seated SlumpTests Median, Ulnar, Radial Tests were found to reproduce the patient's primary complaints suggesting some irritation tothese branches.Special Tests: sample text
Functional Tests: sample textProvocation/Alleviation Tests: sample text
Treatment Report:Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identifysignificant clinical findings. From this information, a complete plan of care is established. The Therapist applied specificmanual techniques to improve the mobility of both joints and tissue. This may include joint mobilization, oscillation andpassive stretching to enhance range of movement, transverse friction massage to reduce scar tissue, effleurage to
EXT: Initial Evaluation 2
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot2
decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normal movement patterns.TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. Increase ROM by 25% 1. ROM WFL2. Increased strength by 1/3 muscle grade 2. Strength WNL3. Decrease Pain/pain score improvement by 10% 3. Eliminate Pain4. Improve Neuro-Motor control 4. Return to active Sport or ADL without Pain5. Patient stated goal 5. Patient stated goal6. Other 6. Other
Plan: Physical Therapy 3x/week x 4weeks per protocol when available. Therapy to include: Therapeutic exercises (OKCand CKC) for strength and mobility; Neuromuscular Re-education for balance, coordination, and posture; modalities forpain reduction, circulation, and mm re-education including Ultrasound (1Mhz/3Mhz, 0.8-2.0 w/cm2, 12 minutes), ElectricStimulation ( 20 minutes, frequency and intensity as needed for motor/sensory effect), Iontophoresis (40/80dexamethasone, time variable), Ice/Heat (15-20 minutes); Manual Therapy to include joint mobilizations Gr I-III, traction,mm stretching, functional massage, and STM; Gait Training on even/uneven surfaces including stair training for safety;HEP instruction and progression; work hardening/conditioning to prepare for demands of occupation.
I certify that I have examined this patient and physical therapy is medically necessary. The services will be provided whilethe patient is under my care. The plan established will be renewed every thirty days or more often if the patient's conditionrequires it.
________________________________________________________________Date: 2/23/2010Therapists Signature - Lloyd L Braun MPT
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
EVALUATION
Date: 2/23/2010 Precautions: sample textPatient Code: PPT00103 DOB: 6/19/1957 Age: 52Patient: Kari Abbot Date of Initial Eval: 2/23/2010Physician: Dr. Kristin Davis, MD Date Plan Established: 2/23/2010Primary Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb
Time Treatment Started: 9:05 AM Time Treatment Ended: 9:55 AM Total Treatment Time: 50 minutes
History: Patient is a 52 year old Female who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: right shoulder bursitis. Symptoms are relieved by sample text and madeworse by sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textPalpation: sample textFunctional Activity Level: sample textGait: sample text
AROM RIGHT LEFT PROM RIGHT LEFT MMT RIGHT LEFTExtension Extension Extension /5 /5
Flexion Flexion Flexion /5 /5Abduction Abduction Abduction /5 /5Adduction Adduction Adduction /5 /5
ER ER ER /5 /5
IR IR IR /5 /5
Special Tests Right Left DTR Right LeftEmpty Can Biceps
Impingement Brachioradialis
Speed's TricepsApprehension Grip Strength Right Left
Scapular RhythmTOS
Problem List1. 3. 5.2. 4. 6.
EXT: Initial Evaluation - Columns
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PlanetrehabInitial EvaluationDate: 2/23/2010
Patient: Kari Abbot2
Plan of Care: I plan to treat the patient with .
Short Term Goals to be met in weeks: Long Term Goals to be met in weeks:1. 1.2. 2.3. 3.4. 4.
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YES
Rehabilitation Potential: GOOD Questions answered: YES
Patient was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes.
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 2/23/2010
Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Kristin Davis, MD
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PlanetrehabPhysical Therapy Evaluation
Date: 2/23/2010Patient: Kari Abbot
1
Planetrehab Physical Therapy3 Petroleum Center1001 W. Pinhook Suite 113Lafayette, LA 70503800-982-5447888-648-1554 (fax)
PHYSICAL THERAPY EVALUATION
Client Name: Kari Abbot Date of Eval: 2/23/2010Physician: Dr. Kristin Davis, MD Date of Onset: 11/12/2004Employer: Date of Birth: 6/19/1957
Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb
Relevant History:Patient relates that sample text. This patient's medical history is otherwise unremarkable.
Employment Data: Manager Currently Working: (X) Yes () No Restricted Duty: () Yes (X) No
Physical Demand Level: () Light (X) Light/Medium () Medium () Medium/Heavy () Heavy () Very Heavy
Treatment Report:Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significantclinical findings. From this information, a complete plan of care is established. The Therapist applied specific manual techniques toimprove the mobility of both joints and tissue. This may include joint mobilization, oscillation and passive stretching to enhancerange of movement, transverse friction massage to reduce scar tissue, effleurage to decrease edema in a joint or limb,proprioceptive neuromuscular facilitation (PNF) to restore normal movement patterns. TOTAL TIME FOR MANUAL THERAPY:minimum of 45 minutes.
Objective Summary:This patient has ROM and Strength Limitations as noted below, and specifically demonstrates poor neuromotor control of sample
text.
Assessment:Pain Tool Assessment: Indicates Symptom Magnification? () Yes (X) No
Pain Tools Used: () Dallas (X) Oswestry (X) Ransford (X) VAS () Waddell () Other(s):
This patient has signs and symptoms consistent with the diagnosis, and will benefit from physical therapy for manual therapy,neuromuscular reeducation, therapeutic exercise, and modalities.
Prognosis:This patient is in otherwise good health and has good potential.
Rehabilitation Potential: () Poor () Fair (X) Good () Excellent
Plan:Treatment: Evaluation, Moist Heat, Therapeutic Exercise, Neuromuscular Reeducation, Manual Therapy, SpinalBracing/Stabilization Program.
