WORKMED DOL-OWCP SOAP NOTES

WORKMED DOL-OWCP S.O.A.P.

Daily Treatment Notes
Patient Name
Date

Month Day Year
Date
File #
DCN
SUBJECTIVE:
Modifiers

GT 59 25 95 Prolonged (99359) Non face-to-face service (9358) (99214) (99213) (99212) (97162) PT EVAL
Patient Response From Last Visit

Improving Same Worse Initial Visit
Pain Scale

Mild = 1,2,3 Moderate = 4,5,6 Severe = 7,8,9 Extreme = 10
Objective:

P=Pain/Tender MS = Muscle Spasm TP = Trigger Point MF = Myofibrosis E = Edema/Swelling
Reduced ROM

Shoulder/Knee Foot/Ankle Thoracic Spine Lumbar Spine Pelvic Region Cervical Spine
Asssessment (Progress):

Receiving Necessary Care Post MVA As Expected Flare Up Improving w/ Treatment Acute Exascerbation Post Injury Post MVA Slower Than Expected
Limited by:
Diagnosis

New Diagnosis Same Diagnosis
Diagnosis 1 (if applicable)
Diagnosis 2 (If applicable)
Diagnosis 3 (if applicable)
Diagnosis 4 (if applicable)
Diagnosis 5 (if applicable)
Diagnosis 6 (if applicable)
Diagnosis 7 (if applicable)
Diagnosis 8 (if applicable)
PPT(97750)
Self Care /HMT (97535): 1.
Group Therapy (97150)
Education Training for PT Self Mgnt (98960 2)
PLAN

Treatment Plan MODIFIED from last visit Treatment Plan UNCHANGED from last visit
Chiropractic Manipulation

Cervical Thoracic Lumbar Sacrum Elbow Ankle Ribs Feet Pelvic Knee Shoulder Wrist B/R/L
(98940)
(989410)
(98942)
(98943)
Strapping (292.295):

Cervicals Thoracics Lumbars B / L / R Knee / Ankle / Foot B/L/R Shoulder / Elbow / Wrist
Performed to:

Stabilize Restrict Motion Reduce Pain Protect the Affected Area
Therapeutic Exercises (97110)

C/T/L Strengthening Exercises C/T/L Therapeutic Stretching
Number of C/T/L Strengthening Exercises Units?
Number of C/T/L Therapeutic Stretching Units?
Performed to:

Improve function Joint Mobility Strength Stability Flexibility Endurance Balance Muscular Re-Education
Manual Therapy (97140)

C/T/L Hip Shoulder Leg Foot TMJ Elbow Wrist
Manual Therapy (97140) Number of Units
NMR (97112) - Performed to...

Increase ROM Decompress Discs Alleviate Joint Pain Improve Disc Integrity
NMR (97112) Number of Units
Therapeutic Massage Therapy

Cervicals Thorasics Lumbars B/L/R Feet B/L/R Knee B/L/R Shoulder B/L/R Wrist
Therapeutic Massage Therapy Number of Units
Paraffin (97018)
Iontophoresis (97033)

C T L S P
Iontophoresis (97033) Unit(s)
Therapeutic Activities (97530)

C T L
Therapeutic Activities (97530) Units
Gait Therapy (97116) Units
New or Established Patient?

New Patient Established Patient
Discussed POC/Expected Outcomes?

Yes
How Long Was Treatment (In Minutes)
Referral
Visit Frequency:

Continue Prescribed Care Plan as Scheduled PRN Change Frequency to Monthly Change Frequency to Weekly
Orders:

TENS Unit Issued Cervical/Lumbar Traction Unit Issued Patient Issued Instructions for HOme/Work Brace Evaluation Primary Care Physician Orthopedist Neurologist Physical Therapist
NOTES
Doctor Initials
PT Tech: Initials
Patient Signature

Clear
Should be Empty:

WORKMED DOL-OWCP S.O.A.P.

SUBJECTIVE: