1 Rehab information and terms All initial evaluation have the sentence, "Goals and plans discussed with the patient and agreed upon." under the treatment section whether or not it is dictated. All initial evaluations have the sentence, "If there are any questions, please do not hesitate to contact me by telephone at <insert area code and phone number of group>. Thank you for the referral." as the final sentence before the signature line. Here are the numbers: (OVIEDO) #20 - (407) ; (LUCERNE) #85 - (407) When two names are used on the signature block the proper format is as follows: FIRST PERSON, XX SECOND PERSON, XX/C&C/xx Lic. # XXXXX Lic. # XXXXX ORRS/XXXXX Rehab. If you are making a numbered list such as: Item number one. Item number two. Item number three. DO NOT use tabs or spaces to make the numbers or text line up. If you do this I will have to find each and every one and manually delete them. Use your word processors automatic Numbered Line style or function. If you don t know how to do that consult the manual, call the company or purchase a guide book.
2 If the report takes more than one page begin second pages like this: PAGE TWO PATIENT NAME All pages for rehab have margins of 1" on top, bottom, left and right. Check them. All text needs to be in Times New Roman font, size 12. S: O: A: and P: are always capitalized and bolded. Use MEDICAL RECORD# not ACCOUNT NUMBER: Use REF. PHYSICIAN: not REFERRING PHYSICIAN: Use PATIENT NAME: not PATIENT: PATIENT NAME:, MEDICAL RECORD#, DATE:, DOB: and REF. PHYSICIAN: are always capitalized and bolded. ASSESSMENT:, GOALS:, TREATMENT: and PLAN: are always all capitalized, bolded and underlined. INITIAL EVALUATION, DAILY NOTE and DISCHARGE SUMMARY are always capitalized, bolded, underlined and centered at the top. The MEDICAL RECORD# which as dictated by therapist is NOT the same as the JOB#. JOB# should be on your patient list at the end of the file.
3 The last line of every signature block should begin with ORRS/. So it should read: ORRS/XXXXXXXX Rehab. ORRS/Sligh Blvd. Rehab. ORRS/Southlake Wellness Rehab. ORRS/South Seminole Rehab. ORRS/Winter Park Rehab. ORRS/SandLake Rehab. Also please make sure that there is only one space between the words, somebody has two or three in their macro and it s driving me batty. When centering headings at the top of the page use the center function or command DO NOT use tabs or spaces. If you are unsure of a sentence, word, name, etc. bring it to the editor s attention. Just underlining that portion of the report is NOT sufficient and may not get the editor s attention. Make sure you underline, bold, capitalize and italicize the portion of the report in question. When typing dates use the MM/DD/YY format. Use the "/" not the "-". (please refer to body sheet for sites and parameters) Achilles (not achilles) active range of motion ADLs (not ADL's) auditory comprehension BAPS board or BAPS (always all capitalized) BIRC (stands for Brain Injury Rehabilitation Center)
4 carpal (not carpel) closed kinetic chain lower extremity strengthening exercises Codman's exercises cue cues Cybex (not cybex, it's a brand name and should be capitalized) D2 flexion exercises diadochokinetic rate dorsiflexion (not dorsi-flexion) double knee to chest duty cycle dystrophile (not distrofile, etc.) E-stim. (not E-stem or E-stim) fascia lata Finkelstein's sign fluidotherapy (not fluido therapy) FREQUENCY AND DURATION OF SERVICES: functional activities functional sport specific exercises gastroc/soleus glenohumeral joint grip strength
5 Houghston's exercises IFC (not IFT, it stands for interferential current) impulse inertia machine in all planes (not plains) iontophoresis LIDO (always all capitalized) lumborum (not lumborium) MHz (not Mhz or mhz or MHZ or megahertz or megahurts) mobs (not mobes) motoric struggle multi-syllabic neuro gliding Niercheal exercises Noye's hopping NSAIDs (not NSAID's) one-on-one (not 101) oral motor exercises oral agility exercises palmar (not palmer) passive range of motion phonophoresis pinch strength
6 plyometric exercises PNF rhythmic stabilization PREs prone Houghston's exercises prone proprioception rpm (not rpms, yes I know they say rpms but don't type that) scapular stabilization exercises single knee to chest subtalar (not subtaylor) supine swing phase Swiss ball (not swiss ball) talocrural (not talocrule) Thera-Band (not theraband or Theraband or Thera-band or thera-band) Thera-Putty tib-fib UBE (always all capitalized) warm and form (not Warmen form) watts/cm2 (not w/cm squared or watt/cm2 or watts per centimeter squared) word fluency word retrieval
7 Frequently used Chiropractic Terms ADLs +2 and symmetrical Bragard's Cavitation of the sacroiliac joints and lumbosacral spine Cavitation central canal stenosis Cervical distraction test Cervical sprain/strain cervical facets cervicodorsal joints / spine cervicogenic cephalgia/neck CMT to low back CMT compression/distraction test costotransverse joint dysfunction cryo treatment DDx purposes decreased IVF Dejerine's Triad double leg raise
8 DTRs Erector spinae muscle test F/D and CMT full spine Faber's test HMP. F/D and CMT full spine Home care: Decrease ADLs, ice pack q.i.d. 15 minutes, Williams' flexion hypertonic hypertonicity hypomobility hyporeflexia inferential treatment innominate innominates Interferential And Synaptic Therapy Kemp's test lumbar orthopedic provocative test lumbar spondylosis McKenzie extension exercises Microcurrent Therapy military neck Minor's sign
9 mobilization of the occiput myofascial trigger points neural foraminal narrowing neurocompressive pathologies osteophyte formation paravertebral region positive neutral and Jackson's cervical compression test, and negative shoulder compression test and cervical distraction test prone LPS adjustment provocative tests Psoas Muscle Test radiculopathy/paresthesias Release Work test short course of supportive care side posture adjustment bilaterally Psoas Muscle Test subscapularis muscle Temporomandibular joint The Yeoman's Test Thomas Test toe and heel walk Toggle Drop test
10 Ultrasound to SIJs Unlevel SI joints Williams' flexion Frequently Referred Doctors Names Dr. Crofford Dr. Tidwell Dr. Sharfman Dr. Asmann Dr. Bott Dr. Imfeld Dr. Roddy Dr. Kilbride
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