Frequency: 3 times per week Duration: 4 Weeks
EXT: Initial Evaluation - Comprehensive
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PlanetrehabPhysical Therapy Evaluation
Date: 2/23/2010Patient: Kari Abbot
2
Short Term Goals: Long Term Goals:1) Increase ROM by 25% 1) ROM WNL2) Increase Strength by 1/3 Muscle Grade 2) Strength WNL3) Decrease Pain / Pain Score Improvement by 10% 3) Eliminate Pain4) Improve Neuro-Motor Control 4) Return to Active Sport or ADL without Pain.
Patient was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes.
I certify that I examined the patient (Kari Abbot) and therapy is necessary on an outpatient basis and these services will beprovided while the patient is under my care. The above plan of care is established and will be reviewed every 30 days. The
rehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 2/23/2010Therapists Signature - Lloyd L Braun MPT
As the treating physician I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy is necessary onan outpatient basis and these services will be provided while the patient is under my care. The above plan of care is establishedand will be reviewed every 30 days. This signature serves as a prescription confirmation. I have included specific additionalinstructions or modifications as warranted on the lines below:
________________________________________________________________Date: _____________________Physician Signature
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PlanetrehabPhysical Therapy Evaluation
Date: 2/23/2010Patient: Kari Abbot
3
Initial Physical Examination:ROM Weight Bearing Non Weight Bearing Strength
Cervical Left Right Left Right Left RightFlexion
Extension
Side Bending
Rotation
ROM Weight Bearing Non Weight Bearing StrengthLumbar Left Right Left Right Left Right
FlexionExtension
Side Bending
Rotation
AROM PROM Strength
Upper Extremities Left Right Left Right Left Right
Shoulder FlexionExtension
ABductionInternal Rot.
External Rot.
Scapular Rot.Elbow Flexion
Extension
Supination
Pronation
Wrist Flexion
Extension
Ulnar Dev.
Radial Dev.
AROM PROM Strength
Lower Extremities Left Right Left Right Left Right
Hip FlexionExtension
ABductionInternal Rot.
External Rot.
Knee FlexionExtension
Tibial RotationAnkle Dorsiflex
Plantarflexion
Inversion
Eversion
Additional Findings:
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PlanetrehabInitial EvaluationDate: 11/12/2009
Patient: Kari Abbot1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
INITIAL EVALUATION
PATIENT INFORMATION:
Name: Kari Abbot SSN: 555-55-5555 DOB: 6/19/1957
Medical Diagnosis: right shoulder bursitisICD-9-CM Code: 337.21 Reflex sympathetic dystrophy ofthe upper limb
Physician: Dr. Kristin Davis, MD Patient Occupation: Manager
Working: (X) Yes () No Last Day Worked: Date of Onset: 11/12/2009
() Light Duty (X) Moderate () Full Duty
Subjective:sample text
Posture:sample text
ROM:sample text
Strength:sample text
Special Tests:sample text
Palpation:sample text
Problems/Impairments:sample text
Goals:sample text
Plan:sample text
EXT: Evaluation - Short
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PlanetrehabInitial EvaluationDate: 11/12/2009
Patient: Kari Abbot2
Treatment Report:Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identifysignificant clinical findings. From this information, a complete plan of care is established. The Therapist applied specificmanual techniques to improve the mobility of both joints and tissue. This may include joint mobilization, oscillation andpassive stretching to enhance range of movement, transverse friction massage to reduce scar tissue, effleurage todecrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normal movement patterns.TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
()()()()()
(X)
97010 Cold Pack97014 E-Stim97032Tens/IFC97033 Iontophoresis97035 Ultrasound97100 Therapeutic Exercises
()(X)
()()()()
97116 Gait Training97140 Manual/JT Mobs/MFR97530 Therapeutic Activities97112 Neuromuscular Re-education97537 Community/Work Re-integration
(X)()
Other: HEPOther:
Patient was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes.
Patient's Informed Consent After Initial Evaluation
I do hereby consent to the plan of care established, treatments discussed and goals set forth by the therapist at LeadingEdge Physical Therapy and Sports, Inc. I have been given the opportunity to ask questions and fully understand the planof care at this time. I agree with the plan for my treatment and may opt to withdraw my consent for further treatment at anytime.
_______________________________________________ Date: ________________Patient Signature
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
_______________________________________________ Date: ________________Dr. Kristin Davis, MD Signature
Thank you again Dr. Davis for this referral and please call with any recommendations or questions that you may have.Your support of this practice is appreciated.
_______________________________________________ Date: 11/12/2009Lloyd L Braun MPT Signature
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PlanetrehabInitial Evaluation and Plan of Care
Date: 2/23/2010Patient: Kari Abbot
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
INITIAL EVALUATION AND PLAN OF CARE
Date: 2/23/2010 Precautions: sample textPatient Code: PPT00103 DOB: 6/19/1957 Age: 52Patient: Kari Abbot Date of Initial Eval: 2/23/2010Physician: Dr. Kristin Davis, MD Date Plan Established: 2/23/2010Primary Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb
Time Treatment Started: 9:05 AM Time Treatment Ended: 9:55 AM Total Treatment Time: 50 minutes
History: Patient is a 52 year old Female who is in good health. Past Medical History: sample text. Current Medication:sample text. Chief Complaint At This Time: right shoulder bursitis. Symptoms are relieved by sample text and made
worse by sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textPalpation: sample textFunctional Activity Level: sample textGait: sample text
Precautions:1. sample text2. sample text3. sample text4. sample text
Related interventions attempted:1. Resting and pacing activities without clinical interventions2. Over the counter medications3. sample text
The patient's past medical history includes:1. The patient's past medical history includes sample text.
The patient's current medications are sample text.
The patient's medical diagnostic testing has included physician clinical evaluation with/without X-rays, MRI, EMG studies.
Our therapy clinical testing included direct verbal interview, visual evaluation, active and assisted mobility assessment,manual strength assessment, and painful palpation evaluation.
EXT: Initial Evaluation and Plan of Care 1
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PlanetrehabInitial Evaluation and Plan of Care
Date: 2/23/2010Patient: Kari Abbot
3
4. Clinical pool therapy directly supervised in the pool by thetreating therapist
5. Clinical gym strengthening sample text6. Home exercise and self-care training
Frequency: 3 times per week Duration: 4 weeks
Kari Abbot was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes.
