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Follow Up Visit form by 1Bj3s5

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									              AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                 Follow Up Visit
PAGE 1 of 7                                                   Time Patient Arrived____________
Name:                                                        Medical Record#                  Age:          Today’s Date:          -2012
CHIEF COMPLAINT(PLEASE CIRCLE): PAIN IN: □ RIGHT □ LEFT                                        Body Area/Part:

SUBJECTIVE: List full names of people in exam room with you today (name/relationship)_____                                             □ No one

1. Date of injury/onset for this problem?________________ OR Date of last surgery done by Dr. Larson on you: _________
2. If pain started from an injury, how did injury occur? ________________________________________________________
3. Is your pain or medical condition since last visit (Please check box): □ NO PAIN                        □ BETTER     □ UNCHANGED □ WORSE
4. Are you having any swelling at your injury site?                   □ NO       □ YES       If YES, explain:
5. Are you taking Pain Pills and/or anti-inflammatories? □ YES                       □ NO (if NO, go to question 6)
          a) If YES, are they helping you? □ YES □ NO
          b) If YES, what pain pills are you taking now?
              c) If YES, how many pain pills do you take on an average day?
              d) If YES, are you going to a Pain Management Clinic □ NO                     □ YES If YES, which Doctor?
6. Are you going to physical therapy or hand therapy?                      □ YES      □ NO       (if NO, go to question 7)
         a) If you are going to physical therapy, is it helping you?               □ YES       □ NO
7. Are you doing physical therapy or hand therapy exercises at home?                            □ YES     □ NO
8. Are you wearing a brace?             □ YES       □ NO (if NO, go to question 9)
         a) If you are wearing a brace, is the brace helping you?                 □ YES       □ NO
9. Did you receive an injection during your last visit?                □ YES       □ NO          (if NO, go to question 10)
          a) Which injection did you receive? □ CORTISONE □ SYNVISC □ SUPARTZ
          b) Is the injection still helping you?   □ YES □ NO          (if YES, go to question 10)
          c) If not, how long did the injection help you? Days              Weeks            Months
10. Do you want to continue your current treatment plan, or would you like to make a change in your treatment to better help
    you?      □ MAKE NO CHANGES                     □ MAKE CHANGE               If change, please explain:_________________________
11. If employed, will you need new work restrictions or work release today? □ YES                         □ NO
PLEASE LET US KNOW IF ANYTHING HAS CHANGED IN YOUR HEALTH SINCE YOUR LAST VISIT WITH DR. LARSON:
12. Has anything changed in your ALLERGIC REACTIONS TO MEDICATIONS or FOODS:
     □ NO       □ YES If yes, please explain:________________________________________________________________
13. Has anything changed in your MEDICATIONS/PRESCRIPTIONS: (Have you started or discontinued any medications) :
     □ NO       □ YES If yes, please explain:________________________________________________________________
14. Has anything changed in your SOCIAL HISTORY: (home, job, tobacco use, alcohol use, drug use, brace wear, etc,):
     □ NO       □ YES If yes, please explain:_________________________________________________________________
15. Has anything changed in your FAMILY HISTORY: (any family members have new illnesses since you last saw Dr. Larson):
     □ NO       □ YES If yes, please explain:_________________________________________________________________
16. Has anything changed in your MEDICAL HISTORY: (Do have any new illnesses since you last saw Dr. Larson):
     □ NO       □ YES If yes, please explain:_________________________________________________________________
17. Has anything changed in your SURGICAL HISTORY: (Have you had any new surgeries since your last visit here):
     □ NO       □ YES If yes, please explain:_________________________________________________________________
18. Has anything changed in your BODY complaints: (REVIEW OF SYSTEMS: head, eyes, ears, nose, throat, lungs, heart,
gastrointestinal systems (bowels, stomach), muscles, bones, joints, urination, bladder, neurological (nerves), blood, blood
vessels, blood clots, lymph nodes, cancer, tumors, psychiatric, mental problems, weakness, tiredness, pain management, etc).
    □ NO       □ YES If yes, please explain:___________________________________________________________________
The above form completed by (PRINT Your Name):                                               Your Signature:                   Date:      /2012
TO BE SIGNED AND REVIEWED BY DR. LARSON:                                                 STEVEN B. LARSON, M.D.       DATE:            2012

Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11
              AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                         Follow Up Visit
PAGE 2 of 7
PATIENT NAME:_____________________________MR#_______ DATE:____________-2012
                                                              TO BE COMPLETED BY DR. LARSON ONLY



FOR USE BY CLINIC STAFF ONLY:
Problem List Updated? □ YES □ NO
If patient is female, is she pregnant?       □ NO □ YES □ Male
Plan reviewed from previous visit or Operative Note? □ YES           □ NO
Patient in Global Period (within 90 days of OR Procedure)? □ NO            □ YES
New X-rays done today? □ YES □ NO
Most recent X-rays available for Dr. Larson to review on: □ Computer or □ X-ray box?
Is patient returning back today for follow up on a special study (e.g. MRI, EMG/NCV, consult)? □ YES    □ NO
          If YES, is written report available □ YES □ NO
Are MRI films available? □ YES □ NO □ N/A □ On Computer □ On View Box
Has patient removed clothing for Dr. Larson to examine, and gown or paper shorts on patient if needed? □ YES                         □ NO □ N/A

Completed by:       □ SH □ RP          □ JV     □ JB     □ NB          □ SL □ PL            OTHER:



OBJECTIVE:           PHYSICAL EXAM BY DR. LARSON: □ RUE     □ LUE □ RLE □ LLE
( See Physical exam done on sheet for: □ KNEE □ SHOULDER □ HAND/WRIST □ HIP □ FOOT/ANKLE                                               □ ELBOW )

SKIN EXAM (Check normal findings):       □ no wounds □ no ecchymosis □ no drainage □ no erythema □ no fluctuance □ no signs of infections
    □ no scars   □ no swelling
□ SKIN EXAM ABNORMAL             (Check abnormal findings):    □ wound, □ ecchymosis, □ drainage, □ erythema, □ fluctuance, □ signs of infections,
    □ scars □ swelling
Explain:
                                                                          _______________

MUSCULOSKELETAL EXAM:               □ RUE      □ LUE           □   RLE       □   LLE        Body Part:

AROM:EXT:               FLEX:                  □ Not able to test AROM            STRENGTH: Extension        /5   Flexion   /5     □ Not able to test strength
TTP:       □ NO □ YES      If YES, please explain:




□ PROCEDURE PERFORMED: □                            DISTAL RADIUS FX             □ METACARPAL FX         □ METATARSAL FX     □ PHALANX FX
□ OTHER PROCEDURE:
□ CLOSED REDUCTION OFFERED                      □ PATIENT DECLINES               □ ACCEPTS           □ WANTS TO WAIT AND MAYBE DO IT LATER
□ Patient counseled for procedure including risks, benefits, alternatives to procedure, and possible complications including those complications which are
unforeseen and unmentioned. All questions from patient answered. Informed consent verbally achieved.
□ SEE DICTATED PROCEDURE NOTE IN MEDICAL RECORD
□   ANESTHESIA USED:         □     HEMATOMA BLOCK                  □   DIGITAL BLOCK          □   LOCAL ANESTHESIA

