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I would like to offer this report as a confidential example of the typeofreporting I'm looking for: You can adapt this type of reporting &Invoicingto any report format. I hope you accept the ideas listed as my efforttoassist you in getting your reports and invoices approved without havingtosent them back to you, not approved, because of missing or incorrectdocumentation.
----- Prior Report Recommendations -----1.) Maintain contact with PT to insure compliance and progress.
Insure adjuster authorization to attend next visit with Dr. Bernard on10/27/11.
3.) If authorized by the adjuster, plan to attend the 10/27/11appointment with IW and Dr. Bernard and determine IW's current symptomsandresponse to the PT and medications Rx'd 4.) Visit with IW and Dr.
Bernardat time of examination. Obtain the MD's impressions, recommendations,current activity restrictions, anticipated date of MMI, PPI andpermanentactivity restrictions.
5.) Insure adjuster authorization for any treatmentor testing and facilitate scheduling.
THE INFORMATION PROVIDED IN THIS REPORT IS PERSONAL AND CONFIDENTIAL.
Has relocated out of state of employer of May work at nurse's station, no direct patient contact.
Weigh t limit 15 lbs.
Date of next MD Appointment: schedafter cervical myelogram/CT scan done Arrange for evaluation by surgeon in AL where IW now lives.
Rec'd PT reports through AlignNetworks.
scheduled, but missed 9/29/11 and 10/7/11.
neck was too inflamed on those dates for her to participate in PT.
I met with IW at the office of Dr. Bernard on 10/27/11.
thatshe had undergone a total of 12 PT visits. The report from her PT atTotalRehab noted she had a 30% improvement in her symptoms and range ofmotion.
However, it was noted that she had 30 lb grip strength on the left on9/19/11, initial eval, and this decreased to 15 lb on 10/17/11. Ms.
Medinafelt she was improving somewhat, but her pain remained at level 5-6(scale1-10, 10 being worst pain).
She noted that her pain would increase to agreater degree after PT - but it never got better than level 5-6.
stated that PT tried some manual traction was, but it aggravated herpainand it was discontinued.
She noted that at Total Rehab she was given exercise instructions and completes exercises designed to improve herflexibility and strength. She also was given home exerciseinstructions.
The PT also utilized some modalities to reduce pain.
iceand heat to her neck and upper back area at home to relieve her pain.
Sheis taking Lortab 10 (1/2 tab) about 2 x's/day, Advil 3 x's/day(recommendedby MD).
She has not had any GI irritation from the Advil.
takesher muscle relaxer, Robaxin, 3 x's/day as Rx'd.
Ms. Medina c/o neck pain that evolves into a headache, pain inthe trapezius area of her upper back and pain, numbness and tingling inherleft arm.
Dr. Bernard noted that all conservative measures have been utilized to treat IW and she has clear symptoms of nerve irritationthatmight be due to a disc herniation not visualized on MRI.
hasrequested that IW undergo cervical myelogram with CT scan - to be doneateither EAMC or Hughston Clinic in Columbus, GA as these facilitiesprovidereliable testing.
He continued her medications and wrote another Rx Dr. Bernard continued her previously Rx'd activity Previously Dr. Bernard thought he would be able to place IW at MMI inapprox 90 days.
He plans to obtain an FCE with PPI evaluation in order todetermine PPI and permanent activity restrictions.
myelogram shows abnormalities, she may require surgical interventionthat Official Disability Guideline notes that individuals with cervical disc protrusion are at risk of losing up to 365 days fromwork.
1.) Have located orthopedic back surgeons in IW's current location.
2.)Have provided medical records to those surgeons for review.
insured that one of the orthopedic back surgeons, Dr. Bernard, will seeIWand treat her, if indicated.
5.) Have initiated contact with IW. 5.) Have arranged for and attended first appointment with Dr. Bernard and haveadvised adjuster of information obtained.
authorization for MRI and have arranged for completion with OneCallMedicalas instructed. 8.) Have facilitated scheduling of PT.
maintainedcontact with IW, MD and obtained information re response to tx and MD'simpressions and recommendations.
Off work. Has relocated out of state of employer of injury.
Bernard 8/18/11, restricted to sedentary to light duty status.
work atnurse's stations, no direct patient contact.
Goals:recommendation, current activity restrictions, anticipated date of MMI,PPIand permanent activity restrictions.
forany recommended tests or therapies and facilitate scheduling.
Provideupdated information to adjuster and employer.
Rx'dactivity restrictions and facilitate RTW if indicated.
1.) Insure adjuster authorization for cervical myelogram/CT scan andfacilitate scheduling.
2.) Obtain report of testing and provide to recommendations following myelogram.
recommended tx and facilitate scheduling.
returnto his office, insure adjuster authorization to attend next visit.
Ifauthorized by the adjuster, plan to attend the appointment with IW andDr.
Bernard and determine IW's current symptoms and response to the txrecommended and medications Rx'd 6.) Visit with IW and Dr. Bernard attimeof examination. Obtain the MD's impressions, recommendations, current activity restrictions, anticipated date of MMI, PPI and permanentactivityrestrictions.
7.) Insure adjuster authorization for any treatment or |-------+---------------------+------------++---+---+---+-+++---------||10/17/2|MedSrv-Review Med |-------+---------------------+------------++---+---+---+-+++---------||10/25/2|MedSrv-Review Med |-------+---------------------+------------++---+---+---+-+++---------||10/25/2|Corresp-Physical/Occu| |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Exp-Travel Time |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Exp-Mileage |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Conf/Vis-Client |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Conf/Vis-Physician |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|MedSrv-Review Med |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Exp-Photocopies |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Corresp-Insurance |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Corresp-Physician |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Exp-Long Distance |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Corresp-Insurance |-------+---------------------+------------++---+---+---+-+++---------||10/27/2|Progress/Status |-------+---------------------+------------++---+---+---+-+++---------|

Source: https://www.airmcm.com/guidelines/Account%20Templates/Med%20Insights/MedInsights%20General%20Templates/report%20example%2010272011.pdf