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be provided
while the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 2/23/2010Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Kristin Davis, MD
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PlanetrehabInitial Evaluation and Plan of Care
Date: 2/23/2010Patient: Kari Abbot
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
INITIAL EVALUATION AND PLAN OF CARE
Patient: Kari AbbotD.O.B.: 6/19/1957
Physician: Dr. Kristin Davis, MD
Primary Diagnosis:337.21 Reflex sympathetic dystrophy of the upper limb
Treatment Diagnosis:Gait deteriorationADL deteriorationMuscle weakness
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information,data from measurements and identify significant clinical findings. From this information, a completeplan of care is established. The Therapist applied specific manual techniques to improve the mobilityof both joints and tissue. This may include joint mobilization, oscillation and passive stretching toenhance range of movement, transverse friction massage to reduce scar tissue, effleurage todecrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Date of onset: 11/12/2004
Precautions:sample text
History: Patient is an 52 year old Female suffering sample text.
Related interventions attempted:1. Resting and pacing activities without clinical interventions2. Over the counter medications
3. sample text
The patient's past medical history includes:1. The patient's past medical history includes sample text.
The patient's current medications are sample text.
The patient's medical diagnostic testing has included physician clinical evaluation with/without X-rays,
EXT: Initial Evaluation and Plan of Care
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PlanetrehabInitial Evaluation and Plan of Care
Date: 2/23/2010Patient: Kari Abbot
2
MRI, EMG studies.
Our therapy clinical testing included direct verbal interview, visual evaluation, active and assistedmobility assessment, manual strength assessment, and painful palpation evaluation.
Significant Clinical Findings and Observation:1. sample text
Posture and presentation:1. Well groomed, alert, optimistic, and fairly well informed andoriented to their predicament.
2. Head and shoulders posture is noted sample text.3. Spine alignment is noted sample text4. Hips and pelvis orientation is noted sample text5. Legs, knees, and ankles are noted sample text
Pain:1. At worst: 10/10 provoked most by sample text2. At best: 1/10 comforted best by sample text3. Palpation: Patient reports pain with palpation sample text
Skin condition and swelling:1. Skin intact with good color and temperature throughout.2. Swelling noted sample text
Range of Motion:1. General 95% of normal expected2. Restricted in 75 to 90% of normal expected
Strength:1. General 95% of normal expected
2. Restricted in 75 strength to 90% of normal expected
Functional Activity Problems:1. sample text.2. Sustained stance is limited to sample text.3. The patient presents with a shuffled, short-step,
unsteady gait pattern. Distance limited to sample text. Cane, walker,wheelchair dependent.
4. Sustained sitting limited to sample text.5. Sleep is disturbed, limited to sample text. Best position sample text. sample text
avoided.
6. Household care involving sample text is avoided.7. Yard work involving sample text is avoided.8. Work tasks involving sample text are avoided.9. Sports activity involving sample text is avoided.
Short Term Goals:1. Increase mobility by 25% within 2 weeks.2. Restore /5 strength in the within 2 weeks.3. Decrease pain below /10 in within 2 weeks.
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PlanetrehabProgress Report and Plan of Care
Date: 12/1/2009Patient: Toby Castle
f
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
PROGRESS REPORT AND PLAN OF CARE
Date of Visit: 12/1/2009
Patient Name: Toby CastleDate of Birth: 9/23/1987Physician: Dr. Ned Isakoff, MDDiagnosis: 844.1 Sprain in medial collateral ligament of kneeDate of onset: 11/25/2009
Date of Eval: 12/1/2009Visits attended to date: 1Visits missed to date: 0
Time Treatment Started: 9:03 AMTime Treatment Ended: 9:59 AMTotal Treatment Time: 56 minutes
History: Toby Castle is a 22 year old Male presenting with complaints of ACLR. Initial onset ofsymptoms appeared sample text. Previous intervention for this condition included sample text.Diagnostic Tests for this condition include sample text. Currently complains of sample text pain of
rated 8/10 at worst in last 48 hours. Increased symptoms/difficulty with sample text. Sample textseems to relieve symptoms. Sample text disturbed sleep.
Patient Problems:
1. Posture:2. Tenderness: Grade tenderness (I-IV) to palpation was appreciated3. ROM: Cardinal Planes ; Coupled Planes4. Joint Mobility: Grade hypermobility/hypomobility was found at segments5. Flexibility:6. Strength:7. Neurologic Findings: Deep Tendon Reflexes of were , pinwheel sensation to dermatomes was
, myotomes of was found to be .8. Nerve Tensioning Tests: Seated Lasegue Tests, SLR, Well Leg SLR (crossover sign),
Bowstring, and Seated Slump Tests Median, Ulnar, Radial Tests were found to reproduce thepatient's primary complaints suggesting some irritation to these branches.
9. Special Tests:10. Functional Tests:11. Provocation/Alleviation Tests:
EXT: Plan of Care
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PlanetrehabProgress Report and Plan of Care
Date: 12/1/2009Patient: Toby Castle
potential is good.
Thank you again Dr. Isakoff for this referral and please call with any recommendations or questionsthat you may have. Your support of this practice is appreciated.
____________________________________________________ Date: 12/1/2009Therapists Signature - Joe Davola PT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign inagreement. Therapy is necessary on an outpatient basis and these services will be provided while thepatient is under my care. The above plan of care is established and will be reviewed every 30 days.This signature serves as a prescription confirmation. I have included specific additional instructions ormodifications as warranted on the lines below:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________ Date: ________________Physician Signature - Dr. Ned Isakoff, MD
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PlanetrehabProgress ReportDate: 3/24/2010
Patient: Kari Abbot2
Continue Present Treatment Plan with Physician Approval Frequency: 3 times per weekModify Current Treatment Plan: Modifications: Duration: 4 WeeksDischarge: See Discharge Summary Treatment: Moist Heat,
Therapeutic Exercise,NeuromuscularReeducation, ManualTherapy, SpinalBracing/StabilizationProgram.