□ ARTHROCENTESIS PROCEDURE
□ ARTHROCENTESIS PROCEDURE mentioned as a treatment option
□ ARTHROCENTESIS OFFERED □ PATIENT DECLINES □ ACCEPTS                    □ WANTS TO WAIT AND MAYBE DO IT MUCH LATER
□ PATIENT COUNSELED ON THE PROCEDURE, RISKS, BENEFITS, AND POSSIBLE COMPLICATIONS, POST PROCEDURE COURSE
□ STERILE PREP AND TECHNIQUE
□ Ethyl Chloride Freezing Spray
BODY PART: □ R □ L □ Knee joint □ Subacromial Bursa □ AC Joint □ Elbow lateral epicondyle □ Hip GT bursa □ Ankle joint
 □ Ganglion cyst__________________ Tendon sheath:_________________________    □ Other: _________
□ Triamcinolone: □ 80mg □ 40mg Other:_____________
□ Bethamethasone: □ 6mg □ 3mg, Other:_____________
□ Standard mixture: □ YES □ NO Explain;
□ Supartz injection done today □ #1 □ #2 □ #3 □ #4 □ #5
□ Sodium Hyaluronate 25mg/2.5ml Standard mixture: □YES □NO Explain;
□ SEE DICTATED PROCEDURE NOTE AND COUNSELING NOTE IN MEDICAL RECORD.
______%RELIEF FROM INJECTION
      DEGREES FLEXION JW SH RP JV                              DR.L      OTHER:____    (MAY BE COMPLETED BY ORTHOPEDIC TECHNICIAN)

COMPLETED BY:                                                          STEVEN B. LARSON, M.D.            DATE:              2012
Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11
              AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                  Follow Up Visit
PAGE 3 of 7
PATIENT NAME:_____________________________MR#_______ DATE:____________-2012
                                                         TO BE COMPLETED BY DR. LARSON ONLY

□ YES   RADIOLOGY REPORT AMERICAN ORTHOPEDICS AND SPORTS MEDICINE:
#1 DATE OF STUDY: ____________/2012
RADIOGRAPHIC TECHNIQUE: □ LEFT               □ RIGHT                              VIEWS: □ 1 view □ 2 views     □ 3 views    □ 4 views
□AP □LAT      □Oblique □Laurin □Sunrise [Standing AP views of knees: □ Bilateral □ Unilateral ] □Scapula view □Axillary □Carpal Tunnel View OTHER:
FINDINGS: □ NORMAL □ Type 2 Acromion                                                                                                                 ______
□ ACCEPTABLE ALIGNMENT
Heterotopic bone growing back: □ No □ Yes    Infection seen: □ No □ Yes

IMPRESSION: (See Dr. Larson Dictation      □ YES)   □ NORMAL       □ EPOF □ Type 2 Acromion

□ ACCEPTABLE ALIGNMENT
_____________________________STEVEN B. LARSON, M.D.


#2 DATE OF STUDY: ____________/2012
RADIOGRAPHIC TECHNIQUE: □ LEFT               □ RIGHT                              VIEWS: □ 1 view □ 2 views     □ 3 views    □ 4 views
□AP □LAT      □Oblique □Laurin □Sunrise [Standing AP views of knees: □ Bilateral □ Unilateral ] □Scapula view □Axillary □Carpal Tunnel View OTHER:
FINDINGS: □ NORMAL □ Type 2 Acromion


IMPRESSION: (See Dr. Larson Dictation      □ YES)   □ NORMAL       □ EPOF □ Type 2 Acromion


_____________________________STEVEN B. LARSON, M.D.


#3 DATE OF STUDY: ____________/2012
RADIOGRAPHIC TECHNIQUE: □ LEFT               □ RIGHT                              VIEWS: □ 1 view □ 2 views     □ 3 views    □ 4 views
□AP □LAT      □Oblique □Laurin □Sunrise [Standing AP views of knees: □ Bilateral □ Unilateral ] □Scapula view □Axillary □Carpal Tunnel View OTHER:
FINDINGS: □ NORMAL □ Type 2 Acromion


IMPRESSION: (See Dr. Larson Dictation      □ YES)   □ NORMAL       □ EPOF □ Type 2 Acromion


_____________________________STEVEN B. LARSON, M.D.




□ NEW SPECIAL STUDIES or X-RAYS VISUALIZED/REVIEWED ( □ YES or THIRD RADIOLOGY REPORT FOR AOSM)? :

