Sample Templates

Documentation Templates
FOCUS MORE ON PATIENT CARE
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
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 not print 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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EXT: Initial Evaluation 1

Planetrehab Physical Therapy 3 Petroleum Center 1001 W. Pinhook Suite 113 Lafayette, LA 70503 800-982-5447 888-648-1554 (fax)
INITIAL EVALUATION
PATIENT INFORMATION:
Name: Kari Abbot Patient Code: PPT00103 Date of Initial Evaluation: 2/23/2010 Date of Onset: 11/12/2009 Sex: Female DOB: 6/19/1957 ICD-9-CM Code: 337.21 Reflex sympathetic dystrophy of the upper limb Physician: Dr. Kristin Davis, MD Date Last Seen by Physician: 2/22/2010
Evaluation History: Kari Abbot is a 52 year old Female and presents with complaints of right shoulder bursitis. The patient's symptoms first appeared on 11/12/2004 and was diagnosed by Dr. Kristin Davis, MD and was last seen by Dr. Davis on 2/22/2010. 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: Midday Status: PM Status: () better () worse () better () worse () better () worse
Pain Rating: Best: ()/10 Worst: ()/10 Average: ()/10

Planetrehab Initial Evaluation Date: 2/23/2010 Patient: Kari Abbot 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 Strength Right Right Left Left Comments: 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 and identify significant clinical findings. From this information, a complete plan of care is established. 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 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 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 () weeks 1. () 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 at this 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 2/23/2010 Lloyd L Braun MPT 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. The rehabilitation potential is good. ___________________________________________________________________________ Date ________________ Physician Signature
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EXT: Initial Evaluation 2

Planetrehab Rehabilitation 3 Petroleum Center 1001 W. Pinhook Lafayette, LA 70503 800-982-5447 888-648-1554 (fax)
PHYSICAL THERAPY EVALUATION

Date of Visit: Patient Name: Date of Birth: Physician: Date of Eval: Date of Onset: Diagnosis: 2/23/2010 Kari Abbot 6/19/1957 Dr. Kristin Davis, MD 2/23/2010 11/12/2004 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 symptoms 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 5/10 at worst in last 48 hours. Increased symptoms/difficulty with sample text. Sample text seems to relieve symptoms. Sample text disturbed sleep. C/C and/or functional loss: sample text Patient Goals: sample text PMH: sample text Medications: sample text Contraindications/Precautions: sample text Social 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 text Tenderness: Grade sample text tenderness (I-IV) to palpation was appreciated Joint Mobility: Grade sample text hypermobility/hypomobility was found at sample text segments Flexibility: sample text Strength: sample text Neurologic Findings: Deep Tendon Reflexes of sample text were sample text, pinwheel sensation to sample text dermatomes 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 Slump Tests Median, Ulnar, Radial Tests were found to reproduce the patient's primary complaints suggesting some irritation to these branches. Special Tests: sample text Functional Tests: sample text Provocation/Alleviation Tests: sample text Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 friction massage to reduce scar tissue, effleurage to
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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: 1. Increase ROM by 25% 2. Increased strength by 1/3 muscle grade 3. Decrease Pain/pain score improvement by 10% 4. Improve Neuro-Motor control 5. Patient stated goal 6. Other Long Term Goals to be met in 8 weeks: 1. ROM WFL 2. Strength WNL 3. Eliminate Pain 4. Return to active Sport or ADL without Pain 5. Patient stated goal 6. Other
Plan: Physical Therapy 3x/week x 4weeks per protocol when available. Therapy to include: Therapeutic exercises (OKC and CKC) for strength and mobility; Neuromuscular Re-education for balance, coordination, and posture; modalities for pain reduction, circulation, and mm re-education including Ultrasound (1Mhz/3Mhz, 0.8-2.0 w/cm2, 12 minutes), Electric Stimulation ( 20 minutes, frequency and intensity as needed for motor/sensory effect), Iontophoresis (40/80 dexamethasone, 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 while the 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: 2/23/2010 Therapists Signature - Lloyd L Braun MPT
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EXT: Initial Evaluation - Columns

EVALUATION
Date: 2/23/2010 Precautions: sample text Patient Code: PPT00103 DOB: 6/19/1957 Age: 52 Patient: Kari Abbot Date of Initial Eval: 2/23/2010 Physician: Dr. Kristin Davis, MD Date Plan Established: 2/23/2010 Primary 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Extension Flexion Abduction Adduction ER IR RIGHT LEFT PROM Extension Flexion Abduction Adduction ER IR RIGHT LEFT MMT Extension Flexion Abduction Adduction ER IR RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
Special Tests Empty Can Impingement Speed's Apprehension Scapular Rhythm TOS
Right
Left
DTR Biceps Brachioradialis Triceps Grip Strength
Right
Left
Right
Left
Problem List 1. 2.
3. 4.
5. 6.
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Plan of Care: I plan to treat the patient with . Short Term Goals to be met in weeks: 1. 2. 3. 4. Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD Long Term Goals to be met in weeks: 1. 2. 3. 4. Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES 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 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: 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 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. 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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EXT: Initial Evaluation - Comprehensive


Client Name: Physician: Employer:
Kari Abbot
Dr. Kristin Davis, MD
Date of Eval: Date of Onset: Date of Birth:
2/23/2010
11/12/2004 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 significant clinical findings. From this information, a complete plan of care is established. 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 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, Spinal Bracing/Stabilization Program. Frequency: 3 times per week Duration: 4 Weeks
Planetrehab Physical Therapy Evaluation Date: 2/23/2010 Patient: Kari Abbot 1
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Short Term Goals: 1) Increase ROM by 25% 2) Increase Strength by 1/3 Muscle Grade 3) Decrease Pain / Pain Score Improvement by 10% 4) Improve Neuro-Motor Control
Long Term Goals: 1) ROM WNL 2) Strength WNL 3) Eliminate Pain 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 be 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.

As the treating physician I have reviewed this plan of care for my patient and hereby sign in agreement. 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. This signature serves as a prescription confirmation. I have included specific additional instructions or modifications as warranted on the lines below:
________________________________________________________________ Date: _____________________ Physician Signature
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Initial Physical Examination:

ROM Cervical Flexion Extension Side Bending Rotation ROM Lumbar Flexion Extension Side Bending Rotation Weight Bearing Left Right Non Weight Bearing Left Right Strength Left Right
Weight Bearing Left Right
Non Weight Bearing Left Right
Strength Left Right
AROM Upper Extremities Shoulder Flexion Extension ABduction Internal Rot. External Rot. Scapular Rot. Elbow Flexion Extension Supination Pronation Wrist Flexion Extension Ulnar Dev. Radial Dev. Left Right Left
PROM Right Left
Strength Right
AROM Lower Extremities Hip Flexion Extension ABduction Internal Rot. External Rot. Knee Flexion Extension Tibial Rotation Ankle Dorsiflex Plantarflexion Inversion Eversion Additional Findings: Left Right Left
PROM Right Left
Strength Right
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EXT: Evaluation - Short

INITIAL EVALUATION
Name: Kari Abbot Medical Diagnosis: right shoulder bursitis Physician: Dr. Kristin Davis, MD Working: (X) Yes () No Last Day Worked: () 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
SSN: 555-55-5555 DOB: 6/19/1957 ICD-9-CM Code: 337.21 Reflex sympathetic dystrophy of the upper limb Patient Occupation: Manager Date of Onset: 11/12/2009
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Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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.
() () () () () (X) 97010 Cold Pack 97014 E-Stim 97032Tens/IFC 97033 Iontophoresis 97035 Ultrasound 97100 Therapeutic Exercises () (X) () () () () 97116 Gait Training 97140 Manual/JT Mobs/MFR 97530 Therapeutic Activities 97112 Neuromuscular Re-education 97537 Community/Work Reintegration (X) () Other: HEP Other:
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 Leading Edge Physical Therapy and Sports, Inc. I have been given the opportunity to ask questions and fully understand the plan of care at this 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 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. The rehabilitation 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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EXT: Initial Evaluation and Plan of Care 1

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. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Precautions: 1. sample text 2. sample text 3. sample text 4. sample text Related interventions attempted: 1. Resting and pacing activities without clinical interventions 2. 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, 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.
Planetrehab Initial Evaluation and Plan of Care Date: 2/23/2010 Patient: Kari Abbot 1
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Significant Clinical Findings and Observation: 1. sample text Posture and presentation: 1. Well groomed, alert, optimistic, and fairly well informed and oriented to their predicament. 2. Head and shoulders posture is noted sample text. 3. Spine alignment is noted sample text 4. Hips and pelvis orientation is noted sample text 5. Legs, knees, and ankles are noted sample text Pain: 1. At worst: 10/10 provoked most by sample text 2. At best: 1/10 comforted best by sample text 3. 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 100% of normal expected 2. Restricted in sample text to 75% of normal expected Strength: 1. General 100% of normal expected 2. Restricted in sample text strength to 75% 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 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. Goals: Short Term: 1. Increase sample text mobility by 25% within 2 weeks. 2. Restore 3/5 strength in the sample text within 2 weeks. 3. Decrease pain below 5/10 in sample text within 2 weeks. 4. Improve balance and neuro-motor control by 50% within 2 weeks. 5. Restore sample text ft. sample text ambulation capacity within 2 weeks. Long Term: 1. Restore ROM to WNL within 4 weeks. 2. Restore 5/5 strength in sample text within 4 weeks. 3. Decrease/Eliminate pain sample text within 4 weeks. 4. Restore 90% balance and neuro-motor control within 4 weeks. 5. Restore sample text ft. sample text ambulation capacity within 4 weeks. 6. Restore sample text ADL function in sample text within 4 to 8 weeks. Treatment Plan Suggested: 1. Manual therapy sample text 2. Modality treatment sample text 3. Balance and gait therapy sample text
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4. Clinical pool therapy directly supervised in the pool by the treating therapist 5. Clinical gym strengthening sample text 6. 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. The rehabilitation potential is good. Thank you for this referral.
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EXT: Initial Evaluation and Plan of Care 2

INITIAL EVALUATION AND PLAN OF CARE

Patient: Kari Abbot D.O.B.: 6/19/1957 Physician: Dr. Kristin Davis, MD Primary Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb Treatment Diagnosis: Gait deterioration ADL deterioration Muscle 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 complete plan of care is established. 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 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. 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 interventions 2. 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,
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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. Significant Clinical Findings and Observation: 1. sample text Posture and presentation: 1. Well groomed, alert, optimistic, and fairly well informed and oriented to their predicament. 2. Head and shoulders posture is noted sample text. 3. Spine alignment is noted sample text 4. Hips and pelvis orientation is noted sample text 5. Legs, knees, and ankles are noted sample text Pain: 1. 2. 3. At worst: At best: Palpation: 10/10 provoked most by sample text 1/10 comforted best by sample text 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 expected 2. Restricted in 75 to 90% of normal expected Strength: 1. 2. General 95% of normal expected 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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4. 5.
Improve balance and neuro-motor control by % within 2 weeks. Restore ft. ambulation capacity within 2 weeks.
Long Term Goals: 1. Restore ROM to WNL within 4 weeks. 2. Restore /5 strength in within 4 weeks. 3. Decrease/Eliminate pain within 4 weeks. 4. Restore % balance and neuro-motor control within 4 weeks. 5. Restore ft. ambulation capacity within 4 weeks. 6. Restore ADL function in within 4 to 8 weeks. Treatment Plan Suggested: 1. Manual therapy 2. Modality treatment 3. Balance and gait therapy 4. Clinical pool therapy directly supervised in the pool by the treating therapist 5. Clinical gym strengthening 6. 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 hereby certify that I have personally examined the patient and have established that therapy is appropriate and necessary. These services will be provided while the patient is under my care. The above Plan of Care is being initiated and will be reviewed every 30 days. I estimate these services will be needed for weeks and rehabilitation potential is fair / good / excellent. Respectfully submitted, ____________________________________________________ Date: 2/23/2010 Therapist Signature - Lloyd L Braun MPT PLAN OF CARE CERTIFICATION: As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. 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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EXT: Plan of Care

f
PROGRESS REPORT AND PLAN OF CARE

Date of Visit: 12/1/2009 Patient Name: Toby Castle Date of Birth: 9/23/1987 Physician: Dr. Ned Isakoff, MD Diagnosis: 844.1 Sprain in medial collateral ligament of knee Date of onset: 11/25/2009 Date of Eval: 12/1/2009 Visits attended to date: 1 Visits missed to date: 0 Time Treatment Started: 9:03 AM Time Treatment Ended: 9:59 AM Total Treatment Time: 56 minutes History: Toby Castle is a 22 year old Male presenting with complaints of ACLR. Initial onset of symptoms 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 text seems to relieve symptoms. Sample text disturbed sleep. Patient Problems: 1. 2. 3. 4. 5. 6. 7. Posture: Tenderness: Grade tenderness (I-IV) to palpation was appreciated ROM: Cardinal Planes ; Coupled Planes Joint Mobility: Grade hypermobility/hypomobility was found at segments Flexibility: Strength: 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 the patient's primary complaints suggesting some irritation to these branches. 9. Special Tests: 10. Functional Tests: 11. Provocation/Alleviation Tests:
Planetrehab Progress Report and Plan of Care Date: 12/1/2009 Patient: Toby Castle
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Assessment: Patient presents with signs and symptoms consistent with . This is consistent with diagnostic tests and physician diagnosis. Previous intervention for this includes . Toby Castle presents with pain and loss of function including overhead use of UE / don/doff clothing/ altered gait mechanics as well as decreased ROM/flexibility, strength, soft tissue mobility, and stability. Symptoms are provoked with resistive testing and special tests while alleviated in the resting position. Toby Castle denied constitutional signs. Impairments limit their QOL, IADL's, function at home at work at school. The complexity of Toby Castle's physical problem requires skilled PT to return to pre injury level of function. Toby Castle has been informed of their diagnosis, risks associated with PT, and prognosis and agrees with the proposed plan. Toby Castle appears to have the cognitive ability to understand PT and is an appropriate PT candidate. Goals established to meet their functional losses and personal goals. It is expected that patient's condition will require a brief lengthy intervention based on their co-morbidities and degree of deficits. Safety concerns identified during the intervention include . Rehabilitation potential is based on findings, history, expected tolerances to intervention, and level of compliance that is expected by patient. Short Term Goals: (4 weeks) 1. Introduce patient to 2 home exercises and demonstrate accuracy. 2. Improve mobility of to 3. Patient to tolerate minutes of continuous supervised therapeutic and neuromuscular exercises without increase in pain. Long Term Goals: (8 weeks) 1. 2. 3. 4. 5. 6. 7. 8. Be I in pain management principles Transition to I HEP consisting of 4 exercises Return to desired leisure activities including with < 2/10 pain level. Return to occupational tasks without restrictions and < 2/10 pain level Demonstrate strength gains of to Demonstrate nml scapulohumeral kinematics during final tasks to reduce risk of future injury. Ambulate community distances with pain free and safely. Improve functional scales by .
Plan: Physical Therapy 3x/week x 4weeks per protocol when available. Therapy to include: Therapeutic exercises (OKC and CKC) for strength and mobility; Neuromuscular Re-education for balance, coordination, and posture; modalities for pain reduction, circulation, and mm re-education including Ultrasound (1Mhz/3Mhz, 0.8-2.0 w/cm2, 12 minutes), Electric Stimulation ( 20 minutes, frequency and intensity as needed for motor/sensory effect), Iontophoresis (40/80 dexamethasone, 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. Toby Castle was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes. I certify recertify that I examined the patient and therapy is necessary 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. I estimate these services will be needed for 4 weeks and rehabilitation
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potential is good. Thank you again Dr. Isakoff for this referral and please call with any recommendations or questions that you may have. Your support of this practice is appreciated. ____________________________________________________ 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 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. 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. Ned Isakoff, MD
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EXT: Progress/Recertification Note