Other:
________________________________________________________________Date:3/24/2010Therapists Signature - Alec Berg PT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The aboveplan of care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. Ihave included specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Kristin Davis, MD
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PlanetrehabProgress ReportDate: 3/24/2010
Patient: Kari Abbot3
Reassessment Measures:ROM Weight Bearing Non Weight Bearing StrengthCervical Left Right Left Right Left Right
FlexionExtension
Side Bending
Rotation
ROM Weight Bearing Non Weight Bearing StrengthLumbar Left Right Left Right Left Right
FlexionExtensionSide Bending
Rotation
AROM PROM StrengthUpper Extremities Left Right Left Right Left Right
Shoulder FlexionExtension
ABduction
Internal Rot.External Rot.Scapular Rot.
Elbow FlexionExtension
Supination
PronationWrist Flexion
ExtensionUlnar Dev.
Radial Dev.
AROM PROM StrengthLower Extremities Left Right Left Right Left Right
Hip FlexionExtension
ABduction
Internal Rot.External Rot.
Knee Flexion
ExtensionTibial Rotation
Ankle DorsiflexPlantarflexionInversionEversion
Additional Findings:
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PlanetrehabRe-evaluation
Date: 3/24/2010Patient: Kari Abbot
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503
800-982-5447888-648-1554 (fax)
RE-EVALUATION
Date: 3/24/2010 Precautions: sample textPatient Code: PPT00103 DOB: 6/19/1957 Age: 52Patient: Kari Abbot Date of Initial Eval: 2/23/2010Physician: Dr. Kristin Davis, MD Date Plan Established: 2/23/2010Primary Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb
Time Treatment Started: 9:21 AM Time Treatment Ended: 10:15 AM Total Treatment Time: 54 minutes
History: Patient is a 52 year old Female who is in good health. Past Medical History: sample text. Current Medication:sample text. Chief Complaint At This Time: right shoulder bursitis. Symptoms are relieved by sample text and madeworse by sample text. Prior Function Level: sample text.
Treatment Report: The Therapist applied specific manual techniques to improve the mobility of both joints and tissue.This may include joint mobilization, oscillation and passive stretching to enhance range of movement, transverse frictionmassage to reduce scar tissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation(PNF) to restore normal movement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 50 minutes.
SUBJECTIVE:Patient reports sample text.
() Increase () Decrease () No Change PAIN with pain scale /10
() Increase () Decrease () No Change STIFFNESS
() Increase () Decrease () No Change DIFFICULTY
() Increase () Decrease () No Change STIFFNESS{}.
OBJECTIVE:() + () - Postural Deviation () + () - Gait Deviation
() + () - Swelling () + () - Assistive Device
() Increase () Decrease () No Change Tenderness
() Increase () Decrease () No Change Muscle Spasm/guarding
() Increase () Decrease () No Change Tightness
() Increase () Decrease () No Change ROM as follows:
() Increase () Decrease () No Change Strength
EXT: Re-evaluation
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PlanetrehabRe-evaluation
Date: 3/24/2010Patient: Kari Abbot
2
Other findings:
ASSESSMENT:sample text
PLAN:sample text
I certify that I re-examined the patient and additional therapy is necessary on an outpatient basis and these services willbe provided while the patient is under my care. The above plan of care is established and will be reviewed every 30 days.The rehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 3/24/2010Therapists Signature - Alec Berg PT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I have
included specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Kristin Davis, MD
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PlanetrehabKnee EvaluationDate: 12/2/2009
Patient: Audrey Macklin1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
ANKLE EVALUATION
Date: 12/2/2009 Precautions: sample textPatient Code: PPT00046 DOB: 1/2/1987 Age: 22Patient: Audrey Macklin Date of Initial Eval: 12/2/2009Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/2/2009Primary Diagnosis: 845.02 Sprains of ankle- calcaneofibular (ligament)
Time Treatment Started: 1:02 PM Time Treatment Ended: 2:01 PM Total Treatment Time: 59 minutes
History: Patient is a 22 year old Female who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: right ankle sprain. Symptoms are relieved by sample text and madeworse by sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textPalpation: sample textFunctional Activity Level: sample textGait: sample text
AROM RIGHT LEFT MMT RIGHT LEFT GIRTH RIGHT LEFT
Plantarflexion Plantarflexion /5 /5 MM
Dorsiflexion Dorsiflexion /5 /5 5th MT
Inversion Inversion /5 /5 Figure 8
Eversion Eversion /5 /5 15cm MM
SPECIAL TESTS RIGHT LEFT
S/L Stance
Single Toe Raise
Problem List1. 3. 5.2. 4. 6.
Plan of Care: I plan to treat the patient with sample text.
