sample templates

7/30/2019 Sample Templates

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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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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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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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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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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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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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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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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)


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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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.


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.



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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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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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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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'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


_______________________________________________ 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


1


888-648-1554 (fax)

INITIAL EVALUATION AND PLAN OF CARE



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.



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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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.




___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


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1


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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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


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


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:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


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PlanetrehabProgress ReportDate: 3/24/2010


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


1

Planetrehab Rehabilitation3 Petroleum Center1001 W. PinhookLafayette, LA 70503

800-982-5447888-648-1554 (fax)

RE-EVALUATION



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


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.


________________________________________________________________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:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


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PlanetrehabKnee EvaluationDate: 12/2/2009

Patient: Audrey Macklin1


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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


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.



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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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




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



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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


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.


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


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: ()







___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


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PlanetrehabCervical Evaluation

Date: 12/1/2009Patient: Victor Wexler

2


Mastoid Process Spurling (Foraminal Comp)

Scalenes Shoulder Abduction (Comp)

Sternocleidomastoid Adson (TOS)

Cervical Paraspinals Roos (TOS)

Trapezius

Levator Scapulae

Rhomboids

Other:


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: ()



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: ____________________Physician Signature - Dr. Geoffrey Harharwood, MD

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PlanetrehabElbow EvaluationDate: 12/10/2009

Patient: Wendy Walters1


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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



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.



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


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ELBOW/WRIST EVALUATION







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


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


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


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






___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


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ELBOW EVALUATION







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


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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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







___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


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Planetrehab

Initial EvaluationDate: 2/23/2010



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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


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.


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


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


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






___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

________________________________________________________________ Date: ____________________Physician Signature - Dr. Sara Sitardites, MD

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PlanetrehabHip Evaluation

Date: 12/3/2009Patient: Rick Overton

1


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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.



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


Lumbar paraspinals Hip Scour

Piriformis OBER

Greater Trochanter FABER

Ischial Tuberosity Piriformis

Other: Thomas

Trendelenburg

EXT: Evaluation Hip 2

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Patient: Toby Castle2



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



________________________________________________________________Date: 12/1/2009Therapists Signature - Joe Davola PT


___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

________________________________________________________________ Date: ____________________Physician Signature - Dr. Ned Isakoff, MD

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Patient: Toby Castle2


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)


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: ()


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


___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

________________________________________________________________ Date: ____________________Physician Signature - Dr. Ned Isakoff, MD

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PlanetrehabLumber Evaluation

Date: 12/1/2009Patient: Carlos Jacott

1


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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


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.



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


2

SPECIAL TESTS RIGHT LEFT SPECIAL TESTS RIGHT LEFT







________________________________________________________________Date: 12/1/2009 Therapists Signature -Joe Davola PT


___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

________________________________________________________________ Date: ____________________Physician Signature - Dr. John Grossbard, MD

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PlanetrehabLumbar Evaluation


1


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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


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.



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





I certify that I examined the patient and therapy is necessary on an outpati

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