Planetrehab Rehabilitation 3 Petroleum Center 1001 W. Pinhook 800-982-5447 888-648-1554 (fax)
PROGRESS/RECERTIFICATION NOTE
Name: Kari Abbot Date of Initial Eval: 2/23/2010 Patient Code: PPT00103 DOB: 6/19/1957 MD: Dr. Kristin Davis, MD Age: 52
Medical Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb Treatment Diagnosis (reason for therapy): right shoulder bursitis
PROGRESS OF TREATMENT TO DATE:

# of Visits this certification Period: 8 Functional Outcomes/Problems Still Present: sample text Service Dates: 2/23/2010 - 3/24/2010
Rationale for Continued Treatment: sample text
RECOMMENDATION/PLAN OF PROGRESS (FUNCTIONAL GOALS):

Short Term Goals: sample text Long Term Goals: sample text
Plans/Interventions: sample text
Therapists Signature:
Date: 3/24/2010
Physicians Prescription: Doctor, please indicate your treatment preferences, sign and return this form to our clinic. Frequency: Duration: Other Treatment:
5X a Week 1 Week
4X a Week 2 Weeks
3X a Week 3 Weeks
2X a Week 4 Weeks
Other: ________________ Other: ________________
PHYSICIAN RECERTIFICATION:
I have reviewed this plan of treatment and recertify a continuing need for services. Physician Signature:_____________________________________________________ Date: ___________________
Planetrehab Progress/Recertification Note Date: 3/24/2010 Patient: Kari Abbot 1
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EXT: Progress Note 1

PROGRESS NOTE
Patient Name: Physician: Employer: Kari Abbot Dr. Kristin Davis, MD Date of Eval: Date of Onset: Date of Birth: 2/23/2010 11/12/09 6/19/1957
Date of Visit: 3/24/2010 Diagnosis:

337.21 Reflex sympathetic dystrophy of the upper limb Employment Data: Physical Demand Level: () Light () Light/Medium () Medium () Medium/Heavy () Heavy () Very Heavy Currently Working: () Yes () No Restricted Duty: () Yes () No
Treatment Report:
##i-tr##
Participation & Compliance:

Attendance: Motivation: Poor () () Fair () () Good () () The Patient Attended 4 Visits The Patient Missed 5 Visits
Symptom Behavior & Presentation:

Pain Tool Assessment: Indicates Symptom Magnification? () Yes (X) No Pain Tools Used: () Dallas (X) Oswestry (X) Ransford (X) VAS () Waddell () Other(s):
Change in Pain Assessment [] [] [] [] Decreased Pain Complaints No Change in Pain Increased Pain Complaints Increased Symptom Magnification
Objective Progress:
() () () () () () () () Slow Progress Satisfactory Progress Good Progress Excellent Progress Progress has Plateaued Patient has Regressed Patient has Dropped Out Other: Short Term Goals 1)Increase ROM by 25% 2)Increase Strength by 1/3 Muscle Grade 3)Decrease Pain / Pain Score Improvement by 10% 4)Improve Neuro-Motor Control Long Term Goals 1)ROM WNL 2)Strength WNL 3)Eliminate Pain 4)Return to Active Sport or ADL without Pain. Percent Met:
Rehabilitation Potential: () Poor () Fair (X) Good () Excellent
Plan:
Planetrehab Progress Report Date: 3/24/2010 Patient: Kari Abbot 1
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Continue Present Treatment Plan with Physician Approval Modify Current Treatment Plan: Modifications: Discharge: See Discharge Summary
Frequency: Duration: Treatment:
3 times per week 4 Weeks Moist Heat, Therapeutic Exercise, Neuromuscular Reeducation, Manual Therapy, Spinal Bracing/Stabilization Program.
Other:
________________________________________________________________ Date: 3/24/2010 Therapists Signature - Alec Berg PT As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. 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. 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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Reassessment Measures:
ROM Cervical Flexion Extension Side Bending Rotation ROM Lumbar Flexion Extension Side Bending Rotation Weight Bearing Left Right Non Weight Bearing Left Right Strength Left Right
Weight Bearing Left Right
Non Weight Bearing Left Right
Strength Left Right
AROM Upper Extremities Shoulder Flexion Extension ABduction Internal Rot. External Rot. Scapular Rot. Elbow Flexion Extension Supination Pronation Wrist Flexion Extension Ulnar Dev. Radial Dev. Left Right Left
PROM Right Left
Strength Right
AROM Lower Extremities Hip Flexion Extension ABduction Internal Rot. External Rot. Knee Flexion Extension Tibial Rotation Ankle Dorsiflex Plantarflexion Inversion Eversion Left Right Left
PROM Right Left
Strength Right
Additional Findings:
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EXT: Progress Note 2

PROGRESS REPORT
Date: 3/24/2010 Date of Visit: 3/24/2010 Patient Name: Kari Abbot Patient Code: PPT00103 Physician: Dr. Kristin Davis, MD Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb Date of onset: 11/12/2004 Date of Initial Evaluation: 2/23/2010 Visits attended to date:8 Visits missed to date: 2 Kari has been seen for 8 visits in physical therapy to this point. Treatment has included: sample text Kari reports she feels 75% better since being in physical therapy. Kari currently rates her pain as 5/10 at worst and 8/10 at best. Observation and Evaluation as of Today: sample text If Dr. Davis concurs, I would like to continue to treat Kari Abbot for another month to address remaining impairments. 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: 3/24/2010 Therapists Signature - Alec Berg PT As the treating physician I have reviewed this progress note for my patient and hereby sign in agreement. I have included specific additional instructions or modifications on the lines below: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Planetrehab Progress Note Date: 3/24/2010 Patient: Kari Abbot
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EXT: Re-evaluation
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 made worse 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 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 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
Planetrehab Re-evaluation Date: 3/24/2010 Patient: Kari Abbot 1
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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 will be 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: 3/24/2010 Therapists Signature - Alec Berg PT As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. 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. This signature serves as a prescription confirmation. I have included specific additional instructions or modifications as warranted on the lines below: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________
Planetrehab Re-evaluation Date: 3/24/2010 Patient: Kari Abbot 2
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EXT: Evaluation - Ankle 1

ANKLE EVALUATION
Date: 12/2/2009 Precautions: sample text Patient Code: PPT00046 DOB: 1/2/1987 Age: 22 Patient: Audrey Macklin Date of Initial Eval: 12/2/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/2/2009 Primary 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 made worse by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Plantarflexion Dorsiflexion Inversion Eversion SPECIAL TESTS S/L Stance Single Toe Raise RIGHT RIGHT LEFT LEFT MMT Plantarflexion Dorsiflexion Inversion Eversion RIGHT /5 /5 /5 /5 LEFT /5 /5 /5 /5 GIRTH MM 5th MT Figure 8 15cm MM RIGHT LEFT
Problem List 1. 2.
3. 4.
5. 6.
Plan of Care: I plan to treat the patient with sample text.
Planetrehab Knee Evaluation Date: 12/2/2009 Patient: Audrey Macklin 1
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Short Term Goals to be met in 4 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
Long Term Goals to be met in 8 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
________________________________________________________________ Date: ____________________ Physician Signature - Dr. Lindsay Enwright, MD
Planetrehab Knee Evaluation Date: 12/2/2009 Patient: Audrey Macklin 2
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EXT: Evaluation - Ankle 2

ANKLE EVALUATION
Date: 12/2/2009 Precautions: sample text Patient Code: PPT00046 DOB: 1/2/1987 Age: 22 Patient: Audrey Macklin Date of Initial Eval: 12/2/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/2/2009 Primary 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 made worse by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
AROM Plantarflexion Dorsiflexion Inversion Eversion PALPATION Lateral Ligaments - ATF Lateral Ligaments - CF Lateral Ligaments - PTF Medial ligaments Medial ligaments (Deltoid) Achilles Tendon Peroneal Tendons Other: RIGHT LEFT RIGHT MMT Plantarflexion Dorsiflexion Inversion Eversion LEFT RIGHT /5 /5 /5 /5 LEFT /5 /5 /5 /5 GIRTH MM 5th MT Figure 8 15cm MM RIGHT LEFT RIGHT LEFT
SPECIAL TESTS Anterior Drawer Talar Tilt Homan Sign (DVT) Thompson
Planetrehab Ankle Evaluation Date: 12/2/2009 Patient: Audrey Macklin 1
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Problem List 1. Decreased ROM 2. Decreased Strength
3. Decreased Function 4. Pain
5. Difficulty walking 6. Functional limitation
Plan of Care: I plan to treat the patient with (X) Balance/Proprioception Training () Iontophoresis () Electrical Stimulation () Joint Mobilization () Gait Training () Neuromuscular re-ed () Home Program (X) Patient Education () Hot/Cold Pack () Soft tissue mobilization Other: () Short Term Goals to be met in 4 weeks: 1. Increase ROM by 25% 2. Increased strength by 1/3 muscle grade 3. Decrease Pain/pain score improvement by 10% 4. Improve Neuro-Motor control 5. Patient stated goal 6. Other Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
(X) Taping (X) Therapeutic Activity () Therapeutic Exercise () Traction () Ultrasound
Long Term Goals to be met in 8 weeks: 1. ROM WFL 2. Strength WNL 3. Eliminate Pain 4. Return to active Sport or ADL without Pain 5. Patient stated goal 6. Other Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES 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 condition requires it.
Planetrehab Ankle Evaluation Date: 12/2/2009 Patient: Audrey Macklin 2
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EXT: Evaluation - Cervical 1

CERVICAL EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00021 DOB: 12/3/1971 Age: 38 Patient: Victor Wexler Date of Initial Eval: 12/1/2009 Physician: Dr. Geoffrey Harharwood, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 719.45 Pain in joint - pelvic region and thigh 808.49 Other fracture of pelvis Time Treatment Started: 12:00 PM Time Treatment Ended: 12:55 PM Total Treatment Time: 55 minutes
History: Patient is a 38 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Pelvis Fx. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
ROM: cervical Forward Bending Backward Bending Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: upper ext. Shoulder Extension Shoulder Flexion Shoulder IR Shoulder ER Shoulder Abduction Shoulder Adduction SPECIAL TESTS Empty Cans HS 90/90 Apprehension Compression RIGHT RIGHT LEFT LEFT MMT Shoulder Extension Shoulder Flexion Shoulder IR Shoulder ER Shoulder Abduction Hip Adduction Elbow Extension Elbow Flexion Wrist Extension Wrist Flexion RIGHT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5
Problem List 1. sample text 2. sample text
3. sample text 4. sample text

Planetrehab Cervical Evaluation Date: 12/1/2009 Patient: Victor Wexler 1
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Plan of Care: I plan to treat the patient with sample text. Short Term Goals to be met in 4 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD Long Term Goals to be met in 8 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
________________________________________________________________ Date: ____________________ Physician Signature - Dr. Geoffrey Harharwood, MD
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EXT: Evaluation Cervical 2

CERVICAL EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00021 DOB: 12/3/1971 Age: 38 Patient: Victor Wexler Date of Initial Eval: 12/1/2009 Physician: Dr. Geoffrey Harharwood, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 719.45 Pain in joint - pelvic region and thigh 808.49 Other fracture of pelvis Time Treatment Started: 12:00 PM Time Treatment Ended: 12:55 PM Total Treatment Time: 55 minutes
History: Patient is a 38 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Pelvis Fx. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
ROM: cervical Forward Bending Backward Bending Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: upper ext. Shoulder Extension Shoulder Flexion Shoulder IR Shoulder ER Shoulder Abduction Shoulder Adduction Grip Pinch RIGHT LEFT MMT Cervical Flexion C1-2 Cervical Side Flexion C3 Shed Elevation C4 Thumb Extension C8 Shoulder Abduction Finger Abd/Add T1 Elbow Extension Elbow Flexion Wrist Extension Wrist Flexion RIGHT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5
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PALPATION Mastoid Process Scalenes Sternocleidomastoid Cervical Paraspinals Trapezius Levator Scapulae Rhomboids Other:
RIGHT
LEFT
SPECIAL TESTS Spurling (Foraminal Comp) Shoulder Abduction (Comp) Adson (TOS) Roos (TOS)
RIGHT
LEFT
Plan of Care: I plan to treat the patient with () Balance/Proprioception Training () Iontophoresis () Electrical Stimulation () Joint Mobilization () Gait Training () Neuromuscular re-ed () Home Program () Patient Education () Hot/Cold Pack () Soft tissue mobilization Other: () Short Term Goals to be met in 4 weeks: 1. Increase ROM by 25% 2. Increased strength by 1/3 muscle grade 3. Decrease Pain/pain score improvement by 10% 4. Improve Neuro-Motor control 5. Patient stated goal 6. Other Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
() Taping () Therapeutic Activity () Therapeutic Exercise () Traction () Ultrasound
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 condition requires it. ________________________________________________________________ Date: 12/1/2009 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 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. 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. Geoffrey Harharwood, MD
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EXT: Evaluation - Elbow 1

ELBOW EVALUATION
Date: 12/10/2009 Precautions: sample text Patient Code: PPT00049 DOB: 4/10/1973 Age: 36 Patient: Wendy Walters Date of Initial Eval: 12/10/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/10/2009 Primary 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 by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Elbow Flexion Elbow Extension Forearm Pronation Supination Bilateral Wrist Bilateral Shoulders RIGHT LEFT MMT Elbow Forearm Elbow Flexion Elbow Extension Forearm Pronation Forearm Supination
Neuro: sample text

SPECIAL TESTS Tennis Elbow Grip Strength (2nd notch) RIGHT LEFT
Planetrehab Elbow Evaluation Date: 12/10/2009 Patient: Wendy Walters 1
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Measurements: 1. Elbow Flex 90, neutral: Left: lb., Right: lb 2. Elbow Ext, neutral: Left: lb., Right: lb. 3. Elbow Ext, Supination: Left: lb, Right: lb. 4. Elbow Ext, Pronation: Left: lb, Right: lb. Problem List 1. Decreased ROM 2. Decreased Strength Plan of Care: 1. 2. 3. 4. 5. Ultrasound 100% 1.5 W/cm2 for eight minutes to . Instruct in HEP. Cold pack for 15 minutes following treatment PRN.
Short Term Goals to be met in weeks: 1. Decrease complaints of pain to /10 level at worst. 2. Patient to be independent in HEP. 3. 4. Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
Long Term Goals to be met in weeks: 1. Abolish complaints of . 2. 3. 4. Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
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EXT: Evaluation Elbow/Wrist