DATE:                     /2012    □ Portland Med Ctr □ Goodlettsville □ Skyline MC □ HMC □ SRMC □ Other:
STUDY: □ XR □ MRI □ EMG/NCV □ BDT: □ CT SCAN
TECHNIQUE: □ L □ R _________ ____ □ 1 view □ 2 views □ 3 views □ 4 views □ AP,LAT □ Oblique □ Laurin                          □ Laurin/Lat
□ Bilateral Standing AP views of knees □ Standing AP views of pelvis □ Scapula view
□ Study images visualized and reviewed by Dr. Larson
Radiologist report available: □ YES(See Radiologist report) □ N0, , Agree with Radiologist Report: □ YES □ NO
FINDINGS: □ NORMAL                                                                                                                   ___________


___________________________________________________________________________________________________________________________
IMPRESSION: □ NORMAL □ EPOF
__________________________Steven B. Larson, M.D,


□ YES OLD RADIOGRAPHS/STUDIES VISUALIZED AND REVIEWED: STUDY: XR MRI EMG/NCVDATE:
Radiologist report available: □YES □N0 Study visualized /reviewed by Dr. Larson: □YES □NO Agree with Radiologist Report: □YES □NO

□ L □ R BODY PART: _________ ____ IMPRESSION: □ NORMAL □ EPOF                           _____________________                            _______________


COMPLETED BY:                                                   STEVEN B. LARSON, M.D.           DATE:                      2012
Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11
              AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                  Follow Up Visit
PAGE 4 of 7
PATIENT NAME:_____________________________MR#_______ DATE:____________-2012
                                                         TO BE COMPLETED BY DR. LARSON ONLY

□ YES NEW CONSULT REVIEWED:                    TYPE:______                   __________ DOCTOR:___________                    __
RECOMMENDATIONS:         □ See consult in med records:
□ YES   NEW LAB TEST/S REVIEWED: Test/ Date collected/ Result:________________________________________________________
___________________________________________________________________________________________________________________________________

ASSESSMENT                    DOING WELL:          □ YES □ BETTER □              UNCHANGED            □ WORSE           □ OTHER:____________
DIAGNOSIS:         R     L 1.
                   R     L   2.
                   R     L   3.
                   R     L   4.
                   R     L   5.
                   R     L   6.
                   R     L   7.
                   R     L   8.
      Pt on □ Coumadin or □ Plavix □ Pain management pt □ Functional Overlay □ Non-compliant □ Other ___________
PLAN
PATIENT RECEIVED COUNSELING ON:
□ DIAGNOSIS and TREATMENT PLAN
□ MRI results □ Test results □ Recommendations from consultant □ Special Studies Results:_____________________ □ Pathology Reports □ Other:________
□ Patient Education Brochure for diagnosis has been discussed with patient and given to patient. Name on Brochure: ______________________
□ PATIENT COUNSELED ON TREATMENT OPTIONS, □ NON-OPERATIVE AND □ OPERATIVE,
□ INJECTION THERAPY.
□ RECOMMENDED TREATMENT PLAN AND PROGNOSIS DISCUSSED WITH PATIENT.
□ NON COMPLIANCE COUNSELING: Patient has been counseled that if non-compliance with my instructions occurs, then a worsening of the patient’s condition or an
adverse outcome could occur. □ Possible leading to a need for surgery □ Possible leading to additional treatment.
□ PAIN MANAGEMENT, ACTIVITY MODIFICATION, TO AVOID ACTIVITY WHICH INCREASES PAIN. COMMENTS:
□ ACTIVITY LEVEL, COMMENTS:
□ WEIGHT BEARING ON AFFECTED EXTREMITY:                         □ WBAT □ NWB □ TWB □ Non-Painful WB                   □ PARTIAL WB______LBS □ FULL
□ FRACTURE: NO SURGERY OR REDUCTION NEEDED AT THIS TIME FOR FRACTURE, BUT IF FRACTURE DISPLACES SIGNIFICANTLY, REDUCTION
OR SURGERY MAY BE NEEDED.
□ NO SURGERY NEEDED, PATIENT COUNSELED ON REASONS WHY
□ SURGERY: COUNSELED THAT IF CONDITION WORSENS, MANIPULATION OR SURGERY MAY BE NEEDED LATER.
□ SURGERY NOT RECOMMENDED AT THIS TIME, BUT IS AN OPTION IF NON-OPERATIVE TREATMENT IS UNSATISFACTORY
□ SURGERY: PATIENT COUNSELED FOR SURGERY, NATURE OF, POST OP COURSE,
□ SURGERY OFFERED,              □ PATIENT DECLINED AT THIS TIME □ PATIENT ACCEPTS SURGERY                              □ WANTS SURGERY LATER
□ WOUND CARE AND DRESSING CHANGES, □ QD dressing changes □ B.I.D. dressing changes                          □ Wet to Dry
□ SMOKING: CESSATION OF SMOKING TO IMPROVE FRACTURE HEALING, NICOTINE PATCH, POSSIBLE DELAYED/NON-UNION
□ WEIGHT LOSS: THE PATIENT WAS COUNSELED ON THE BENEFITS OF WEIGHT LOSS
□ PATIENT COUNSELED ON USING ANTIBIOTICS BEFORE DENTAL PROCEDURE, AFTER TOTAL JOINT REPLACEMENT
□ MRI: INDICATIONS AND NEED FOR MRI FOR FURTHER EVALUATION TO DETERMINE DIAGNOSES.
□   OTHER:

