SOAP SOAP format for treatment notesStep 1 of 520%Patient Name and DOBReport type* Initial Evaluation Daily Note Progress report DischargeName of referring providerPlease list the name of the referring provider for physical therapy. If the phone and fax are known, please addDiagnosisPayor* Altruism Aetna BCBS Cigna Concierge Humana Medicare Private pay UHCDate of service MM slash DD slash YYYY Location of Service* Office Visit Telehealth/E-Visit Home visitSelect office visit, E-visit, or home visitTelevisit/ E-Visit* Patient initiated request for Telehealth E-visit Patient provided consent to participate in the telehealth Evisit Patient is located at home/officeSUBJECTIVENPRS* 0/10 1/10 2/10 3/10 4/10 5/10 6/10 7/10 8/10 9/10 10/10Numerical Pain Rating Scale where 0 is no pain and 10 is the worst pain imaginableSymptoms following last treatment session no change better worseHome exercise need review not performing performing no difficultySubjectiveThe patient **, is a **-year-old, un/married fe/male presenting to physical therapy (PT) to address ** HPI: Onset **. Treatment thus far has included ** with ** benefit PMH: Reports/Denied,dizziness, double vision, difficulty swallowing, speaking, wakes with tingling in hands, loss of strength in hands, recent infection, recent changes in bladder, denied unexpected/unintended weight loss in the past 3 months, ** difficulty walking, and ** falls. ** history of cancer reported. Patient is ** referred **, with a prescription from ** Pre-morbid Activity included ** Current activity includes ** Functional Limitations include ** Pain description: Worse with Better with Pain in the morning Pain int he evening Pain with activity Radiating painOBJECTIVEPre-session Posture AROM Palpation Joint mobility Outcome measure Special Tests GaitCheck all assessedGait Assessment Step length asymmetrical Right leg not passing left Left leg not passing right Trendelenburg right Trendelenburg left Modified trendelenburg right Mod Trendelenburg left Increased trunk flexion Wide base of support Decreased speed Discontinuous pattern Decreased stance right Decreased stance left decreased swing right decreased swing left absent heel strikeCervical Special Tests Bakody's Sign Cervical Distraction Test Cervical Rotation Lateral Flexion Test Craniocervical Flexion Test Deep Neck Flexor Endurance Test Posterior- Anterior Segmental Mobility Segmental Mobility Sharp-Purser Test Spurling's Maneuver Transverse Ligament Test ULNT - Median ULNT - Radial ULNT - Ulnar Vertebral Artery TestObjective FindingsDescribe your findings above "Elevated first rib right...limited right hip extension at terminal stance...". Describe your session; "Treatment began with joint mobilization followed by stretching/NMS. Strengthening for …, followed by … for functional training. Education provided for and HEP updated/reviewed... Next session..."Manual Therapy Treatment 97140Describe what was performedTherapeutic Exercise Treatment 97110Describe what was performedNeuromuscular Reeducation Treatment 97112Describe what was performedTherapeutic Activity Treatment 97530Describe what was performedEducation/Self-care Treatment 97535Describe what was performedGait Training Treatment 97116Describe what was performedAssessmentPatient presents with ** due to underlying movement impairment of ** syndrome and underlying **, with ** irritability and ** reactivity. Previous history of ** should be considered. Skilled intervention indicated to restore joint motion, strength, and normal ** to return to pain-free function.Problem ListGoals: Patient will demonstrate Improved ROM as indicated by increase in goniometric measurement of 10 deg within 4 weeks decreased pain as indicated by NPRS of less than 2/10 with activity Improved strength as indicated by increase in MMT grade to 3+/5 Improved gait as indicated by increase in gait speed as measured by 6 minute walk test distance improved function as indicated by improved outcomes measure scorePOC* Proceed with PT intervention Return as needed Refer to MD for imaging Refer to MD due to red flags Eval only; no treatment indicated Wait for insurance approval Eval only; patient choice Continue POC Discharge from PT 97110, 97112, 97116, 97140, 97530, 97535, 97761, 97760 Evisit/Telehealth Refer to Occupational Therapy Refer to additional providerSelect all that applyCPT Codes*Evaluation 97162, 97163, 97164)R/E 97164Therex 97110NMS 97112TherAct 97530ManTher 97140Gait 97116Education/ HEP 97535Orthotic 97760L splintTelephone 98966 (No MCR)Telehealth 98972 (21+) (No MCR)Evisit G2063 (21+) Modifier CR + 95 + GT (MCR) Signature and State License #Treating Therapist*Dr. Abraham Lieberman, PT, DPT, FAAOMPT #1192943Dr.Brianna Denaye Eby, PT, DPT #1309221Corey Warner, PTADr. Alison Vargo, PT, ScD, OCS, FAAOMPT #1197201Cornelius Provost, PTA # 2146859Kelsey Wade, PTA #2123968Ileana Villarreal, COTADr. Mitchell Rickey, PT, DPT #1336070Chana Stewart, OTR #119312Type Name and License NumberPlease email or fax report to*please put the referring provider's nameSelect the appropriate choice*Therapist in officeTherapist at HomePatient at homeFileMax. file size: 64 MB.Δ