ELBOW/WRIST EVALUATION
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 by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
AROM Elbow Flexion Elbow Extension Wrist Flexion Wrist Extension Supination Pronation Wrist Ulnar Dev Wrist Radial Dev PALPATION Lateral Epicondyle Medial Epicondyle Snuff box Thenar Eminence Other: RIGHT LEFT RIGHT MMT Elbow Flexion Elbow Extension Wrist Flexion Wrist Extension Supination Pronation Wrist Ulnar Dev Wrist Radial Dev LEFT RIGHT /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 SPECIAL TESTS Lateral Epicondylitis Medical Epicondylitis Tinels (Carpel Tunnel) Tinels (Cubital Tunnel) Finkelstein (De Quervains) PROM Elbow Flexion Elbow Extension Wrist Flexion Wrist Extension Supination Pronation Wrist Ulnar Dev Wrist Radial Dev RIGHT LEFT
Planetrehab Elbow/Wrist Evaluation Date: 12/10/2009 Patient: Wendy Walters 1
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Plan of Care: I plan to treat the patient with () Balance/Proprioception Training () Iontophoresis () Electrical Stimulation () Joint Mobilization () Gait Training () Neuromuscular re-ed () Home Program () Patient Education () Hot/Cold Pack () Soft tissue mobilization Other: () Short Term Goals to be met in weeks: 1. Increase ROM by 25% 2. Increased strength by 1/3 muscle grade 3. Decrease Pain/pain score improvement by 10% 4. Improve Neuro-Motor control 5. Patient stated goal 6. Other Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
Long Term Goals to be met in weeks: 1. ROM WFL 2. Strength WNL 3. Eliminate Pain 4. Return to active Sport or ADL without Pain 5. Patient stated goal 6. Other Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
Planetrehab Elbow/Wrist Evaluation Date: 12/10/2009 Patient: Wendy Walters 2
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EXT: Evaluation Elbow 2

ELBOW EVALUATION
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 by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
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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 condition requires it. ________________________________________________________________ Date: 12/10/2009 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 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. 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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EXT: Evaluation - Extremity


Date: 2/23/2010 Precautions: Patient Code: PPT00103 DOB: 6/19/1957 Age: 52 Patient: Kari Abbot Date of Initial Eval: 2/23/2010 Physician: Dr. Kristin Davis, MD Date Plan Established: 2/23/2010 Primary 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. 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): 6/10 Difficulty 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 condition How sustained: unknown Occupation/Activities: yard work, house work Pert. Med. History: arthroscopic sx 2x to R knee last one was done 7 yrs ago, chronic LBP, arthritis, asthma, hernia, HTN Date of surgery: n/a Medical Test ##i-sub## Result: (xrays - Dr. Handler ) N/A Medication 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
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(-) Surgical scar (-) Atrophy Joint mobility: ( ) Increased (X) Decreased gr. 2 R knee into terminal knee ext. Other: ROM: SHOULDER
ROM Flexion 0-180 Extension 0-50 Abduction 0-180 ER 0-90 IR 0-70 RIGHT LEFT PAIN SPECIAL TESTS ( ) Apley's ( ) Drop Arm ( ) Impingement ( ) Other:
HIP
ROM Flexion 0-120 Extension 0-50 Abduction 0-45 Adduction 0-30 ER 0-45 IR 0-45 RIGHT LEFT PAIN SPECIAL TESTS ( ) Faber ( ) Thomas ( ) Other:
ELBOW
ROM Flexion 0-145 Extension 145-0 Pron 0-90 Sup 0-90 RIGHT LEFT PAIN SPECIAL TESTS ( ) Lat/Med Epicondylitis ( ) Other:
KNEE
ROM Flexion 0-135 Extension 135-0 RIGHT 95 c painful arc 8090 WFL LEFT 108 WNL PAIN ++R SPECIAL TESTS (-) Drawer's (-) Lachman's ( ) Other:
WRIST/HAND
ROM Flexion 0-70 Extension 0-80 Ulnar Dev Rad Dev RIGHT LEFT PAIN SPECIAL TESTS ( ) De Quervain's ( ) Tinel's
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ANKLE
ROM Flexion 0-30 RIGHT LEFT PAIN SPECIAL TESTS ( ) Drawer's MMT: All muscles WNL strength unless otherwise indicated below: 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, jt line= 40.75, infra=36
Extension 0-50
Abduction 0-35 ER 0-15
ASSESSMENT PT 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 min difficulty. 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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EXT: Evaluation - Foot 1

FOOT EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00018 DOB: 8/18/1971 Age: 38 Patient: Frances Bay Date of Initial Eval: 12/1/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 715.17 Osteoarthrosis, localized, primary ankle/foot 719.47 Pain in joint- ankle and foot Time Treatment Started: 4:01 PM Time Treatment Ended: 4:53 PM Total Treatment Time: 52 minutes
History: Patient is a 38 year old Female who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Left foot fusion. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
ROM: ankle Dorsiflexion Plantar flexion Great Toe Extension SPECIAL TESTS S/L Stance Single Toe Raise RIGHT RIGHT LEFT LEFT STRENGTH: ankle Dorsiflexion Plantar flexion Great Toe Extension RIGHT LEFT SPECIAL TEST Balance test RIGHT LEFT
Plan of Care: I plan to treat the patient with sample text.
Planetrehab Foot Evaluation Date: 12/7/2009 Patient: Frances Bay 1
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Short Term Goals to be met in 4 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
Long Term Goals to be met in 8 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
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EXT: Evaluation Foot 2

FOOT EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00018 DOB: 8/18/1971 Age: 38 Patient: Frances Bay Date of Initial Eval: 12/1/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 715.17 Osteoarthrosis, localized, primary ankle/foot 719.47 Pain in joint- ankle and foot Time Treatment Started: 4:01 PM Time Treatment Ended: 4:53 PM Total Treatment Time: 52 minutes
History: Patient is a 38 year old Female who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Left foot fusion. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
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EXT: Evaluation - Hand 1

HAND EVALUATION
Date: 2/22/2010 Precautions: sample text Patient Code: PPT00151 DOB: 4/19/1953 Age: 56 Patient: Robert Becker Date of Initial Eval: 2/22/2010 Physician: Dr. Joe Mayo, MD Date Plan Established: 2/22/2010 Primary Diagnosis: 816.02 Fracture of phalanges of hand, closed- distal Time Treatment Started: 9:02 AM Time Treatment Ended: 10:00 AM Total Treatment Time: 58 minutes
History: Patient is a 56 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Longitudinal Fracture - left ring finger. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Involved: Dominant: WNL=Within Normal Limits Shoulder
AROM Flexion Abduction Int Rot Ext Rot RIGHT LEFT PROM Flexion Abduction Int Rot Ext Rot RIGHT LEFT MMT Flexion Abduction Int Rot Ext Rot RIGHT LEFT
Elbow
AROM Extension Flexion RIGHT LEFT PROM Extension Flexion RIGHT LEFT MMT Extension Flexion RIGHT LEFT
Forearm
AROM Pronation Supination RIGHT LEFT PROM Pronation Supination RIGHT LEFT MMT Pronation Supination RIGHT LEFT
Planetrehab Hand Evaluation Date: 2/22/2010 Patient: Robert Becker 1
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Wrist
AROM Extension Flexion Ulnar Dev. Rad. Dev RIGHT LEFT PROM Extension Flexion Ulnar Dev. Rad. Dev RIGHT LEFT MMT Extension Flexion Ulnar Dev. Rad. Dev RIGHT LEFT
Fingers
MCP Ext -Flex Index Middle Ring Little RIGHT LEFT PIP Ext -Flex Index Middle Ring Little RIGHT LEFT DIP Ext -Flex Index Middle Ring Little RIGHT LEFT
Finger Pads from Distal Palmar Crease (cm) Thumb

RIGHT Index Middle Ring Little LEFT MP IP Abd. Ext. RIGHT LEFT
Distance thumb from tip from 5th MCP () cm. () cm. Distance thumb from tip from 5th MCP () cm. () cm. Strength Measurements
RIGHT Grip (Jamar) Lateral (key pinch) S-jaw chunk pinch LEFT
Significant Muscles Weakness:
Edema & Girth Measurements

RIGHT Volumeter (ml) Circumference (cm) LEFT
Functional and Work Ability:
Comments (pain, atrophy, etc.):
Visual Inspection and Palpitation: Sensation:
Patient was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes.
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________________________________________________________________ Date: 2/22/2010 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 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. 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. Joe Mayo, MD
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EXT: Evaluation Hand 2

HAND EVALUATION
Date: 2/22/2010 Precautions: sample text Patient Code: PPT00151 DOB: 4/19/1953 Age: 56 Patient: Robert Becker Date of Initial Eval: 2/22/2010 Physician: Dr. Joe Mayo, MD Date Plan Established: 2/22/2010 Primary Diagnosis: 816.02 Fracture of phalanges of hand, closed- distal Time Treatment Started: 9:02 AM Time Treatment Ended: 10:00 AM Total Treatment Time: 58 minutes
History: Patient is a 56 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Longitudinal Fracture - left ring finger. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Wrist
Fingers
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Thumb
RIGHT MP IP Abd. Ext. LEFT STRENGTH Grip (Jamar) Lateral (key pinch) S-jaw chunk pinch RIGHT LEFT
Distance thumb from tip from 5th MCP () cm. () cm. Distance thumb from tip from 5th MCP () cm. () cm. Special Tests
RIGHT Tinels (Carpal Tunnel) Finkelstein (De Quervains) Tinels (Cubital Tunnel) Snuff Box LEFT
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 condition requires it. ________________________________________________________________ Date: 2/22/2010 Therapists Signature - Joe Davola PT
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As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. 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. 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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EXT: Evaluation Hip 1

HIP EVALUATION
Date: 12/3/2009 Precautions: sample text Patient Code: PPT00014 DOB: 1/8/1957 Age: 52 Patient: Rick Overton Date of Initial Eval: 12/3/2009 Physician: Dr. Sara Sitardites, MD Date Plan Established: 12/3/2009 Primary Diagnosis: 715.15 Osteoarthrosis,localized, primary- pelvic/thigh V43.64 Hip Joint Replacement Time 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 by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Extension Flexion IR ER Abduction Adduction SPECIAL TESTS Hip Scour OBER HS in 90/90 RIGHT RIGHT LEFT PROM Extension Flexion IR ER Abduction Adduction LEFT DTR's Patellar Achilles RIGHT RIGHT LEFT MMT Extension Flexion IR ER Abduction Adduction LEFT RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
Planetrehab Hip Evaluation Date: 12/3/2009 Patient: Rick Overton 1
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________________________________________________________________ Date: ____________________ Physician Signature - Dr. Sara Sitardites, MD
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EXT: Evaluation Hip 2

HIP EVALUATION
Date: 12/3/2009 Precautions: sample text Patient Code: PPT00014 DOB: 1/8/1957 Age: 52 Patient: Rick Overton Date of Initial Eval: 12/3/2009 Physician: Dr. Sara Sitardites, MD Date Plan Established: 12/3/2009 Primary Diagnosis: 715.15 Osteoarthrosis,localized, primary- pelvic/thigh V43.64 Hip Joint Replacement Time 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 by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
AROM Extension Flexion IR ER Abduction Adduction PALPATION Lumbar paraspinals Piriformis Greater Trochanter Ischial Tuberosity Other: RIGHT LEFT RIGHT PROM Extension Flexion IR ER Abduction Adduction LEFT RIGHT LEFT SPECIAL TESTS Hip Scour OBER FABER Piriformis Thomas Trendelenburg MMT Extension Flexion IR ER Abduction Adduction RIGHT RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 LEFT
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EXT: Evaluation - Knee 1

KNEE EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00002 DOB: 9/23/1987 Age: 22 Patient: Toby Castle Date of Initial Eval: 12/1/2009 Physician: Dr. Ned Isakoff, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 844.1 Sprain in medial collateral ligament of knee Time Treatment Started: 9:03 AM Time Treatment Ended: 9:59 AM Total Treatment Time: 56 minutes
History: Patient is a 22 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: ACLR. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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 30 minutes. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Knee Extension Knee Flexion Hip Flexion Hip IR Hip ER RIGHT LEFT GIRTH Joint Line 5 cm JL 10 cm JL 15 cm JL 5 cm JL 10 cm JL 15 cm JL RIGHT DTR's sample text sample text LEFT RIGHT LEFT MMT Hip Flexion Knee Ext. Knee Flexion Terminal Ext. Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
#i-gait##
SPECIAL TESTS sample text sample text sample text sample text sample text RIGHT LEFT
Planetrehab Knee Evaluation Date: 12/1/2009 Patient: Toby Castle 1
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Plan of Care: I plan to treat the patient with sample text. Short Term Goals to be met in 4 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Frequency: 3 X per week Duration: 8 weeks Rehabilitation Potential: Good Long Term Goals to be met in 8 weeks: 1. sample text 2. sample text 3. sample text 4. sample text Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
________________________________________________________________ Date: ____________________ Physician Signature - Dr. Ned Isakoff, MD
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EXT: Evaluation Knee 2

KNEE EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00002 DOB: 9/23/1987 Age: 22 Patient: Toby Castle Date of Initial Eval: 12/1/2009 Physician: Dr. Ned Isakoff, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 844.1 Sprain in medial collateral ligament of knee Time Treatment Started: 9:03 AM Time Treatment Ended: 9:59 AM Total Treatment Time: 56 minutes
History: Patient is a 22 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: ACLR. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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 30 minutes. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Knee Extension Knee Flexion PROM Knee Extension Knee Flexion RIGHT LEFT GIRTH Joint Line 5 cm JL 10 cm JL 15 cm JL 5 cm JL 10 cm JL 15 cm JL RIGHT cm cm cm cm cm cm cm LEFT cm cm cm cm cm cm cm MMT Hip Flexion Knee Ext. Knee Flexion Terminal Ext. Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
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PALPATION Medial joint line Lateral Joint Line Patellar Tendon MCL Popliteal Fossa Other:
RIGHT
LEFT
SPECIAL TESTS Varus Stress (LCL) Valgus Stress (MCL) Anterior Drawer (ACL) McMurry (Meniscus) Apley Comp (Meniscus) Lachman (ACL) Thessaly @ 20 (Meniscus)
RIGHT
LEFT
Plan of Care: I plan to treat the patient with () Balance/Proprioception Training () Iontophoresis () Electrical Stimulation () Joint Mobilization () Gait Training () Neuromuscular re-ed (X) Home Program (X) Patient Education () Hot/Cold Pack () Soft tissue mobilization Other: () Short Term Goals to be met in 4 weeks: 1. Increase ROM by 25% 2. Increased strength by 1/3 muscle grade 3. Decrease Pain/pain score improvement by 10% 4. Improve Neuro-Motor control 5. Patient stated goal 6. Other Frequency: 3 X per week Duration: 8 weeks Rehabilitation Potential: Good
() Taping () Therapeutic Activity (X) Therapeutic Exercise () Traction () Ultrasound
________________________________________________________________ Date: ____________________ Physician Signature - Dr. Ned Isakoff, MD