EXT: Evaluation - Ankle 1
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PlanetrehabKnee EvaluationDate: 12/2/2009
Patient: Audrey Macklin2
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. sample text 1. sample text2. sample text 2. sample text3. sample text 3. sample text4. sample text 4. sample text
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 12/2/2009Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above plan
of care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Lindsay Enwright, MD
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PlanetrehabAnkle EvaluationDate: 12/2/2009
Patient: Audrey Macklin1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
ANKLE EVALUATION
Date: 12/2/2009 Precautions: sample textPatient Code: PPT00046 DOB: 1/2/1987 Age: 22Patient: Audrey Macklin Date of Initial Eval: 12/2/2009Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/2/2009Primary Diagnosis: 845.02 Sprains of ankle- calcaneofibular (ligament)
Time Treatment Started: 1:02 PM Time Treatment Ended: 2:01 PM Total Treatment Time: 59 minutes
History: Patient is a 22 year old Female who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: right ankle sprain. Symptoms are relieved by sample text and madeworse by sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textFunctional Activity Level: sample textGait: sample text
PALPATION RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Lateral Ligaments - ATF Anterior Drawer
Lateral Ligaments - CF Talar Tilt
Lateral Ligaments - PTF Homan Sign (DVT)
Medial ligaments Thompson
Medial ligaments (Deltoid)
Achilles Tendon
Peroneal Tendons
Other:
AROM RIGHT LEFT MMT RIGHT LEFT GIRTH RIGHT LEFT
Plantarflexion Plantarflexion /5 /5 MM
Dorsiflexion Dorsiflexion /5 /5 5th MT
Inversion Inversion /5 /5 Figure 8
Eversion Eversion /5 /5 15cm MM
EXT: Evaluation - Ankle 2
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PlanetrehabAnkle EvaluationDate: 12/2/2009
Patient: Audrey Macklin2
Problem List1. Decreased ROM 3. Decreased Function 5. Difficulty walking2. Decreased Strength 4. Pain 6. Functional limitation
Plan of Care: I plan to treat the patient with(X) Balance/Proprioception Training () Iontophoresis (X) Taping() Electrical Stimulation () Joint Mobilization (X) Therapeutic Activity() Gait Training () Neuromuscular re-ed () Therapeutic Exercise() Home Program (X) Patient Education () Traction
() Hot/Cold Pack () Soft tissue mobilization () UltrasoundOther: ()
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. Increase ROM by 25% 1. ROM WFL2. Increased strength by 1/3 muscle grade 2. Strength WNL3. Decrease Pain/pain score improvement by 10% 3. Eliminate Pain4. Improve Neuro-Motor control 4. Return to active Sport or ADL without Pain5. Patient stated goal 5. Patient stated goal6. Other 6. Other
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I have examined this patient and physical therapy is medically necessary. The services will be provided whilethe patient is under my care. The plan established will be renewed every thirty days or more often if the patient's conditionrequires it.
________________________________________________________________Date: 12/2/2009Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I have
included specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Lindsay Enwright, MD
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PlanetrehabCervical Evaluation
Date: 12/1/2009Patient: Victor Wexler
2
PALPATION RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Mastoid Process Spurling (Foraminal Comp)
Scalenes Shoulder Abduction (Comp)
Sternocleidomastoid Adson (TOS)
Cervical Paraspinals Roos (TOS)
Trapezius
Levator Scapulae
Rhomboids
Other:
Problem List1. Decreased ROM 3. Decreased Function 5. Difficulty walking2. Decreased Strength 4. Pain 6. Functional limitation
Plan of Care: I plan to treat the patient with() Balance/Proprioception Training () Iontophoresis () Taping() Electrical Stimulation () Joint Mobilization () Therapeutic Activity() Gait Training () Neuromuscular re-ed () Therapeutic Exercise() Home Program () Patient Education () Traction() Hot/Cold Pack () Soft tissue mobilization () UltrasoundOther: ()
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. Increase ROM by 25% 1. ROM WFL2. Increased strength by 1/3 muscle grade 2. Strength WNL3. Decrease Pain/pain score improvement by 10% 3. Eliminate Pain4. Improve Neuro-Motor control 4. Return to active Sport or ADL without Pain5. Patient stated goal 5. Patient stated goal6. Other 6. Other
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I have examined this patient and physical therapy is medically necessary. The services will be provided while
the patient is under my care. The plan established will be renewed every thirty days or more often if the patient's conditionrequires it.
________________________________________________________________Date: 12/1/2009Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Geoffrey Harharwood, MD
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PlanetrehabElbow EvaluationDate: 12/10/2009
Patient: Wendy Walters1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
ELBOW EVALUATION
Date: 12/10/2009 Precautions: sample textPatient Code: PPT00049 DOB: 4/10/1973 Age: 36Patient: Wendy Walters Date of Initial Eval: 12/10/2009Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/10/2009Primary Diagnosis: 726.32 Enthesopathy of elbow- lateral epicondylitis
Time Treatment Started: 10:00 AM Time Treatment Ended: 10:55 AM Total Treatment Time: 55 minutes
History: Patient is a 36 year old Female who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: left elbow. Symptoms are relieved by sample text and made worse bysample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textPalpation: sample textFunctional Activity Level: sample textGait: sample text
AROM RIGHT LEFT MMT
Elbow Flexion Elbow
Elbow Extension Forearm
Forearm Pronation Elbow Flexion
Supination Elbow Extension
Bilateral Wrist Forearm Pronation
Bilateral Shoulders Forearm Supination
Neuro:
sample text
SPECIAL TESTS RIGHT LEFT
Tennis Elbow
Grip Strength (2nd notch)
EXT: Evaluation - Elbow 1
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PlanetrehabElbow/Wrist Evaluation
Date: 12/10/2009Patient: Wendy Walters
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
ELBOW/WRIST EVALUATION
Date: 12/10/2009 Precautions: sample textPatient Code: PPT00049 DOB: 4/10/1973 Age: 36Patient: Wendy Walters Date of Initial Eval: 12/10/2009Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/10/2009Primary Diagnosis: 726.32 Enthesopathy of elbow- lateral epicondylitis
Time Treatment Started: 10:00 AM Time Treatment Ended: 11:00 AM Total Treatment Time: 60 minutes
History: Patient is a 36 year old Female who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: left elbow. Symptoms are relieved by sample text and made worse bysample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textFunctional Activity Level: sample textGait: sample text
AROM RIGHT LEFT MMT RIGHT LEFT PROM
Elbow Flexion Elbow Flexion /5 /5 Elbow Flexion
Elbow Extension Elbow Extension /5 /5 Elbow Extension
Wrist Flexion Wrist Flexion /5 /5 Wrist Flexion
Wrist Extension Wrist Extension /5 /5 Wrist Extension
Supination Supination /5 /5 Supination
Pronation Pronation /5 /5 Pronation
Wrist Ulnar Dev Wrist Ulnar Dev /5 /5 Wrist Ulnar Dev
Wrist Radial Dev Wrist Radial Dev /5 /5 Wrist Radial Dev
PALPATION RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Lateral Epicondyle Lateral Epicondylitis
Medial Epicondyle Medical Epicondylitis
Snuff box Tinels (Carpel Tunnel)
Thenar Eminence Tinels (Cubital Tunnel)
Other: Finkelstein (De Quervains)
EXT: Evaluation Elbow/Wrist
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PlanetrehabElbow/Wrist Evaluation
Date: 12/10/2009Patient: Wendy Walters
2
Problem List1. Decreased ROM 3. Decreased Function 5. Difficulty walking2. Decreased Strength 4. Pain 6. Functional limitation
Plan of Care: I plan to treat the patient with() Balance/Proprioception Training () Iontophoresis () Taping() Electrical Stimulation () Joint Mobilization () Therapeutic Activity() Gait Training () Neuromuscular re-ed () Therapeutic Exercise() Home Program () Patient Education () Traction
() Hot/Cold Pack () Soft tissue mobilization () UltrasoundOther: ()
Short Term Goals to be met in weeks: Long Term Goals to be met in weeks:1. Increase ROM by 25% 1. ROM WFL2. Increased strength by 1/3 muscle grade 2. Strength WNL3. Decrease Pain/pain score improvement by 10% 3. Eliminate Pain4. Improve Neuro-Motor control 4. Return to active Sport or ADL without Pain5. Patient stated goal 5. Patient stated goal6. Other 6. Other
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I have examined this patient and physical therapy is medically necessary. The services will be provided whilethe patient is under my care. The plan established will be renewed every thirty days or more often if the patient's conditionrequires it.
________________________________________________________________Date: 12/10/2009Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I have
included specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Lindsay Enwright, MD
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PlanetrehabElbow EvaluationDate: 12/10/2009
Patient: Wendy Walters1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
ELBOW EVALUATION
Date: 12/10/2009 Precautions: sample textPatient Code: PPT00049 DOB: 4/10/1973 Age: 36Patient: Wendy Walters Date of Initial Eval: 12/10/2009Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/10/2009Primary Diagnosis: 726.32 Enthesopathy of elbow- lateral epicondylitis
Time Treatment Started: 0:00 AM Time Treatment Ended: 0:00 AM Total Treatment Time: 0 minutes
History: Patient is a 36 year old Female who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: left elbow. Symptoms are relieved by sample text and made worse bysample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textFunctional Activity Level: sample textGait: sample text
AROM RIGHT LEFT MMT RIGHT LEFT PROM
Elbow Flexion Elbow Flexion /5 /5 Elbow Flexion
Elbow Extension Elbow Extension /5 /5 Elbow Extension
Wrist Flexion Wrist Flexion /5 /5 Wrist Flexion
Wrist Extension Wrist Extension /5 /5 Wrist Extension
Supination Supination /5 /5 Supination
Pronation Pronation /5 /5 Pronation
Wrist Ulnar Dev Wrist Ulnar Dev /5 /5 Wrist Ulnar Dev
Wrist Radial Dev Wrist Radial Dev /5 /5 Wrist Radial Dev
PALPATION RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Lateral Epicondyle Lateral Epicondylitis
Medial Epicondyle Medical Epicondylitis
Snuff box Tinels (Carpel Tunnel)
Thenar Eminence Tinels (Cubital Tunnel)
Other: Finkelstein (De Quervains)
EXT: Evaluation Elbow 2
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PlanetrehabElbow EvaluationDate: 12/10/2009
Patient: Wendy Walters2
Problem List1. Decreased ROM 3. Decreased Function 5. Difficulty walking2. Decreased Strength 4. Pain 6. Functional limitation
Plan of Care: I plan to treat the patient with() Balance/Proprioception Training () Iontophoresis () Taping() Electrical Stimulation () Joint Mobilization () Therapeutic Activity() Gait Training () Neuromuscular re-ed () Therapeutic Exercise() Home Program () Patient Education () Traction
() Hot/Cold Pack () Soft tissue mobilization () UltrasoundOther: ()
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. Increase ROM by 25% 1. ROM WFL2. Increased strength by 1/3 muscle grade 2. Strength WNL3. Decrease Pain/pain score improvement by 10% 3. Eliminate Pain4. Improve Neuro-Motor control 4. Return to active Sport or ADL without Pain5. Patient stated goal 5. Patient stated goal6. Other 6. Other
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I have examined this patient and physical therapy is medically necessary. The services will be provided whilethe patient is under my care. The plan established will be renewed every thirty days or more often if the patient's conditionrequires it.
________________________________________________________________Date: 12/10/2009Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Lindsay Enwright, MD
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Planetrehab
Initial EvaluationDate: 2/23/2010
Patient: Kari Abbot1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
PHYSICAL THERAPY EVALUATION
Date: 2/23/2010 Precautions:Patient Code: PPT00103 DOB: 6/19/1957 Age: 52Patient: Kari Abbot Date of Initial Eval: 2/23/2010Physician: Dr. Kristin Davis, MD Date Plan Established: 2/23/2010Primary Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb
Time Treatment Started: 9:05 AM Time Treatment Ended: 9:55 AM Total Treatment Time: 50 minutes
History: Patient is a 52 year old Female who is in good health. Past Medical History: sample text. Current Medication:sample text. Chief Complaint At This Time: right shoulder bursitis. Symptoms are relieved by sample text and madeworse by sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Subjective:Patient c/o pain lateral knee area and inf. patellar area c diff. bending knee at 80 deg.Subjective pain scale (1=least pain, 10=worst pain): 6/10Difficulty with functional activities: stairs down>up, squatting, sit to stand
Date of onset: chronic 1 yr.; fell 1 wk ago and landed on knee which aggravated original conditionHow sustained: unknownOccupation/Activities: yard work, house workPert. Med. History: arthroscopic sx 2x to R knee last one was done 7 yrs ago, chronic LBP, arthritis, asthma, hernia, HTNDate of surgery: n/aMedical Test ##i-sub## Result: (xrays - Dr. Handler ) N/AMedication taken for pain: Mobic
Objective:Gait: ( ) Normal ( ) Guarded (X) Leg problem Comment:
Body build: ( ) Short/stocky (X) Intermediate ( ) Slender
Head position & bearing: ( ) Good (X) Forward head ( ) Other:
Palpation:(+) Swelling R knee medial/lateral(+) Tenderness, Gr. lat knee and inferior patellar area(-) Spasm / muscle guarding(+) Tightness hamstrings/quads R/gastrocs B
EXT: Evaluation - Extremity
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Planetrehab
Initial EvaluationDate: 2/23/2010
Patient: Kari Abbot3
ANKLEROM RIGHT LEFT PAIN SPECIAL TESTS
Flexion 0-30 ( ) Drawer's
Extension 0-50
MMT: All muscles WNL strengthunless otherwise indicatedbelow: UE: LE: R knee ext. 3+-4/5 ( ) Other: mm grith measurements:R: suprapat = 43.5, joint line 43.5,infrapat=37 cm; L supra=42.5, jtline= 40.75, infra=36
Abduction 0-35
ER 0-15
ASSESSMENTPT impression: fair prognosis
STG (in 2 weeks)(X) Decreased pain / tenderness by at least 30 %(X) Increased ROM by at least 10 deg.( ) Increased strength(X) Gait: (X) Increased WB status ( ) with / without assist device
( ) Walk X feet ( ) with / without assist. device
(X) Functional activities: dec. diff FA by at least 30 %(X) Patient education: (X) Proper body mechanics(X) Joint conservation techniques
LTG (in 6 weeks)(X) Eliminate or decrease pain / tenderness by at least 90 %(X) WNL / WFL ROM(X) WNL strength(X) Gait: Normal WB / gait pattern ( ) with / without assist device
Walk X feet ( ) with / without assist. device(X) Able to perform above functional activities without c with mindifficulty.
