GENERAL INFORMATION:

 Date of referral – February 17, 2023

SUBJECTIVE:

 Description of pain
 Frequency of pain

HPI (Ending should always be referred to PT,

 2 months PTIE, what type of pain that the patient experienced?

 Specify what the rehab doctor do to the patient before he/she refer to the PT department
 The ending part of the HPI should always be referred to PT

P/SHx

 Financial stability

H/W situation:

 Type of bed

MEDICATION

 When the patient used the corticosteroid injection?

 Include the patient medication or maintenance for HTN

OCULAR INSPECTION:

 Remove or separate the x3 in the A/C/C part because they have different use or purpose.
 Example:
o Pt is A/C/C
o Pt is oriented x3 or x4
 Be specific of the laterality whether it is (+) or (-).

PALPATION:

 Specify the laterality whether it is (+) or (-).

 Pt is normotonic on all tested body parts (Pt is hypertonic on (B) LE)
 ROM:
 Add difference in the knee extension
 Add values in the DF
 Specify in the findings all the affected movement