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EXT: Evaluation - Lumbar 1

LUMBAR EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00022 DOB: 12/29/1963 Age: 45 Patient: Carlos Jacott Date of Initial Eval: 12/1/2009 Physician: Dr. John Grossbard, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 722.73 Intervertebral disc disorder w/ myelopathy- lumbar 724.2 Lumbago- back disorder Time 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 worse by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
ROM: lumbar Forward Bending Backward Bending Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: lower ext. Hip Extension Hip Flexion Hip IR Hip ER Hip Abduction Hip Adduction RIGHT LEFT MMT Hip Extension Hip Flexion Hip IR Hip ER Hip Abduction Hip Adduction Knee Flexion Knee Extension Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5
Planetrehab Lumber Evaluation Date: 12/1/2009 Patient: Carlos Jacott 1
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SPECIAL TESTS
RIGHT
LEFT
SPECIAL TESTS
RIGHT
LEFT
________________________________________________________________ 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 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. 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. John Grossbard, MD
Planetrehab Lumber Evaluation Date: 12/1/2009 Patient: Carlos Jacott 2
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EXT: Evaluation Lumbar 2

LUMBAR EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00022 DOB: 12/29/1963 Age: 45 Patient: Carlos Jacott Date of Initial Eval: 12/1/2009 Physician: Dr. John Grossbard, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 722.73 Intervertebral disc disorder w/ myelopathy- lumbar 724.2 Lumbago- back disorder Time 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 worse by sample text. Prior Function Level: sample text. Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
ROM: lumbar Flexion Extension Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: lower ext. Hip Extension Hip Flexion Hip IR Hip ER Hip Abduction Hip Adduction RIGHT LEFT MMT Strength Hip Flexion L2 Knee Extension L3 Dorsiflexion L4 Great Toe Extension Eversion S1 Plantar Flexion S1 Knee Flexion S12 RIGHT /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5
Planetrehab Lumbar Evaluation Date: 12/1/2009 Patient: Carlos Jacott 1
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PALPATION Lumbar Paraspinals PSIS Proximal Buttock Piriformis Ischial Tuberosity Sciatic Notch Quadratus Lumborum Other:
RIGHT
LEFT
SPECIAL TESTS SLR Slump Piriformis Thomas Cough Sneeze
RIGHT
LEFT
Long Term Goals to be met 8 in weeks: 1. ROM WFL 2. Strength WNL 3. Eliminate Pain 4. Return to active Sport or ADL without Pain 5. Patient stated goal 6. Other Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES 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 condition requires it. ________________________________________________________________ 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 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. 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. John Grossbard, MD

Planetrehab Lumbar Evaluation Date: 12/1/2009 Patient: Carlos Jacott 2
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EXT: Evaluation - Shoulder 1

SHOULDER EVALUATION
Date: 12/4/2009 Precautions: sample text Patient Code: PPT00036 DOB: 10/21/1956 Age: 53 Patient: Harry Morgan Date of Initial Eval: 12/4/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/4/2009 Primary Diagnosis: 726.12 Bicipital tenosynovitis of shoulder 726.10 Disorders of bursae and tendons- shoulder region Time Treatment Started: 10:00 AM Time Treatment Ended: 11:00 AM Total Treatment Time: 60 minutes
History: Patient is a 53 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Left shoulder impingement. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. Ultrasound was used to increase blood flow to targeted tissue, and/or to decrease pain and/or to provide deep tissue heat through high frequency sound waves. A coupling medium of gel was applied to the area to be treated. The transducer head of the device was then placed on the gel and the parameters of the signal determined by the therapist. Treatment consisted of constant slow movements of the transducer head over the area to be treated. TOTAL TIME FOR ULTRASOUND: minimum of 8 minutes. Therapist provided one on one treatment with the patient to improve functional performance. Dynamic activities were utilized targeting the patient's functional limitations. Clinician utilized exercise machines or devices as well as manual resistive techniques as appropriate. TOTAL TIME FOR THERAPEUTIC ACTIVITIES: minimum of 45 minutes. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text
AROM Extension Flexion Abduction Adduction ER IR RIGHT LEFT PROM Extension Flexion Abduction Adduction ER IR RIGHT LEFT MMT Extension Flexion Abduction Adduction ER IR RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
Planetrehab Shoulder Evaluation Date: 12/4/2009 Patient: Harry Morgan 1
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Special Tests Empty Can Impingement Speed's Apprehension Scapular Rhythm TOS
Right
Left
DTRs Biceps Brachioradialis Triceps Grip Strength
Right
Left
Right
Left
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EXT: Evaluation Shoulder 2

SHOULDER EVALUATION
Date: 12/4/2009 Precautions: sample text Patient Code: PPT00036 DOB: 10/21/1956 Age: 53 Patient: Harry Morgan Date of Initial Eval: 12/4/2009 Physician: Dr. Lindsay Enwright, MD Date Plan Established: 12/4/2009 Primary Diagnosis: 726.12 Bicipital tenosynovitis of shoulder 726.10 Disorders of bursae and tendons- shoulder region Time Treatment Started: 10:00 AM Time Treatment Ended: 11:00 AM Total Treatment Time: 60 minutes
History: Patient is a 53 year old Male who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Left shoulder impingement. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. Ultrasound was used to increase blood flow to targeted tissue, and/or to decrease pain and/or to provide deep tissue heat through high frequency sound waves. A coupling medium of gel was applied to the area to be treated. The transducer head of the device was then placed on the gel and the parameters of the signal determined by the therapist. Treatment consisted of constant slow movements of the transducer head over the area to be treated. TOTAL TIME FOR ULTRASOUND: minimum of 8 minutes. Therapist provided one on one treatment with the patient to improve functional performance. Dynamic activities were utilized targeting the patient's functional limitations. Clinician utilized exercise machines or devices as well as manual resistive techniques as appropriate. TOTAL TIME FOR THERAPEUTIC ACTIVITIES: minimum of 45 minutes. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
AROM Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT LEFT PROM Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT LEFT MMT Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5
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PALPATION Supraspinatus Infraspinatus Teres Minor Subdeltoid SC joint AC joint Clavicle Subscapularis Biceps Pectorals Other:
RIGHT
LEFT
SPECIAL TESTS Impingement (int rot and flex) Drop arm (rotator cuff) Yergasons (bicep tendon instability) Apprehension TOS (Adsons) Capsular pattern Painful arc
RIGHT
LEFT
Grip Strength
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 condition requires it. ________________________________________________________________ Date: 12/4/2009 Therapists Signature - Lloyd L Braun MPT
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As the treating physician, I have reviewed this plan of care for my patient and hereby sign in agreement. 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. 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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EXT: Evaluation - Spine

SPINE EVALUATION
Date: 12/1/2009 Precautions: sample text Patient Code: PPT00006 DOB: 5/15/1969 Age: 40 Patient: Ruthie Cohen Date of Initial Eval: 12/1/2009 Physician: Dr. Sara Sitardites, MD Date Plan Established: 12/1/2009 Primary Diagnosis: 722.52 Lumbar intervertebral disc disorder Time Treatment Started: 11:00 AM Time Treatment Ended: 11:55 AM Total Treatment Time: 55 minutes
History: Patient is a 40 year old Female who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: S/P lumbar fusion. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. SUBJECTIVE Patient c/o Subjective pain scale (1=least pain, 10=worst pain): Associated symptom: () tingling () Numbness () Loss of skin sensation How sustained: Date of onset: Pain radiating to / not spreading / localized Symptom aggravated by Pain at night / when in bed: () No () Yes - affected by change in position / activity Back pain better/relieved by: S4 region symptom () Pain / numbness ()Altered sensation Previous treatments for this problem: , with relief / decreased symptom / did not help History of similar problem in the past: () Yes () No Presently, is symptom getting () Better () Worse () About the same Difficulty with functional activities: Pert. Med. History: Medication for pain: Occupation/Activities: Medical Test Result: () N/A OBJECTIVE Gait: () Normal () Guarded () Leg problem Comment: Body Build: () Short/stocky () Intermediate () Slender Head position & bearing: () Good () Forward head
() Other:
Planetrehab Spine Evaluation Date: 12/1/2009 Patient: Ruthie Cohen 1
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Palpation: () Swelling / Edema () Tenderness, Gr. () Spasm / muscle guarding () Tightness () Surgical scar () Atrophy Joint mobility: () Increased () Decreased Other:
ROM: () Cervical () Thoracic () Lumbar
Flexion Extension RIGHT Side Bending Rotation LEFT
MMT: All muscles WNL unless otherwise specified below UE: LE: CS: LS: Special tests: () Compression / Distraction () Not tested () SLR () left () right () Passive Kernig () Other: Reflexes () Not tested Sensation () Not tested ASSESSMENT PT impression: STG (in weeks) () Decreased pain / tenderness () Increased ROM () Increased strength () Gait: () Increased WB status () with / without assist device () Walk x feet () with / without assist. device () Functional activities: () Patient education: () Proper body mechanics () Joint conservation techniques LTG (in weeks) () Eliminate pain / tenderness () WNL / WFL ROM () WNL strength () Gait: Normal WB / gait pattern () with / without assist device Walk x feet () with / without assist. device () Able to perform above functional activities without difficulty. () Independent in HEP upon discharge. () Intact () Decreased
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PLAN: Frequency: / week Duration: weeks () Therapeutic modalities PRN: () Hot () Cold pack () Electric Stim. () Ultrasound () Manual Therapy () Myofascial release / massage () Manual traction () Joint Mob () Therapeutic exercises () Stretching () ROM (PROM / AAROM / AROM) () PRE's () Leg ext / flex machine () Isometric ex. () Stabilization ex. () UE / LE ergometer () Postural training
() Gait training () Treadmill () on even / uneven surfaces () Neuromusc. Re-educ: () balance () coordination () Patient education () Proper body mechanics () Joint Conservation Techniques () Other:
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EXT: Evaluation Vestibular

VESTIBULAR EVALUATION
Date: 12/9/2009 Patient Code: PPT00048 Patient: Trudy Sharp Physician: Dr. Michael Barth, MD Primary Diagnosis: 781.3 Fine Motor Coordination Time Treatment Started: 2:00 PM Precautions: DOB: 6/6/1958 Age: 51 Date of Initial Eval: 12/9/2009 Date Plan Established: 12/9/2009 Total Treatment Time: 69 minutes
Time Treatment Ended: 3:09 PM
History: Patient is a 51 year old Female who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: dizziness. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. The clinician utilized hands on techniques to provide strengthening, ROM, stretching and synergistic movement patterns to joint and muscle groups. Exercises were performed in open and closed kinetic chain and were specifically catered to target the patient's deficient areas. The clinician also utilized combined movement patterns to return patient to their former function level in ADL's and other activities. TOTAL TIME FOR THERAPUTIC EXERCISE: minimum of 45 minutes.
SUBJECTIVE CC: () dizzy/vertigo () imbalance (standing / walking / ADL's) Duration: () secs-min () mins () hours () all day () varies Freq: () daily () on ##i-subcc## off in a wk () asymptomatic for wks () no pattern Intensity: () mild () mod () severe () subj scale Provoked / dec. by: Relieved / dec. by: HPI: Asso. complaints: ADL's with difficulty 0 = not affected 1 = mild 2 = mod 3 = severe () bed mobility () transfers () walking () shopping () household chores () self-care () driving () transportation () reading () social () cognitive () work () others: Home Sit: () Lives alone () With companion House: () stairs steps () carpet () solid floor Hearing: () Loss () Dec () () Aide () Tinnitus () () pressure () pain Pertinent Med Hx: () Diabetes () Cardiac () Hypertension () sinus allergy ( ) Neck pain () LBP Others: Tests done: Dizziness Handicap Inventory Score: (/100)
Planetrehab Vestibular Evaluation Date: 12/9/2009 Patient: Trudy Sharp 1
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OBJECTIVE BP: () mm Hg Gaze / Oculomotor: Eye orientation () N () AbN Room light observation:Intact Smooth Pursuit () Spont. Nystagmus () RB () LB () Vert () Hor Fixation () suppressed () increased () Gaze evoked nystagmus () Fixed beat () Direction-changing () Head thrust VOR: Hori: head turns/ 60 sec () dizzy scale () () oscillopsia Vert: head turns/ 60 sec () dizzy scale () () oscillopsia DVAT: Head stationary () Head shake at 2 Hz () Lines difference () () WNL () AbN ENG/Caloric Test: Audio Test: Positional Test: () R Dix-Hallpike () nyst beat torsio fatigued after seconds () L Dix-Hallpike () nyst beat torsio fatigued after seconds () Motion sensitivity ROS: Sensation: Sensation: UE/LE () deep pressure () light touch () Proprioception () Coordination: () past-pointing () diadokokinesia () heel to shin ROM: Cervical () WNL/WFL () limited LE () WNL/WFL () limited Gross MMT: () Cervical () LE Significant deformities: Palpation: Cervical () mm spasm / tightness Static Balance: Romberg Foam Sh. Rom SLS R/L Dynamic Balance: Fukuda's EC (50) steps () forward step WNL / AbN () veer R / L WNL / AbN Functional reach forward // Ave: () inches Berg Balance Scale /56 () fall risk Dynamic Gait Index /24 () fall risk Gait: Usual gait pattern: () assist. device () WNL () AbN: BOS speed veer/imbalance Walk simult. with head turns Horizontal: () WNL () imbalance () mild () mod () sev () dizzy Vertical: () WNL () imbalance () mild () mod () sev () dizzy Tandem EO (20) steps () WNL () imbalance () mild () mod () sev Normal walk EC (20) steps () WNL () veer R / L () imbalance () mild () mod () sev Others: ASSESSMENT PT Impression: Significant sway in standing and walking activities. Poor tolerance in activities involving head turns/gaze stabilization Abnormal gait:
Fixation-suppressed (with infrared goggles) () Spont nystagmus () RB () LB () Vert () Hori () Gaze-evoked nystagmus () Fixed beat () Direction-changing () Post Head shake nystagmus () beat () Vert.
EO (60) sec sway WNL mild mod fall EC (60) sec sway WNL mild mod fall EO (60) sec sway WNL mild mod fall EC (60) sec sway WNL mild mod fall EO (60) sec sway WNL mild mod fall EC () sec sway WNL mild mod fall EO () sec sway WNL mild mod fall
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Goals: (LTG, in weeks) WNL balance in standing and walking activities without assist WNL tolerance in activities involving head turning Return to usual ADL's/work without difficulty (STG, in weeks) Decreased sway from to in walking simult. with hori/vert head turning 100 ft x 2 sets Decreased sway from to in standing activities, eyes open and closed (Romberg /Sharpened Romberg on solid floor / foam) Able to perform X1 viewing ex. x 1 min. with dizziness PLAN: Physical Therapy to address goals x / wk. for weeks. () Gaze stabilization ex: X1/X2 viewing (stand/walk; plain/busy background) () Standing balance: eyes open/eyes closed, on various surface, wide BOS to dec. BOS with functional activities () Walking balance: decreased BOS, with head turns/whole body turn with functional activities () Canalith repositioning maneuver () HEP with handouts for above exercises () Others:
________________________________________________________________ Date: ____________________ Physician Signature - Dr. Michael Barth, MD
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EXT: Evaluation Vestibular Short