THERAPIES:
□   START Phys Therapy (SEE WRITTEN CONSULT)                   □ START HAND THERAPY ( SEE WRITTEN CONSULT)
□   CONTINUE Physical therapy ________WEEKS                   □ CONTINUE HAND THERAPY ________WEEKS
□   Continue PT exercises at home                              □ Continue Hand Tx exercises at home
□   CONTINUE HOME PT                                           □ CONTINUE HOME HAND TX
□   Discontinue Physical therapy                               □ Discontinue Hand Therapy
□   BACK TO WORK REHABILITATION PROGRAM
□   Therapy Exercises per Dr. Larson instructions, Comments if any:
□   PATIENT DECLINED PHYSICAL THERAPY OR HAND THERAPY AFTER COUNSELING ON THE BENEFITS OF SUCH THERAPY
□   PHYSICAL THERAPY CONSIDERED, NONE NEEDED

□ DURATION OF NEW THERAPY: □ 6 weeks             □ 12 weeks   □ OTHER: _____ weeks
□ START OTHER THERAPY:__________
□ CONT OTHER THERAPY:______________
□ DISCONTINUE OTHER THERAPY:



___________________ COMPLETED BY STEVEN B. LARSON, M.D.                                                         DATE: ______________/2012
Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11
               AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                      Follow Up Visit
Page 5 of 7
 PATIENT NAME:_____________________________MR#_______ DATE:____________-2012

 PLAN – continued.:
CASTING ORDERED:
□ CAST RECOMMENDED FOR TX, PATIENT DECLINES
□ Discontinue current: □ cast □ splint
□ SPLINT: TYPE: __________________________________________
□ NEW CAST ORDERED,TYPE: □ SAC □ SACwTS □ SACwFS_________ □ LAC □ SLWC with Cast Shoe □ OTHER:_____________________
       WEAR CAST FOR _______ WEEKS, THE EXPECTED DURATION OF CASTING.
□ CASTING PROCEDURE COMPLETED, REFER TO DICTATION IN MEDICAL RECORDS. INCLUDES COUNSELING ON TX OPTIONS AND CAST CARE
□ PATIENT COUNSELED ON CAST CARE, COMMENTS:
□ CAST CARE, RETURN TO CLINIC IF ANY PROBLEMS WITH CAST, KEEP CAST CLEAN, DRY, INTACT, ELEVATE PRN SWELLING
□ PATIENT COUNSELED TO WALK FLAT-FOOTED IN WALKING CAST, NOT IN A ROLLING MANNER.
□ NEW SPLINT FIBERGLASS/PLASTER ____Volar Wrist ___Post Elbow ____Short Leg : OTHER TYPE:___________________________
□ CONTINUE CURRENT:             □ Cast □ Splint      □ ALWAYS □ WHEN AMBULATING □ PRN □ Until next visit. Type:____                    ____