PLAN:
Frequency: 3x / week Duration: 4-6 weeks( ) Therapeutic modalities PRN: (X) Hot (X) Cold pack (X) Electric Stim. (X) Ultrasound(X) Manual Therapy (X) Myofascial release / massage
( ) Manual traction(X) Joint Mob
(X) Therapeutic exercises(X) Stretching (X) Isometric ex.(X) ROM (PROM / AAROM / AROM) (X) Stabilization ex.(X) PRE's (X) UE / LE ergometer(X) Leg ext / flex machine (X) Postural training
(X) Gait training (X) Treadmill (X) on even / uneven surfaces(X) Neuromusc. Re-educ: (X) balance (X) coordination(X) Patient education (X) Proper body mechanics
(X) Joint Conservation Techniques(X) Other: received HEp--attached but would need review; TCTT= 40 min.
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PlanetrehabHip Evaluation
Date: 12/3/2009Patient: Rick Overton
2
Problem List1. sample text 3. sample text 5. sample text2. sample text 4. sample text 6. sample text
Plan of Care: I plan to treat the patient with sample text.
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. sample text 1. sample text2. sample text 2. sample text
3. sample text 3. sample text4. sample text 4. sample text
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 12/3/2009Therapists Signature - Lloyd L Braun MPT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Sara Sitardites, MD
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PlanetrehabHip Evaluation
Date: 12/3/2009Patient: Rick Overton
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
HIP EVALUATION
Date: 12/3/2009 Precautions: sample textPatient Code: PPT00014 DOB: 1/8/1957 Age: 52Patient: Rick Overton Date of Initial Eval: 12/3/2009Physician: Dr. Sara Sitardites, MD Date Plan Established: 12/3/2009Primary Diagnosis: 715.15 Osteoarthrosis,localized, primary- pelvic/thigh V43.64 Hip Joint ReplacementTime Treatment Started: 11:00 AM Time Treatment Ended: 12:03 PM Total Treatment Time: 63 minutes
History: Patient is a 52 year old Male who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: Right THA. Symptoms are relieved by sample text and made worse bysample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textFunctional Activity Level: sample textGait: sample text
AROM RIGHT LEFT PROM RIGHT LEFT MMT RIGHT LEFT
Extension Extension Extension /5 /5
Flexion Flexion Flexion /5 /5
IR IR IR /5 /5
ER ER ER /5 /5
Abduction Abduction Abduction /5 /5
Adduction Adduction Adduction /5 /5
PALPATION RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Lumbar paraspinals Hip Scour
Piriformis OBER
Greater Trochanter FABER
Ischial Tuberosity Piriformis
Other: Thomas
Trendelenburg
EXT: Evaluation Hip 2
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PlanetrehabKnee EvaluationDate: 12/1/2009
Patient: Toby Castle2
Problem List1. sample text 3. sample text 5. sample text2. sample text 4. sample text 6. sample text
Plan of Care: I plan to treat the patient with sample text.
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. sample text 1. sample text2. sample text 2. sample text
3. sample text 3. sample text4. sample text 4. sample text
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 8 weeks Goals and plans discussed with patient: YESRehabilitation Potential: Good Questions answered: YES
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 12/1/2009Therapists Signature - Joe Davola PT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Ned Isakoff, MD
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PlanetrehabKnee EvaluationDate: 12/1/2009
Patient: Toby Castle2
PALPATION RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Medial joint line Varus Stress (LCL)
Lateral Joint Line Valgus Stress (MCL)
Patellar Tendon Anterior Drawer (ACL)
MCL McMurry (Meniscus)
Popliteal Fossa Apley Comp (Meniscus)
Other: Lachman (ACL)
Thessaly @ 20 (Meniscus)
Problem List1. Decreased ROM 3. Decreased Function 5. Difficulty walking2. Decreased Strength 4. Pain 6. Functional limitation
Plan of Care: I plan to treat the patient with() Balance/Proprioception Training () Iontophoresis () Taping() Electrical Stimulation () Joint Mobilization () Therapeutic Activity() Gait Training () Neuromuscular re-ed (X) Therapeutic Exercise(X) Home Program (X) Patient Education () Traction() Hot/Cold Pack () Soft tissue mobilization () UltrasoundOther: ()
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. Increase ROM by 25% 1. ROM WFL2. Increased strength by 1/3 muscle grade 2. Strength WNL3. Decrease Pain/pain score improvement by 10% 3. Eliminate Pain4. Improve Neuro-Motor control 4. Return to active Sport or ADL without Pain5. Patient stated goal 5. Patient stated goal6. Other 6. Other
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 8 weeks Goals and plans discussed with patient: YESRehabilitation Potential: Good Questions answered: YES
I certify that I have examined this patient and physical therapy is medically necessary. The services will be provided whilethe patient is under my care. The plan established will be renewed every thirty days or more often if the patient's condition
requires it.