VESTIBULAR EVALUATION
Date: 12/9/2009 Patient Code: PPT00048 Patient: Trudy Sharp Physician: Dr. Michael Barth, MD Primary Diagnosis: 781.3 Fine Motor Coordination Time Treatment Started: 2:00 PM Precautions: DOB: 6/6/1958 Age: 51 Date of Initial Eval: 12/9/2009 Date Plan Established: 12/9/2009 Total Treatment Time: 69 minutes
Time Treatment Ended: 3:09 PM
History: Patient is a 51 year old Female who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: dizziness. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. The clinician utilized hands on techniques to provide strengthening, ROM, stretching and synergistic movement patterns to joint and muscle groups. Exercises were performed in open and closed kinetic chain and were specifically catered to target the patient's deficient areas. The clinician also utilized combined movement patterns to return patient to their former function level in ADL's and other activities. TOTAL TIME FOR THERAPUTIC EXERCISE: minimum of 45 minutes. SUBJECTIVE CC: () dizzy/vertigo () imbalance (standing / walking / ADL's) Duration: () secs-min () mins () hours () all day () varies Freq: () daily () on and off in a wk () asymptomatic for wks () no pattern Intensity: () mild () mod () severe () subj scale Provoked / Inc. by: Relieved / dec. by: Medication taken: HPI: Asso. complaints: ADL's with difficulty 0 = not affected 1 = mild 2 = mod 3 = severe () bed mobility () transfers () walking () shopping () household chores () self-care () driving () reading () transportation () social () cognitive () work () others: Home Sit: () Lives alone () With companion House: () stairs steps () carpet () solid floor Hearing: () Loss/Dec () () Aide () Tinnitus () () pressure () pain Pertinent Med Hx: () Diabetes () Cardiac () Hypertension
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() sinus allergy ( ) Neck pain () LBP Others: L eye retinipathy. Tests done: Dizziness Handicap Inventory Score: (/100) OBJECTIVE BP: () mm Hg Gaze / Oculomotor: Eye orientation () N () AbN Room light observation:Intact Smooth Pursuit (-) Spont. Nystagmus (-) Gaze evoked nystagmus () Head thrust VOR: Hori: head turns/ 60 sec () dizzy scale () () oscillopscia Vert: head turns/ 60 sec () dizzy scale () () oscillopscia DVAT: Head stationary () Head shake at 2 Hz () Lines difference () () WNL () AbN ENG/Caloric Test: Audio Test: Positional Test: (-) R Dix-Hallpike (-) L Dix-Hallpike () Motion sensitivity ROS: ROM: Cervical () WNL/WFL () limited LE () WNL/WFL () limited Gross MMT: () Cervical () LE Significant deformities: Palpation: Cervical () mm spasm / tightness Static Balance: Romberg Foam Sh. Rom SLS R/L EO (60) sec EC (60) sec EO (60) sec EC (60) sec EO (60) sec EC (30) sec EO () sec sway () WNL () mild () mod () fall sway () WNL () mild () mod () fall sway () WNL () mild () mod () fall sway () WNL () mild () mod () fall sway () WNL () mild () mod () fall sway () WNL (X) mild () mod () fall sway () WNL () mild () mod () fall
Fixation-suppressed (with infrared goggles) (-) Spont nystagmus () RB () LB () Vert () Hori (-) Gaze-evoked nystagmus () Fixed beat () Direction-changing (-) Post Head shake nystagmus () beat () Vert.
Dynamic Balance: Fukuda's EC (50) steps () forward step WNL / AbN (X) veer R - WNL Functional reach forward // Ave: () inches Berg Balance Scale /56 () fall risk Dynamic Gait Index /24 () fall risk Gait: Usual gait pattern: () assist. device (X) WNL () AbN: BOS speed veer/imbalance Walk simult. with head turns Horizontal: (X) WNL (X) imbalance (X) mild () mod () sev () dizzy Vertical: (X) WNL () imbalance () mild () mod () sev () dizzy Tandem EO (20) steps (X) WNL () imbalance () mild( ) mod () sev
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Normal walk EC (20) steps () WNL (X) veer R / L (X) imbalance (X) mild () mod () sev Others: ASSESSMENT PT Impression: Significant sway in standing and walking activities. Abnormal gait: Goals: (LTG, in 6-8 weeks) Eliminate dizziness WNL balance in standing and walking activities without assist Return to usual ADL's/work without difficulty (STG, in 2 weeks) Decreased severity/frequency of dizziness by 25-50%. Learn activity modification to avoid/minimize symptom. Learn safety during ADL's while still with symptom. Teach HEP as tolerated PLAN: Physical Therapy to address goals x / wk. for weeks. (X) Canalith repositioning maneuver to () x 2 sets, rest in between (X) Post CRM instructions with handouts () Balance re-training (X) HEP with handouts for above exercises (X) Patient education on nature of BPPV (x) Others: Initial HEP - x1 viewing, REO/EC/SRREO with HT's, SREC, Walk with H/V Ht's, tandem walk 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. The rehabilitation potential is good. Thank you for this referral. ________________________________________________________________ Date: 12/9/2009 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 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. 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. Michael Barth, MD
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EXT: Evaluation Wrist/Elbow

WRIST/ELBOW EVALUATION
Date: 3/17/2010 Precautions: sample text Patient Code: PPT00148 DOB: 10/30/1970 Age: 39 Patient: Teri Subbs Date of Initial Eval: 3/17/2010 Physician: Dr. Joe Mayo, MD Date Plan Established: 3/17/2010 Primary Diagnosis: 718.04 Articular cartilage disorder hand 719.44 Pain in joint - hand Time Treatment Started: 10:01 AM Time Treatment Ended: 10:59 AM Total Treatment Time: 58 minutes
History: Patient is a 39 year old Female who is in good health. Past Medical History: sample text. Current Medication: sample text. Chief Complaint At This Time: Right Wrist. 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 from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text
AROM Elbow Flexion Elbow Extension Wrist Flexion Wrist Extension Supination Pronation Wrist Ulnar Dev Wrist Radial Dev RIGHT LEFT MMT Elbow Flexion Elbow Extension Wrist Flexion Wrist Extension Supination Pronation Wrist Ulnar Dev Wrist Radial Dev RIGHT /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 PROM Elbow Flexion Elbow Extension Wrist Flexion Wrist Extension Supination Pronation Wrist Ulnar Dev Wrist Radial Dev
PALPATION Lateral Epicondyle Medial Epicondyle Snuff box Thenar Eminence Other:
RIGHT
LEFT
SPECIAL TESTS Lateral Epicondylitis Medical Epicondylitis Tinels (Carpel Tunnel) Tinels (Cubital Tunnel) Finkelstein (De Quervains)
Planetrehab Elbow/Wrist Evaluation Date: 3/17/2010 Patient: Teri Subbs 1
RIGHT
LEFT
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Plan of Care: I plan to treat the patient with () Balance/Proprioception Training () Iontophoresis () Electrical Stimulation () Joint Mobilization () Gait Training () Neuromuscular re-ed () Home Program () Patient Education () Hot/Cold Pack () Soft tissue mobilization Other: () Short Term Goals to be met in weeks: 1. Increase ROM by 25% 2. Increased strength by 1/3 muscle grade 3. Decrease Pain/pain score improvement by 10% 4. Improve Neuro-Motor control 5. Patient stated goal 6. Other Frequency: 3 X per week Duration: 4 weeks Rehabilitation Potential: GOOD
Long Term Goals to be met in weeks: 1. ROM WFL 2. Strength WNL 3. Eliminate Pain 4. Return to active Sport or ADL without Pain 5. Patient stated goal 6. Other Patient is aware of Diagnosis and Prognosis: YES Goals and plans discussed with patient: YES Questions answered: YES
Planetrehab Elbow/Wrist Evaluation Date: 3/17/2010 Patient: Teri Subbs 2
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EXT: Discharge Summary - Ankle 1

ANKLE DISCHARGE SUMMARY

Date: 2/12/2010 Treatment Need: right ankle sprain Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/2/2009 Patient: Audrey Macklin Date of Onset: 11/22/2009 Gender: Female Age: 22 Number of Visits to Date: 12 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 1 Diagnosis: 845.02 Sprains of ankle- calcaneofibular (ligament) Audrey Macklin was seen in physical therapy from 12/2/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
AROM Plantarflexion Dorsiflexion Inversion Eversion SPECIAL TESTS S/L Stance Single Toe Raise RIGHT RIGHT LEFT LEFT MMT Plantarflexion Dorsiflexion Inversion Eversion RIGHT /5 /5 /5 /5 LEFT /5 /5 /5 /5 GIRTH MM 5th MT Figure 8 15cm MM RIGHT LEFT
Discharge Measurements:
AROM Plantarflexion Dorsiflexion Inversion Eversion RIGHT LEFT MMT Plantarflexion Dorsiflexion Inversion Eversion RIGHT /5 /5 /5 /5 LEFT /5 /5 /5 /5 GIRTH MM 5th MT Figure 8 15cm MM RIGHT LEFT
Planetrehab Ankle Discharge Summary Date of Discharge: 2/10/2010 Patient: Audrey Macklin 1
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SPECIAL TESTS S/L Stance Single Toe Raise
RIGHT
LEFT
Audrey Macklin made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Audrey Macklin is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Ankle 2

ANKLE DISCHARGE SUMMARY

Date: 2/12/2010 Treatment Need: right ankle sprain Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/2/2009 Patient: Audrey Macklin Date of Onset: 11/22/2009 Gender: Female Age: 22 Number of Visits to Date: 12 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 1 Diagnosis: 845.02 Sprains of ankle- calcaneofibular (ligament) Audrey Macklin was seen in physical therapy from 12/2/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
AROM Plantarflexion Dorsiflexion Inversion Eversion PALPATION Lateral Ligaments - ATF Lateral Ligaments - CF Lateral Ligaments - PTF Medial ligaments Medial ligaments (Deltoid) Achilles Tendon Peroneal Tendons Other: RIGHT LEFT RIGHT MMT Plantarflexion Dorsiflexion Inversion Eversion LEFT RIGHT /5 /5 /5 /5 LEFT /5 /5 /5 /5 GIRTH MM 5th MT Figure 8 15cm MM RIGHT LEFT RIGHT LEFT
AROM Plantarflexion Dorsiflexion Inversion Eversion RIGHT LEFT MMT Plantarflexion Dorsiflexion Inversion Eversion RIGHT /5 /5 /5 /5 LEFT /5 /5 /5 /5 GIRTH MM 5th MT Figure 8 15cm MM RIGHT LEFT
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PALPATION Lateral Ligaments - ATF Lateral Ligaments - CF Lateral Ligaments - PTF Medial ligaments Medial ligaments (Deltoid) Achilles Tendon Peroneal Tendons Other:
RIGHT
LEFT
RIGHT
LEFT
Audrey Macklin made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Audrey Macklin is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Cervical 1

CERVICAL DISCHARGE SUMMARY

Date: 2/10/2010 Date of Discharge: 2/10/2010 Patient: Victor Wexler Gender: Male Age: 38 Physician: Dr. Geoffrey Harharwood, MD Diagnosis: 719.45 Pain in joint - pelvic region and thigh Treatment Need: Pelvis Fx Date of Initial Evaluation: 12/1/2009 Date of Onset: 11/23/2009 Number of Visits to Date: 17 Number of Missed Visits: 3 808.49 Other fracture of pelvis
Victor Wexler was seen in physical therapy from 12/1/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Planetrehab Cervical Discharge Summary Date of Discharge: 2/10/2010 Patient: Victor Wexler 1
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Victor Wexler made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Victor Wexler is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Cervical 2

CERVICAL DISCHARGE SUMMARY

Date: 2/10/2010 Date of Discharge: 2/10/2010 Patient: Victor Wexler Gender: Male Age: 38 Physician: Dr. Geoffrey Harharwood, MD Diagnosis: 719.45 Pain in joint - pelvic region and thigh Treatment Need: Pelvis Fx Date of Initial Evaluation: 12/1/2009 Date of Onset: 11/23/2009 Number of Visits to Date: 17 Number of Missed Visits: 3 808.49 Other fracture of pelvis
Victor Wexler was seen in physical therapy from 12/1/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
ROM: cervical Forward Bending Backward Bending Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: upper ext. Shoulder Extension Shoulder Flexion Shoulder IR Shoulder ER Shoulder Abduction Shoulder Adduction Grip Pinch RIGHT LEFT MMT Cervical Flexion C1-2 Cervical Side Flexion C3 Shed Elevation C4 Thumb Extension C8 Shoulder Abduction Finger Abd/Add T1 Elbow Extension Elbow Flexion Wrist Extension Wrist Flexion RIGHT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5
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PALPATION Mastoid Process Scalenes Sternocleidomastoid Cervical Paraspinals Trapezius Levator Scapulae Rhomboids Other:
RIGHT
LEFT
SPECIAL TESTS Spurling (Foraminal Comp) Shoulder Abduction (Comp) Adson (TOS) Roos (TOS)
RIGHT
LEFT
ROM: cervical Forward Bending Backward Bending Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: upper ext. Shoulder Extension Shoulder Flexion Shoulder IR Shoulder ER Shoulder Abduction Shoulder Adduction Grip Pinch RIGHT LEFT MMT Cervical Flexion C1-2 Cervical Side Flexion C3 Shed Elevation C4 Thumb Extension C8 Shoulder Abduction Finger Abd/Add T1 Elbow Extension Elbow Flexion Wrist Extension Wrist Flexion PALPATION Mastoid Process Scalenes Sternocleidomastoid Cervical Paraspinals Trapezius Levator Scapulae Rhomboids Other: RIGHT LEFT SPECIAL TESTS Spurling (Foraminal Comp) Shoulder Abduction (Comp) Adson (TOS) Roos (TOS) RIGHT RIGHT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 /5 /5 LEFT
Victor Wexler made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Victor Wexler is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Elbow 1

ELBOW DISCHARGE SUMMARY

Date: 2/10/2010 Treatment Need: left elbow Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/10/2009 Patient: Wendy Walters Date of Onset: 12/3/2009 Gender: Female Age: 36 Number of Visits to Date: 11 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 1 Diagnosis: 726.32 Enthesopathy of elbow- lateral epicondylitis Wendy Walters was seen in physical therapy from 12/10/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Neuro: sample text

Measurements: 1. Elbow Flex 90, neutral: Left: lb., Right: lb 2. Elbow Ext, neutral: Left: lb., Right: lb. 3. Elbow Ext, Supination: Left: lb, Right: lb. 4. Elbow Ext, Pronation: Left: lb, Right: lb.
Planetrehab Elbow Discharge Summary Date of Discharge: 2/10/2010 Patient: Wendy Walters 1
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Neuro:
Measurements: 1. Elbow Flex 90, neutral: Left: lb., Right: lb 2. Elbow Ext, neutral: Left: lb., Right: lb. 3. Elbow Ext, Supination: Left: lb, Right: lb. 4. Elbow Ext, Pronation: Left: lb, Right: lb. Wendy Walters made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Wendy Walters is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Elbow/Wrist

ELBOW/WRIST DISCHARGE SUMMARY

Date: 2/10/2010 Treatment Need: left elbow Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/10/2009 Patient: Wendy Walters Date of Onset: 12/3/2009 Gender: Female Age: 36 Number of Visits to Date: 11 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 1 Diagnosis: 726.32 Enthesopathy of elbow- lateral epicondylitis Wendy Walters was seen in physical therapy from 12/10/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Planetrehab Elbow/Wrist Discharge Summary Date of Discharge: 2/10/2010 Patient: Wendy Walters 1
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Wendy Walters made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Wendy Walters is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
Planetrehab Elbow/Wrist Discharge Summary Date of Discharge: 2/10/2010 Patient: Wendy Walters 2
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EXT: Discharge Summary Elbow 2

ELBOW DISCHARGE SUMMARY

Date: 2/10/2010 Treatment Need: left elbow Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/10/2009 Patient: Wendy Walters Date of Onset: 12/3/2009 Gender: Female Age: 36 Number of Visits to Date: 11 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 1 Diagnosis: 726.32 Enthesopathy of elbow- lateral epicondylitis Wendy Walters was seen in physical therapy from 12/10/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
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Wendy Walters made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Wendy Walters is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Foot 1

FOOT DISCHARGE SUMMARY

Date: 1/15/2010 Treatment Need: Left foot fusion Date of Discharge: 1/15/2010 Date of Initial Evaluation: 12/1/2009 Patient: Frances Bay Date of Onset: 8/14/2009 Gender: Female Age: 38 Number of Visits to Date: 12 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 2 Diagnosis: 715.17 Osteoarthrosis, localized, primary ankle/foot 719.47 Pain in joint- ankle and foot Frances Bay was seen in physical therapy from 12/1/2009 to 1/15/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Planetrehab Foot Discharge Summary Date of Discharge: 1/15/2010 Patient: Frances Bay 1
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Frances Bay made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Frances Bay is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Foot 2

FOOT DISCHARGE SUMMARY

Date: 1/15/2010 Treatment Need: Left foot fusion Date of Discharge: 1/15/2010 Date of Initial Evaluation: 12/1/2009 Patient: Frances Bay Date of Onset: 8/14/2009 Gender: Female Age: 38 Number of Visits to Date: 12 Physician: Dr. Lindsay Enwright, MD Number of Missed Visits: 2 Diagnosis: 715.17 Osteoarthrosis, localized, primary ankle/foot 719.47 Pain in joint- ankle and foot Frances Bay was seen in physical therapy from 12/1/2009 to 1/15/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Frances Bay made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Frances Bay is discharged from physical therapy at this time.
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Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Hand 1

HAND DISCHARGE SUMMARY

Date: 4/6/2010 Treatment Need: Longitudinal Fracture - left ring finger Date of Discharge: 4/6/2010 Date of Initial Evaluation: 2/22/2010 Patient: Robert Becker Date of Onset: 2/16/2010 Gender: Male Age: 56 Number of Visits to Date: 8 Physician: Dr. Joe Mayo, MD Number of Missed Visits: 2 Diagnosis: 816.02 Fracture of phalanges of hand, closed- distal Robert Becker was seen in physical therapy from 2/22/2010 to 4/6/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Involved: Dominant: WNL=Within Normal Limits Initial Evaluation Measurements: Shoulder
Elbow
Forearm
Planetrehab Hand Discharge Summary Date of Discharge: 4/6/2010 Patient: Robert Becker 1
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Wrist
Fingers

Significant Muscles Weakness: Edema & Girth Measurements

Functional and Work Ability: Comments (pain, atrophy, etc.): Visual Inspection and Palpitation: Sensation: Discharge Measurements:
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Shoulder
Elbow
Forearm
Wrist
Fingers

Significant Muscles Weakness:
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Edema & Girth Measurements

Functional and Work Ability: Comments (pain, atrophy, etc.): Visual Inspection and Palpitation: Sensation: Robert Becker made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Robert Becker is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
________________________________________________________________ Date: 2/22/2010 Therapists Signature - Joe Davola PT
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EXT: Discharge Summary Hand 2

HAND DISCHARGE SUMMARY

Date: 4/6/2010 Treatment Need: Longitudinal Fracture - left ring finger Date of Discharge: 4/6/2010 Date of Initial Evaluation: 2/22/2010 Patient: Robert Becker Date of Onset: 2/16/2010 Gender: Male Age: 56 Number of Visits to Date: 8 Physician: Dr. Joe Mayo, MD Number of Missed Visits: 2 Diagnosis: 816.02 Fracture of phalanges of hand, closed- distal Robert Becker was seen in physical therapy from ##date_of_admission## to ##date_of_discharge##. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements: Wrist
Fingers
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Thumb
Discharge Measurements: Wrist

Fingers
Thumb
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Robert Becker made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Robert Becker is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Hip 1

HIP DISCHARGE SUMMARY

Date: 2/10/2010 Treatment Need: Right THA Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/3/2009 Patient: Rick Overton Date of Onset: 10/29/2009 Gender: Male Age: 52 Number of Visits to Date: 11 Physician: Dr. Sara Sitardites, MD Number of Missed Visits: 1 Diagnosis: 715.15 Osteoarthrosis,localized, primary- pelvic/thigh V43.64 Hip Joint Replacement Rick Overton was seen in physical therapy from 12/3/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Planetrehab Hip Discharge Summary Date of Discharge: 2/10/2010 Patient: Rick Overton 1
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Rick Overton made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Rick Overton is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Hip 2

HIP DISCHARGE SUMMARY

Date: 2/10/2010 Treatment Need: Right THA Date of Discharge: 2/10/2010 Date of Initial Evaluation: 12/3/2009 Patient: Rick Overton Date of Onset: 10/29/2009 Gender: Male Age: 52 Number of Visits to Date: 11 Physician: Dr. Sara Sitardites, MD Number of Missed Visits: 1 Diagnosis: 715.15 Osteoarthrosis,localized, primary- pelvic/thigh V43.64 Hip Joint Replacement Rick Overton was seen in physical therapy from 12/3/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
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Rick Overton made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Rick Overton is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Knee 1

KNEE DISCHARGE SUMMARY

Date: 2/12/2010 Date of Discharge: 2/10/2010 Patient: Toby Castle Gender: Male Age: 22 Physician: Dr. Ned Isakoff, MD Diagnosis: 844.1 Sprain in medial collateral ligament of knee Treatment Need: ACLR Date of Initial Evaluation: 12/1/2009 Date of Onset: 11/23/2009 Number of Visits to Date: 12 Number of Missed Visits: 1
Toby Castle was seen in physical therapy from 12/1/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
AROM Knee Extension Knee Flexion Hip Flexion Hip IR Hip ER RIGHT LEFT GIRTH Joint Line 5 cm JL 10 cm JL 15 cm JL 5 cm JL 10 cm JL 15 cm JL RIGHT DTR's sample text sample text LEFT RIGH T LEFT MMT Hip Flexion Knee Ext. Knee Flexion Terminal Ext. Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
#i-gait##
Planetrehab Knee Discharge Summary Date of Discharge: 2/10/2010 Patient: Toby Castle 1
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AROM Knee Extension Knee Flexion Hip Flexion Hip IR Hip ER RIGHT LEFT GIRTH Joint Line 5 cm JL 10 cm JL 15 cm JL 5 cm JL 10 cm JL 15 cm JL RIGHT DTR's sample text sample text LEFT RIGHT LEFT MMT Hip Flexion Knee Ext. Knee Flexion Terminal Ext. Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
#i-gait2##
Toby Castle made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Toby Castle is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Knee 2

KNEE DISCHARGE SUMMARY

Date: 2/12/2010 Date of Discharge: 2/10/2010 Patient: Toby Castle Gender: Male Age: 22 Physician: Dr. Ned Isakoff, MD Diagnosis: 844.1 Sprain in medial collateral ligament of knee Treatment Need: ACLR Date of Initial Evaluation: 12/1/2009 Date of Onset: 11/23/2009 Number of Visits to Date: 12 Number of Missed Visits: 1
Toby Castle was seen in physical therapy from 12/1/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
AROM Knee Extension Knee Flexion PROM Knee Extension Knee Flexion RIGHT LEFT GIRTH Joint Line 5 cm JL 10 cm JL 15 cm JL 5 cm JL 10 cm JL 15 cm JL PALPATION Medial joint line Lateral Joint Line Patellar Tendon MCL Popliteal Fossa Other: RIGHT LEFT RIGHT cm cm cm cm cm cm cm LEFT cm cm cm cm cm cm cm SPECIAL TESTS Varus Stress (LCL) Valgus Stress (MCL) Anterior Drawer (ACL) McMurry (Meniscus) Apley Comp (Meniscus) Lachman (ACL) Thessaly @ 20 (Meniscus) RIGHT LEFT MMT Hip Flexion Knee Ext. Knee Flexion Terminal Ext. Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
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AROM Knee Extension Knee Flexion PROM Knee Extension Knee Flexion RIGHT LEFT GIRTH Joint Line 5 cm JL 10 cm JL 15 cm JL 5 cm JL 10 cm JL 15 cm JL PALPATION Medial joint line Lateral Joint Line Patellar Tendon MCL Popliteal Fossa Other: RIGHT LEFT RIGHT cm cm cm cm cm cm cm LEFT cm cm cm cm cm cm cm SPECIAL TESTS Varus Stress (LCL) Valgus Stress (MCL) Anterior Drawer (ACL) McMurry (Meniscus) Apley Comp (Meniscus) Lachman (ACL) Thessaly @ 20 (Meniscus) RIGHT LEFT MMT Hip Flexion Knee Ext. Knee Flexion Terminal Ext. Ankle DF Ankle PF RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
Toby Castle made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Toby Castle is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Lumbar 1

LUMBAR DISCHARGE SUMMARY

Date: 2/24/2010 Treatment Need: L5-S1 Fusion Date of Discharge: 2/24/2010 Date of Initial Evaluation: 12/1/2009 Patient: Carlos Jacott Date of Onset: 9/14/2009 Gender: Male Age: 45 Number of Visits to Date: 1 Physician: Dr. John Grossbard, MD Number of Missed Visits: 0 Diagnosis: 722.73 Intervertebral disc disorder w/ myelopathy- lumbar 724.2 Lumbago- back disorder Carlos Jacott was seen in physical therapy from 12/1/2009 to 2/24/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
SPECIAL TESTS
RIGHT
LEFT
SPECIAL TESTS
RIGHT
LEFT
Planetrehab Lumbar Discharge Summary Date of Discharge: 2/24/2010 Patient: Carlos Jacott 1
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SPECIAL TESTS
RIGHT
LEFT
SPECIAL TESTS
RIGHT
LEFT
Carlos Jacott made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance, the patient should continue to do well long term. Carlos Jacott is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Lumbar 2

LUMBAR DISCHARGE SUMMARY

Date: 12/1/2009 Treatment Need: CL5-S1 Fusion Date of Discharge: 2/24/2010 Date of Initial Evaluation: 12/1/2009 Patient: Carlos Jacott Date of Onset: 9/14/2009 Gender: Male Age: 45 Number of Visits to Date: 12 Physician: Dr. John Grossbard, MD Number of Missed Visits: 2 Diagnosis: 722.73 Intervertebral disc disorder w/ myelopathy- lumbar 724.2 Lumbago- back disorder Carlos Jacott was seen in physical therapy from 12/1/2009 to 2/24/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
ROM: lumbar Flexion Extension Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: lower ext. Hip Extension Hip Flexion Hip IR Hip ER Hip Abduction Hip Adduction RIGHT LEFT MMT Strength Hip Flexion L2 Knee Extension L3 Dorsiflexion L4 Great Toe Extension Eversion S1 Plantar Flexion S1 Knee Flexion S12 RIGHT RIGHT /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 LEFT
RIGHT
LEFT
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ROM: lumbar Flexion Extension Side Bend Right Side Bend Left Rotation Right Rotation Left ROM: lower ext. Hip Extension Hip Flexion Hip IR Hip ER Hip Abduction Hip Adduction RIGHT LEFT MMT Strength Hip Flexion L2 Knee Extension L3 Dorsiflexion L4 Great Toe Extension Eversion S1 Plantar Flexion S1 Knee Flexion S12 RIGHT RIGHT /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 LEFT
RIGHT
LEFT
Carlos Jacott made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance, the patient should continue to do well long term. Carlos Jacott is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
________________________________________________________________ Date12/1/2009 Therapists Signature - Joe Davola PT
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EXT: Discharge Summary - Shoulder 1

SHOULDER DISCHARGE SUMMARY

Date: 1/8/2010 Date of Discharge: 1/8/2010 Patient: Harry Morgan Gender: Male Age: 53 Physician: Dr. Lindsay Enwright, MD Diagnosis: 726.12 Bicipital tenosynovitis of shoulder Treatment Need: Left shoulder impingement Date of Initial Evaluation: 12/4/2009 Date of Onset: 11/2/2009 Number of Visits to Date: 12 Number of Missed Visits: 0 726.10 Disorders of bursae and tendons- shoulder region
Harry Morgan was seen in physical therapy from 12/4/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
AROM Extension Flexion Abduction Adduction ER IR Special Tests Empty Can Impingement Speed's Apprehension Scapular Rhythm TOS RIGHT Right LEFT Left PROM Extension Flexion Abduction Adduction ER IR RIGHT DTRs Biceps Brachioradialis Triceps Grip Strength Right Left LEFT Right MMT Extension Flexion Abduction Adduction ER IR Left RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
Planetrehab Shoulder Discharge Summary Date of Discharge: 2/10/2010 Patient: Harry Morgan 1
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AROM Extension Flexion Abduction Adduction ER IR Special Tests Empty Can Impingement Speed's Apprehension Scapular Rhythm TOS RIGHT Right LEFT Left PROM Extension Flexion Abduction Adduction ER IR RIGHT DTRs Biceps Brachioradialis Triceps Grip Strength Right Left LEFT Right MMT Extension Flexion Abduction Adduction ER IR Left RIGHT /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5
Harry Morgan made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance, the patient should continue to do well long term. Harry Morgan is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary Shoulder 2