BRACING ORDERED:
□ Buddy Tape Toes: ______________________
□ Buddy Tape Fingers: ______________________
□ BRACE OFFERED TO PATIENT AS TX OPTION, PATIENT DECLINES
□ Patient told to bring current brace to next office visit. □ Patient did not bring brace today.
□ BRACE RECOMMENDED FOR TX, PATIENT DECLINES
□ Discontinue current:         □ brace
□ NEW BRACE ORDERED               R    L    □ SHOULDER □ KNEE □ IMMOBILIZER                      □ WRIST □ CAM WALKER, □ Ankle AIR SPLINT
        □ Thumb Spica Wrist Brace □ Gel Flex Wrist Brace □ Neoprene Thumb Brace □ Universal Knee Brace □ Lace-up Ankle Brace
        □ SEE SUPER BILL SHEET □ OTHER____________
□ PATIENT ALREADY HAS BRACE, TYPE:
□ WEAR BRACE AS NEEDED FOR COMFORT, FOR PAIN MANAGEMENT, TO DECREASE PAIN AS NEEDED. TYPE:
□ WEAR BRACE FOR ______WEEKS, THEN AFTERWARDS AS NEEDED FOR PAIN MANAGEMENT
□ CONTINUE CURRENT: □ Brace               □ ALWAYS □ WHEN AMBULATING □ PRN □ Until next visit. Type:____ ____


► I, (PRINT PATIENT’S NAME)                                 HAVE RECEIVED A
□ BRACE   □ Cane □ Quad Cane □ Crutches □ Walker- no wheels □ Walker with wheels □ Cast Shoe
FROM AMERICAN ORTHOPEDICS AND SPORTS MEDICINE. THE BRACE/DEVICE HAS BEEN FITTED AND
ADJUSTED FOR ME. I HAVE BEEN INSTRUCTED ON PROPER USE OF THE BRACE AND POSSIBLE
COMPLICATIONS FROM BRACE USE. If my insurance doesn’t pay for the brace, then I realize that I might have to
pay.
(SIGNATURE OF PATIENT)                                                                DATE BRACE RECEIVED:                                      /2012
Witnessed by (please circle):                 JW      SH RP            SL JV TK NB Other:________




PRESCRIPTION GIVEN FOR:
□ ARCH SUPPORTS
□ WHEELCHAIR (is medically necessary)
□ OTHER:
□ Need Authorization for Brace from Insurance Company. Patient will be called when brace authorization received to make appointment to come in for brace fitting, counseling
for brace use, and to pick up brace.




___________________ COMPLETED BY STEVEN B. LARSON, M.D.                                        DATE: _________2012

Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11
               AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                     Follow Up Visit
PAGE 6 of 7

PATIENT NAME:_____________________________MR#_______ DATE:____________-2012
                                                           TO BE COMPLETED BY DR. LARSON ONLY
Rx MEDICINES:
□   NONE
□    Discontinue Previous Prescription: __________________________
□    Discontinue current NSAID one week prior to surgery: _________________________
□   Prescription meds considered, none needed
□   Patient requesting me to prescribe narcotic pain medicines instead of non-narcotic pain medicines
□   No narcotic pain medicines recommended by me, but may continue narcotic pain management as previously prescribed by PCP if patient and PCP desire
□   Continue prescription already prescribed from a previous provider. DR.______________RX Med: ____________________________
□   Continue prescription already prescribed from Dr. Larson. RX Med:
□   PATIENT DECLINES OFFER OF RECOMMENDED PRESCRIPTION MEDICINE AFTER COUNSELING
□   PATIENT DECLINES OFFER OF PRESCRIPTION PAIN MEDICINE AFTER COUNSELING
□   Call if refill needed, continue previously ordered RX
□   Patient instructed to take Over the Counter Analgesics: ______Tylenol ______NSAIDs             (Aleve, Advil, Ibuprofen)
□   PLAVIX Patient on – No NSAID’s will be given
□   COUMADIN (WARFARIN) Patient on. – No NSAID’s will be given