________________________________________________________________Date: 12/1/2009Therapists Signature - Joe Davola PT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. Ned Isakoff, MD
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PlanetrehabLumber Evaluation
Date: 12/1/2009Patient: Carlos Jacott
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
LUMBAR EVALUATION
Date: 12/1/2009 Precautions: sample textPatient Code: PPT00022 DOB: 12/29/1963 Age: 45Patient: Carlos Jacott Date of Initial Eval: 12/1/2009Physician: Dr. John Grossbard, MD Date Plan Established: 12/1/2009Primary Diagnosis: 722.73 Intervertebral disc disorder w/ myelopathy- lumbar 724.2 Lumbago- back disorderTime Treatment Started: 10:30 AM Time Treatment Ended: 11:25 AM Total Treatment Time: 55 minutes
History: Patient is a 45 year old Male who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: CL5-S1 Fusion. Symptoms are relieved by sample text and made worseby sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textPalpation: sample textFunctional Activity Level: sample textGait: sample text
ROM: lumbar ROM: lower ext. RIGHT LEFT MMT RIGHT LEFT
Forward Bending Hip Extension Hip Extension /5 /5
Backward Bending Hip Flexion Hip Flexion /5 /5
Side Bend Right Hip IR Hip IR /5 /5
Side Bend Left Hip ER Hip ER /5 /5
Rotation Right Hip Abduction Hip Abduction /5 /5
Rotation Left Hip Adduction Hip Adduction /5 /5
Knee Flexion /5 /5
Knee Extension /5 /5
Ankle DF /5 /5
Ankle PF /5 /5
EXT: Evaluation - Lumbar 1
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PlanetrehabLumber Evaluation
Date: 12/1/2009Patient: Carlos Jacott
2
SPECIAL TESTS RIGHT LEFT SPECIAL TESTS RIGHT LEFT
Problem List1. sample text 3. sample text 5. sample text2. sample text 4. sample text 6. sample text
Plan of Care: I plan to treat the patient with sample text.
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. sample text 1. sample text2. sample text 2. sample text3. sample text 3. sample text4. sample text 4. sample text
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I examined the patient and therapy is necessary on an outpatient basis and these services will be providedwhile the patient is under my care. The above plan of care is established and will be reviewed every 30 days. Therehabilitation potential is good.
Thank you for this referral.
________________________________________________________________Date: 12/1/2009 Therapists Signature -Joe Davola PT
As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. Therapy isnecessary on an outpatient basis and these services will be provided while the patient is under my care. The above planof care is established and will be reviewed every 30 days. This signature serves as a prescription confirmation. I haveincluded specific additional instructions or modifications as warranted on the lines below:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________ Date: ____________________Physician Signature - Dr. John Grossbard, MD
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PlanetrehabLumbar Evaluation
Date: 12/1/2009Patient: Carlos Jacott
1
Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503800-982-5447
888-648-1554 (fax)
LUMBAR EVALUATION
Date: 12/1/2009 Precautions: sample textPatient Code: PPT00022 DOB: 12/29/1963 Age: 45Patient: Carlos Jacott Date of Initial Eval: 12/1/2009Physician: Dr. John Grossbard, MD Date Plan Established: 12/1/2009Primary Diagnosis: 722.73 Intervertebral disc disorder w/ myelopathy- lumbar 724.2 Lumbago- back disorderTime Treatment Started: 10:30 AM Time Treatment Ended: 11:25 AM Total Treatment Time: 55 minutes
History: Patient is a 45 year old Male who is in good health. Past Medical History: sample text. Current Medication:
sample text. Chief Complaint At This Time: CL5-S1 Fusion. Symptoms are relieved by sample text and made worseby sample text. Prior Function Level: sample text.
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data frommeasurements and identify significant clinical findings. From this information, a complete plan of care is established. TheTherapist applied specific manual techniques to improve the mobility of both joints and tissue. This may include jointmobilization, oscillation and passive stretching to enhance range of movement, transverse friction massage to reduce scartissue, effleurage to decrease edema in a joint or limb, proprioceptive neuromuscular facilitation (PNF) to restore normalmovement patterns. TOTAL TIME FOR MANUAL THERAPY: minimum of 45 minutes.
Significant Clinical Findings:Pain Level: sample textObservation: sample textFunctional Activity Level: sample textGait: sample text
ROM: lumbar ROM: lower ext. RIGHT LEFT MMT Strength RIGHT LEFT
Flexion Hip Extension Hip Flexion L2 /5 /5
Extension Hip Flexion Knee Extension
L3/5 /5
Side Bend Right Hip IR Dorsiflexion L4 /5 /5
Side Bend Left Hip ER Great ToeExtension
/5 /5
Rotation Right Hip Abduction Eversion S1 /5 /5
Rotation Left Hip Adduction Plantar Flexion S1 /5 /5
Knee Flexion S1-2
/5 /5
EXT: Evaluation Lumbar 2
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PlanetrehabShoulder Evaluation
Date: 12/4/2009Patient: Harry Morgan
2
Special Tests Right Left DTRs Right Left
Empty Can Biceps
Impingement Brachioradialis
Speed's Triceps
Apprehension Grip Strength Right Left
Scapular Rhythm
TOS
Problem List1. sample text 3. sample text 5. sample text2. sample text 4. sample text 6. sample text
Plan of Care: I plan to treat the patient with sample text.
Short Term Goals to be met in 4 weeks: Long Term Goals to be met in 8 weeks:1. sample text 1. sample text2. sample text 2. sample text3. sample text 3. sample text4. sample text 4. sample text
Frequency: 3 X per week Patient is aware of Diagnosis and Prognosis: YESDuration: 4 weeks Goals and plans discussed with patient: YESRehabilitation Potential: GOOD Questions answered: YES
I certify that I examined the patient and therapy is necessary on an outpati
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