SHOULDER DISCHARGE SUMMARY

Date: 1/8/2010 Date of Discharge: 1/8/2010 Patient: Harry Morgan Gender: Male Age: 53 Physician: Dr. Lindsay Enwright, MD Diagnosis: 726.12 Bicipital tenosynovitis of shoulder Treatment Need: Left shoulder impingement Date of Initial Evaluation: 12/4/2009 Date of Onset: 11/2/2009 Number of Visits to Date: 12 Number of Missed Visits: 0 726.10 Disorders of bursae and tendons- shoulder region
Harry Morgan was seen in physical therapy from 12/4/2009 to 2/10/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
AROM Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT LEFT PROM Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT LEFT MMT Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5
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PALPATION Supraspinatus Infraspinatus Teres Minor Subdeltoid SC joint AC joint Clavicle Subscapularis Biceps Pectorals Other:
RIGHT
LEFT
SPECIAL TESTS Impingement (int rot and flex) Drop arm (rotator cuff) Yergasons (bicep tendon instability) Apprehension TOS (Adsons) Capsular pattern Painful arc Grip Strength
RIGHT
LEFT
AROM Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction PALPATION Supraspinatus Infraspinatus Teres Minor Subdeltoid SC joint AC joint Clavicle Subscapularis Biceps Pectorals Other: Grip Strength RIGHT LEFT RIGHT PROM Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction LEFT RIGHT LEFT MMT Extension Flexion IR ER Abduction Adduction Horizontal Abduction Horizontal Adduction RIGHT RIGHT /5 /5 /5 /5 /5 /5 /5 /5 LEFT /5 /5 /5 /5 /5 /5 /5 /5 LEFT
SPECIAL TESTS Impingement (int rot and flex) Drop arm (rotator cuff) Yergasons (bicep tendon instability) Apprehension TOS (Adsons) Capsular pattern Painful arc
Harry Morgan made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance, the patient should continue to do well long term. Harry Morgan is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Discharge Summary - Spine

SPINE DISCHARGE SUMMARY

Date: 2/9/2010 Date of Discharge: 2/9/2010 Patient: Ruthie Cohen Gender: Female Age: 40 Physician: Dr. Sara Sitardites, MD Diagnosis: 722.52 Lumbar intervertebral disc disorder Treatment Need: S/P lumbar fusion Date of Initial Evaluation: 12/1/2009 Date of Onset: 9/29/2009 Number of Visits to Date: 16 Number of Missed Visits: 2
Ruthie Cohen was seen in physical therapy from 12/1/2009 to 2/9/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular re-education for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Palpation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
MMT: All muscles WNL unless otherwise specified below UE: LE: CS: LS: Special tests: () Compression / Distraction () Not tested () SLR () left () right () Passive Kernig () Other: Reflexes () Not tested Sensation () Not tested () Intact () Decreased
Planetrehab Spine Discharge Summary Date of Discharge: 2/9/2010 Patient: Ruthie Cohen 1
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MMT: All muscles WNL unless otherwise specified below UE: LE: CS: LS: Special tests: () Compression / Distraction () Not tested () SLR () left () right () Passive Kernig () Other: Reflexes () Not tested Sensation () Not tested () Intact () Decreased
Ruthie Cohen made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Ruthie Cohen is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
Planetrehab Spine Discharge Summary Date of Discharge: 2/9/2010 Patient: Ruthie Cohen 2
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EXT: Discharge Summary Wrist/Elbow

WRIST/ELBOW DISCHARGE SUMMARY

Date: 3/24/2010 Treatment Need: right CTR Date of Discharge: 3/24/2010 Date of Initial Evaluation: 2/25/2010 Patient: Lori Jones Date of Onset: 2/10/2010 Gender: Female Age: 53 Number of Visits to Date: 10 Physician: Dr. Sara Sitardites, MD Number of Missed Visits: 0 Diagnosis: 354.0 Mononeuritis of upper limb- carpal tunnel syndrome Lori Jones was seen in physical therapy from 2/25/2010 to 3/24/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular reeducation for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: sample text Observation: sample text Functional Activity Level: sample text Gait: sample text Initial Evaluation Measurements:
Planetrehab Wrist/Elbow Discharge Summary Date of Discharge: 3/24/2010 Patient: Lori Jones 1
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Lori Jones made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Lori Jones is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
Planetrehab Wrist/Elbow Discharge Summary Date of Discharge: 3/24/2010 Patient: Lori Jones 2
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EXT: Discharge Summary 1

DISCHARGE SUMMARY
Date: 3/24/2010 Treatment Need: right CTR Date of Discharge: 3/24/2010 Date of Initial Evaluation: 2/25/2010 Patient: Lori Jones Date of Onset: 2/10/2010 Gender: Female Age: 53 Number of Visits to Date: 10 Physician: Dr. Sara Sitardites, MD Number of Missed Visits: 0 Diagnosis: 354.0 Mononeuritis of upper limb- carpal tunnel syndrome PARTICIPATION & COMPLIANCE Lori Jones was seen in physical therapy from 2/25/2010 to 3/24/2010. Treatment has included manual therapy to improve soft tissue and joint mobility, therapeutic exercise, with may include stretching and strengthening, neuromuscular reeducation for proprioception, posture, and return to functional mobility, and modalities to treat pain, inflammation, muscle spasm and soft tissue restriction. Treatment also included instruction and performance of a home program for ROM and management of pain and inflammation. Significant Clinical Findings: Pain Level: Observation: Palpation: Functional Activity Level: The patient is reporting pain and function FLEXION AROM: (R) (L) PROM: (R) (L) EXTENSION AROM: (R) (L) PROM: (R) (L) ABDUCTION AROM: (R) (L) PROM: (R) (L) Lori Jones made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Lori Jones is discharged from physical therapy at this time. Thank you for this referral. Sincerely,

Planetrehab Discharge Summary Date of Discharge: 3/24/2010 Patient: Lori Jones 1
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DISCHARGE SUMMARY
Date: 3/24/2010 Treatment Need: right CTR Date of Discharge: 3/24/2010 Date of Initial Evaluation: 2/25/2010 Patient: Lori Jones Date of Onset: 2/10/2010 Gender: Female Age: 53 Number of Visits to Date: 10 Physician: Dr. Sara Sitardites, MD Number of Missed Visits: 0 Diagnosis: 354.0 Mononeuritis of upper limb- carpal tunnel syndrome PARTICIPATION & COMPLIANCE Lori Jones attended 10 visits and has missed 0 visits at Planetrehab. CHANGE IN PAIN ASSESSMENT: () () () () () Decreased Pain Complaints No Change In Pain Increased Pain Complaints Increased Symptom Magnification and Non-Organic Pain Behavior Not Applicable
DISCHARGE STATUS: () () () () () () () () Physician Goals Met Therapist Goals Met No Change in Condition Drop Out/Personal Reasons Hospitalization/Medical DC to Gym Exercise Program DC to Home Exercise Program Other:
DATES OF SERVICE FROM: 2/25/2010 to 3/24/2010 TREATMENTS: Moist Heat, Therapeutic Exercise, Neuromuscular Reeducation, Manual Therapy, Spinal Bracing/Stabilization Program. GOALS MET: () Yes () No () Partial Lori Jones was informed of the findings of the evaluation and is aware of the plan of care and expected outcomes. I certify () recertify () that I examined the patient and therapy is necessary 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. I estimate these services will be needed for weeks and rehabilitation potential is good.
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Thank you again Dr. Sitardites for this referral and please call with any recommendations or questions that you may have. Your support of this practice is appreciated. Sincerely,
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PHYSICAL THERAPY DISCHARGE SUMMARY

Date: 3/24/2010 Date of Discharge: 3/24/2010 Patient Name: Date of Birth: Patient Code: Date of Initial Eval: Date of Onset: Physician: Diagnosis: Lori Jones 12/13/1956 PPT00129 2/25/2010 2/10/2010 Dr. Sara Sitardites, MD 354.0 Mononeuritis of upper limb- carpal tunnel syndrome
History: Lori Jones has attended PT . Lori Jones attended 10 visits and has missed 0 visits at Planetrehab. They report significant progress rehab goals. Objective Findings: Pain: () Increased ROM () Increased Strength () Increased Function () Increased
() Decreased () Decreased () Decreased () Decreased
() Unchanged () Unchanged () Unchanged () Unchanged
Treatment Report: Lori Jones's treatment has included and home exercise program. Goals Met: Patient has met personal goals and PT goals. Plan: Patient is discharged to as a result of . Lori Jones made good progress toward goals for physical therapy. Today the patient was instructed in a more comprehensive HEP for the long term. With compliance in this the patient should continue to do well long term. Lori Jones is discharged from physical therapy at this time. Thank you for this referral. Sincerely,
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EXT: Doctor Report

Planetrehab Rehabilitation 3 Petroleum Center 1001 W. Pinhook Lafayette, LA 70503 800-982-5447 888-648-1554 (fax) Dr. Sara Sitardites, MD PO Box7354 Lafayette, LA 70503 Re: Ruthie Cohen DOB: 5/15/1969 2/9/2010 Dear Dr. Sitardites, Ruthie Cohen received 16 visits of physical therapy between 12/1/2009 and 2/9/2010 to address 722.52 Lumbar intervertebral disc disorder. On initial evaluation, Ruthie Cohen was found to have: 1. 2. 3. 4. InitialProblem1 InitialProblem2 InitialProblem3 InitialProblem4
Upon discharge, the patient's progression is as follows: 1. 2. 3. 4. Progress1 Progress2 Progress3 Progress4
Additional Comments Thank you for the opportunity to help Ruthie Cohen. If you have any questions or comments do not hesitate to contact me or my staff. Sincerely,
Joe Davola PT
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EXT: Daily SOAP

DAILY TREATMENT NOTE

Date of Visit: 2/26/2010 Patient: Kari Abbot Patient Code: PPT00103 Physician: Dr. Kristin Davis, MD Date of Onset: 11/12/2009 Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb Number of Visits to Date: 2 Number of Missed Visits to Date: 1 Time Treatment Started: 2:35 PM Time Treatment Ended: 3:30 PM Total Treatment Time: 55 minutes I. SUBJECTIVE COMPLAINT: Kari Abbot is a 52 year old Female and presents with complaints of right shoulder bursitis. Patient complains of sample text. Last treatment helped. Patient requests sample text. II. TREATMENT REPORT: Ultrasound was used to increase blood flow to targeted tissue, and/or to decrease pain and/or to provide deep tissue heat through high frequency sound waves. A coupling medium of gel was applied to the area to be treated. The transducer head of the device was then placed on the gel and the parameters of the signal determined by the therapist. Treatment consisted of constant slow movements of the transducer head over the area to be treated. TOTAL TIME FOR ULTRASOUND: minimum of 8 minutes. 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 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 40 minutes. III. ASSESSMENT/SUMMARY: Patient tolerated today's treatment well. Pain lessened to /10. Mobility improved . Functional ability improved . Patient still suffers . IV. TREATMENT PLAN: Continue manual therapy, PRN modality treatment, clinical gym strengthening, attended pool therapy and progressive home exercise and self-care training. Submitted by the treating therapist.
Planetrehab Daily Treatment Note Date: 2/26/2010 Patient: Kari Abbot 1
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Planetrehab 3 Petroleum Center 1001 W. Pinhook Suite 113 Lafayette, LA 70510Clara Sampson Visit: 3/23/2010
Daily Note - Long
Physical Therapy Daily Note Date: 3/31/2010 Date of Visit: 3/23/2010 Patient: Clara Sampson Patient Age: 31 Gender: Female Physician: Dr. Frankie Merman, MD Diagnosis: 847.0 Sprains and strains of back- neck Treatment Need: Cervical Strain Date of Initial Evaluation: 2/26/2010 Number of visits to Date: 11 Number of missed visits: 6 Time Treatment Started: 7:47 AM Time Treatment Ended: 8:40 AM Total Treatment Time: 53 minutes Subjective: Objective: Ultrasound was used to increase blood flow to targeted tissue, and/or to decrease pain and/or to provide deep tissue heat through high frequency sound waves. A coupling medium of gel was applied to the area to be treated. The transducer head of the device was then placed on the gel and the parameters of the signal determined by the therapist. Treatment consisted of constant slow movements of the transducer head over the area to be treated. TOTAL TIME FOR ULTRASOUND: minimum of 8 minutes. The clinician utilized hands on techniques to provide strengthening, ROM, stretching and synergistic movement patterns to joint and muscle groups. Exercises were performed in open and closed kinetic chain and were specifically catered to target the patient's deficient areas. The clinician also utilized combined movement patterns to return patient to their former function level in ADL's and other activities. TOTAL TIME FOR THERAPUTIC EXERCISE: minimum of 15 minutes. 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 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 15 minutes.
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Page 1 of 2
Measurements
Modalities: Area Treated ()Ultrasound Time () ()w/cm2 ()MHz () cont/()pulsed ()Phonophoresis Time () ()w/cm2 ()MHz () cont/()pulsed ()E-Stim Time () type () ()Iontophoresis Intensity () ()mA min ()Traction Time () Weight () () static/()intermittent ()Hot Pack Time () ()Cold Pack Time () ()Whirlpool Time () A: P: Revised Goals: Alec Berg OT Signature on File
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Page 2 of 2
Daily Note - Short
Physical Therapy Daily Note Date: 3/23/2010 Date of Visit: 3/23/2010 Patient: Clara Sampson Patient Age: 31 Gender: Female Physician: Dr. Frankie Merman, MD Diagnosis: 847.0 Sprains and strains of back- neck Treatment Need: Cervical Strain Date of Initial Evaluation: 2/26/2010 Number of visits to Date: 11 Number of missed visits: 6 Time Treatment Started: 7:45 AM Time Treatment Ended: 8:45 AM Total Treatment Time: 60 minutes Assessment/Summary: Patient tolerated treatment well. Specific manual therapy and neuromuscular techniques were applied for treatment of 847.0 Sprains and strains of back- neck. Treatment Report: The clinician utilized hands on techniques to provide strengthening, ROM, stretching and synergistic movement patterns to joint and muscle groups. Exercises were performed in open and closed kinetic chain and were specifically catered to target the patient's deficient areas. The clinician also utilized combined movement patterns to return patient to their former function level in ADL's and other activities. TOTAL TIME FOR THERAPUTIC EXERCISE: minimum of 30 minutes. 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 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 30 minutes. Alec Berg PT Signature on File
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Page 1 of 1
Daily Note - SOAP Vestibular Rehabilitation - Long
PHYSICAL THERAPY DAILY NOTE Date: 3/31/2010 Date of Visit: 3/23/2010 Patient: Clara Sampson Patient Age: 31 Gender: Female Physician: Dr. Frankie Merman, MD Diagnosis: 847.0 Sprains and strains of back- neck Treatment Need: Cervical Strain Date of Initial Evaluation: 2/26/2010 Number of visits to Date: 11 Number of missed visits: 6 Time Treatment Started: 7:47 AM Time Treatment Ended: 8:40 AM Total Treatment Time: 53 minutes S: O: Patient performed the following exercises: STANDING BALANCE: Total tx. time () mins. X1/X2 viewing () hori. head turns/min. X1/X2 viewing () vert. head turns/min. () floor () foam () Sh. Romb. () walking Romberg eyes open (60) sec. close (60) sec. Foam eyes open (60) sec. close (60) sec. (Full) Sh. Romberg eyes open (60) sec. close (60) sec. Single leg stand () R () L eyes open () sec. Fukuda's stepping eyes closed (50) steps () Forward step () N () AbN () Veer () N () AbN Trampoline Romberg () eyes open (60) sec. () eyes close (60) sec. Sh. Romb () eyes open (60) sec.
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Page 1 of 2
() eyes close (60) sec. Head turn () hori () diago. Marching () eyes open (60) sec. () eyes close (60) sec. Stepping () eyes open (60) sec. () hori head turns () diagonals () eyes close (60) sec. Other: WALKING BALANCE: Total tx. time: () mins. Tandem walking (80 ft) x 4 reps () head turns every 3 steps With head turn () hori @ 80 ft x 4 reps () vert () combo H/V () diagonals () combo diagonals Walk eyes close () steps x (4) reps With () ball () toss () catch () turn every 3 steps 180 deg. () ball raise () lbs () 180 deg. turn @ 3 steps Obstacles Step () over () around Treadmill X () mins. () rail () 1.5 incline () mph () head turns H / V / D x 2 min. Others: A: Tolerated all exercises well. P: Continue program/HEP Alec Berg PT Date: 3/31/2010 Signature on File
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Page 2 of 2
Daily Note - SOAP Vestibular Rehabilitation - Long
PHYSICAL THERAPY DAILY NOTE Date: 3/31/2010 Date of Visit: 3/23/2010 Patient: Clara Sampson Patient Age: 31 Gender: Female Physician: Dr. Frankie Merman, MD Diagnosis: 847.0 Sprains and strains of back- neck Treatment Need: Cervical Strain Date of Initial Evaluation: 2/26/2010 Number of visits to Date: 11 Number of missed visits: 6 Time Treatment Started: 7:47 AM Time Treatment Ended: 8:40 AM Total Treatment Time: 53 minutes S: Patient reports O: Dix-Hallpike test (): ()nystagmus ()beat, torsional () () c/o dizziness () movement sensation () fatigued after seconds Dix-Hallpike test (): () Standing balance: A: (+) BPPV () Pt. tolerated canalith repositioning maneuver (CRM) x 2 sets. Second set with decreased symptom. P: Continue CRM to () x 2 sets. Follow up in a week.
____________________________________________ Date: 3/31/2010 Alec Berg PT Signature on File
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Page 1 of 1
Planetrehab 3 Petroleum Center 1001 W. Pinhook Suite 113 Lafayette, LA 70510Kari Abbot Visit: 2/26/2010
Daily Note - SOAP Short
PHYSICAL THERAPY DAILY NOTE Date: 2/26/2010 Date of Visit: 2/26/2010 Patient: Kari Abbot Patient Age: 52 Gender: Female Physician: Dr. Kristin Davis, MD Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb Treatment Need: right shoulder bursitis Date of Initial Evaluation: 2/23/2010 Number of visits to Date: 2 Number of missed visits: 1 Time Treatment Started: 2:35 PM Time Treatment Ended: 3:30 PM Total Treatment Time: 55 minutes SUBJECTIVE: sample text OBJECTIVE: () hot pack X min. to () pt. supine () pt. prone () pt. seated () cold pack X min. to () pt. supine () pt. prone () pt. seated () pulsed () cont. Ultrasound w/cm2 X 8 min. to () pt. supine () pt. prone () pt. seated () E-Stim X min. to () massage/MRF () stretch () manual traction () UBE X min. () treadmill X min. () Knee flex machine () Knee ext. machine () Therapeutic ex. ASSESSMENT: sample text PLAN: sample text TREATMENT REPORT:
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Page 1 of 2
Ultrasound was used to increase blood flow to targeted tissue, and/or to decrease pain and/or to provide deep tissue heat through high frequency sound waves. A coupling medium of gel was applied to the area to be treated. The transducer head of the device was then placed on the gel and the parameters of the signal determined by the therapist. Treatment consisted of constant slow movements of the transducer head over the area to be treated. TOTAL TIME FOR ULTRASOUND: minimum of 8 minutes. 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 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 40 minutes. Lloyd L Braun MPT Signature on File Date: 2/26/2010
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Page 2 of 2
Daily Note - SOAP
PHYSICAL THERAPY DAILY NOTE Date: 2/26/2010 Date of Visit: 2/26/2010 Patient: Kari Abbot Patient Age: 52 Gender: Female Physician: Dr. Kristin Davis, MD Diagnosis: 337.21 Reflex sympathetic dystrophy of the upper limb Treatment Need: right shoulder bursitis Date of Initial Evaluation: 2/23/2010 Number of visits to Date: 2 Number of missed visits: 1 Time Treatment Started: 2:35 PM Time Treatment Ended: 3:30 PM Total Treatment Time: 55 minutes () SEE INITIAL EVAL SUBJECTIVE: Patient reports () increased pain/symptoms. () decreased pain/symptoms. () No new complaints OBJECTIVE: Modalities: area treated () E-Stim X 15 minutes for Pain Edema ( to Hz.) () Muscle Stim. (Russian Stim) w/ () Ice () Heat X 15 minutes w/quad set) () Ice () Hot Packs X 15 Minutes (Location) () Mechanical Traction () Cervical () Pelvic () lb X 10 minutes () Ultrasound () continuous () pulse () w/CM2 X 8 minutes % Location () Iontophoresis () Anodyne X () 15 () 25 () 45 minutes () other: Comments: MT: () Joint mobs ( PA ): () shoulder () knee
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Page 1 of 4
() () () () () () () () ()
ankle cervical thoracic lumbar SI soft tissue deep tissue mobs myofascial work manual traction
() Friction massage () PROM () Stretching () deferred: () Total minutes: () 8 () 10 () 12 () 15 () Other () Exercises: () as previous on () Treadmill X minutes () Abdominal crunches X minutes () Lumbar Stabilization() () Recumbent Bike X minutes () Shuttle / cds B/U / minutes () Hams/()HC stretch X 3 minutes each () McKenzie: () 1 or () 2 minutes () William's flexion X reps/minutes () UBE X () 4 () 6 minutes () Airdyne Bike X () 5 () 7 () 8 minutes () Theraband (BYGR) X reps () Isometrics () Squats () AROM () Yellow tubing minutes () Stretching () manual () self () QS () SLR () HS () GS () AP () X () minutes () Pendulum () wall crawls X minutes/reps () Dumbbell lbs. X () BAPS () Rocker Board X minutes () Shrugs () Rows (BYG) X reps () Gait Training () PosturoMed bal. X minutes () Pulley 2 X 3 minutes () Abdominal Bracing X minutes total () Prone hangs X minutes ( wt.) () NK () static A ( wt) X total minutes () Bar stretch X minutes (all planes) () TheraBar BG X reps/minutes () HEP () Posture Ed () Gait Training () Functional skills
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Page 2 of 4
() Body Blade () Other: ROM: () knee () shoulder () ankle () cervical () trunk ASSESSMENT: () Tolerated. Rx. () Well () Fair () Poor () Progressing to goals () Improving () Decreased Pain PLAN: () Cont Rx w/ progression as tol. () D/C to HEP () Pt. to see M.D. () Goals met: () All () Most () Some () None Charges: () EVAL () T1x () T2x () T3x () MTx () TRACTION () MH () ICE () STIM () GAIT () MASSAGE () US () Anodyne
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Page 3 of 4
Treatment Report: Therapist performed a comprehensive evaluation in order to gather information, data from measurements and identify significant clinical findings. From this information, a complete plan of care is established. 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 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 40 minutes. Lloyd L Braun MPT Date: 2/26/2010 Signature on File
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Page 4 of 4
Daily Note - Urology
PHYSICAL THERAPY DAILY NOTE Date: 3/23/2010 Date of Visit: 3/23/2010 Patient: Clara Sampson Patient Age: 31 Gender: Female Physician: Dr. Frankie Merman, MD Diagnosis: 847.0 Sprains and strains of back- neck Treatment Need: Cervical Strain Date of Initial Evaluation: 2/26/2010 Number of visits to Date: 11 Number of missed visits: 6 Time Treatment Started: 7:47 AM Time Treatment Ended: 8:40 AM Total Treatment Time: 53 minutes Treatment Report: The clinician utilized hands on techniques to provide strengthening, ROM, stretching and synergistic movement patterns to joint and muscle groups. Exercises were performed in open and closed kinetic chain and were specifically catered to target the patient's deficient areas. The clinician also utilized combined movement patterns to return patient to their former function level in ADL's and other activities. TOTAL TIME FOR THERAPUTIC EXERCISE: minimum of 30 minutes. 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 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 30 minutes.
Subjective: Patient reports using (5) () panty liner () depends () pad in a 24-hour period.
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Page 1 of 3
Leaking with () lifting () coughing () sneezing () exercising () transfers Patient feels symptoms () improving () worsening () same Objective: Biofeedback conducted with () vaginal sensor () rectal sensor () perianal sensor Resting baseline ()mv QF ()mv (10) sec hold ()mv Obturator assist ()mv Adductor assist ()mv Position: () supine () wedge () sitting () standing () with functional activity Coordination: () poor () fair () good () poor return to resting baseline Endurance: seconds times
reps.
Education: () Use of Transversus abdominis during PFM contractions. () Voiding delay strategy.
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Page 2 of 3
Assessment: Patient less leaking demonstrated by fewer numbers of () pads () liners () Depends Showed () better () worse () same coordination and motor control. Is requiring () less () more verbal cueing. Plan: () Alec Berg PT Signature on file
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Page 3 of 3

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FOCUS MORE ON PATIENT CARE

1444 Langfield White Lake, MI 48386 www.planetrehab.com

EXT: Initial Evaluation 1

Pain Rating: Best: ()/10 Worst: ()/10 Average: ()/10

Planetrehab Initial Evaluation Date: 2/23/2010 Patient: Kari Abbot 3

Planetrehab Initial Evaluation Date: 2/23/2010 Patient: Kari Abbot 4

EXT: Initial Evaluation 2

PHYSICAL THERAPY EVALUATION

________________________________________________________________ Date: 2/23/2010 Therapists Signature - Lloyd L Braun MPT

Planetrehab Initial Evaluation Date: 2/23/2010 Patient: Kari Abbot 2

EXT: Initial Evaluation - Columns

DTR Biceps Brachioradialis Triceps Grip Strength

Planetrehab Initial Evaluation Date: 2/23/2010 Patient: Kari Abbot 1

________________________________________________________________ Date: ____________________ Physician Signature - Dr. Kristin Davis, MD

Planetrehab Initial Evaluation Date: 2/23/2010 Patient: Kari Abbot 2

EXT: Initial Evaluation - Comprehensive

PHYSICAL THERAPY EVALUATION

Date of Eval: Date of Onset: Date of Birth:

Planetrehab Physical Therapy Evaluation Date: 2/23/2010 Patient: Kari Abbot 1

________________________________________________________________ Date: 2/23/2010 Therapists Signature - Lloyd L Braun MPT

________________________________________________________________ Date: _____________________ Physician Signature

Planetrehab Physical Therapy Evaluation Date: 2/23/2010 Patient: Kari Abbot 2

Initial Physical Examination:

Weight Bearing Left Right

Non Weight Bearing Left Right

Strength Left Right

PROM Right Left

PROM Right Left

Planetrehab Physical Therapy Evaluation Date: 2/23/2010 Patient: Kari Abbot 3

EXT: Evaluation - Short

Planetrehab Initial Evaluation Date: 11/12/2009 Patient: Kari Abbot 2

EXT: Initial Evaluation and Plan of Care 1

INITIAL EVALUATION AND PLAN OF CARE

________________________________________________________________ Date: ____________________ Physician Signature - Dr. Kristin Davis, MD

EXT: Initial Evaluation and Plan of Care 2

INITIAL EVALUATION AND PLAN OF CARE

EXT: Plan of Care

PROGRESS REPORT AND PLAN OF CARE

____________________________________________________ Date: ________________ Physician Signature - Dr. Ned Isakoff, MD

EXT: Progress/Recertification Note

PROGRESS OF TREATMENT TO DATE:

Rationale for Continued Treatment: sample text

RECOMMENDATION/PLAN OF PROGRESS (FUNCTIONAL GOALS):

Plans/Interventions: sample text

Other: ________________ Other: ________________

Planetrehab Progress/Recertification Note Date: 3/24/2010 Patient: Kari Abbot 1

EXT: Progress Note 1

Date of Visit: 3/24/2010 Diagnosis:

Participation & Compliance:

Symptom Behavior & Presentation:

Rehabilitation Potential: () Poor () Fair (X) Good () Excellent

Frequency: Duration: Treatment:

________________________________________________________________ Date: ____________________ Physician Signature - Dr. Kristin Davis, MD

Planetrehab Progress Report Date: 3/24/2010 Patient: Kari Abbot 2

Weight Bearing Left Right

Non Weight Bearing Left Right

Strength Left Right

PROM Right Left

PROM Right Left

Planetrehab Progress Report Date: 3/24/2010 Patient: Kari Abbot 3

EXT: Progress Note 2

________________________________________________________________ Date: ____________________ Physician Signature - Dr. Kristin Davis, MD

Planetrehab Progress Note Date: 3/24/2010 Patient: Kari Abbot

____________________________________________ Date: Physician Signature - Dr. Kristin Davis, MD

____________________________________________ Date: _ Physician Signature

____________________________________________ Date: Physician Signature - Dr. Kristin Davis, MD

____________________________________ Date: Physician Signature - Dr. Ned Isakoff, MD

Other: Other:

____________________________________________ Date: Physician Signature - Dr. Kristin Davis, MD

____________________________________________ Date: Physician Signature - Dr. Kristin Davis, MD

____________________________________________ Date: Physician Signature - Dr. Kristin Davis, MD

____________________________________________ Date: Physician Signature - Dr. Lindsay Enwright, MD

____________________________________________ Date: Physician Signature - Dr. Lindsay Enwright, MD

____________________________________________ Date: Physician Signature - Dr. Geoffrey Harharwood, MD

____________________________________________ Date: Physician Signature - Dr. Lindsay Enwright, MD

____________________________________________ Date: Physician Signature - Dr. Lindsay Enwright, MD

____________________________________________ Date: Physician Signature - Dr. Lindsay Enwright, MD

____________________________________________ Date: Physician Signature - Dr. Kristin Davis, MD

____________________________________________ Date: Physician Signature - Dr. Lindsay Enwright, MD