NEW MEDICINES PRESCRIBED BY DR. LARSON TODAY (AUTHORIZED TO BE DISPENSED #___)

#____ HYDROCODONE/APAP □ 10/325mg □ 7.5/325mg □ 5/325mg SIG: □ One or two tabs po            □ q4-6HOURS □ Q6HOURS REFILL#____
#____OXYCODONE       □ 10/325mg □ 7.5/325mg □ 5/325/mg       SIG: □ One or two tabs po       □ q4-6HOURS □ Q6HOURS Refills - none
#____MEPERIDINE      □ 50mg                                  SIG: □ One or two tabs po       □ Q4-6hours      □ Q6hours     Refills - none
#____DICLOFENAC □ 75mg □ 100mg         SIG: one tab PO BID □ PRN pain □ x6weeks, then afterwards PRN pain REFILLS#_____
#____CELEBREX    □ 200mg SIG: one caps PO BID □ PRN pain □ x6weeks, then afterwards PRN pain Samples Disp.#______    REFILL#__
#    LUNESTA   □ 2 mg □ 3 mg SIG: one tab po qHS PRN insomnia                                                            REFILLS#
#____NAPROXEN □ 375mg □ 500mg SIG: □ ONE TAB PO BID □ ONE TAB PO TID □ PRN pain                                   □ x6weeks, then afterwards PRN pain Refill#____
#_____IBUPROFEN□ 800mg SIG: one tab PO TID □ PRN pain              □ x6weeks, then afterwards PRN pain              REFILLS#_____
#____MELOXICAM □ 15mg SIG: one tab PO QD □ 7.5mg PO BID □ PRN pain             □ x6weeks, then afterwards PRN pain REFILLS#_____
#____ETODOLAC □ 300mg □ 400mg □ 500mg SIG: one tab BID PO □ PRN pain □ x6weeks, then afterwards PRN pain REFILLS#_____
#____TRAMADOL □ 50mg SIG: one tab PO Q4-6H PRN Pain                              REFILLS#_____
#____FLEXERIL   □ 10mg SIG: one tab PO three times a day PRN muscle spasm                              REFILLS#_____
#____PHENARGAN 25MG SIG: One or two tabs po q6 hours PRN Nausea Refills#_______
#____CEPHALEXIN □ 500mg □ 250mg SIG: One caps po QID                         Refills#_____
#____VOLTAREN GEL 1%, Apply □ 2 gms (Upper body) or □ 4 gms (Lower body) to affected painful area QID as directed REF #_____
#____PENNSAID DROPS Apply _____ drops to painful area _______________________________ REF #_____                       ____ Sample given

#____OTHER#2 _______________________________________________                                    _________________REFILLS#_____
□ Continue pain management as per Patient’s Pain Management Clinic Provider.
□ Glucosamine, 1500mg/day in divided doses with Chondroitin 1200mg/day in divided doses, Over the Counter, for joint cartilage health            _
□ Aspercreme over-the-counter, apply topically QID on affected painful area as directed, or Pain Bust R II cream
□ Patient given sample analgesic cream to try on affected body part: □ Aspercreme □ Pain Buster □ Capsaicin          □ Muscle Rub Cream   □ Ben Gay Other:_________
□ Previous prescription not helping, patient wants to discontinue previous Rx and try new medicine.
□ Patient developed adverse drug reaction to previous Rx, □ Nausea □ itching □ Rash □ Other:
□ RX PATIENT COUNSELED ON DOSAGE, FREQUENCY, ROUTE, INDICATIONS, REFILLS, POSSIBLE SIDE EFFECTS.
□   Patient offered pain management referral: □ YES, referral written □ NO, patient declined
□   Patient told to stop □ Plavix or □ Coumadin        one week before surgery Other Plavix or Coumadin instructions:___________________________
□   Rx written for Supartz (Na Hyaluronate) 25mg/2.5cc. Disp# 5 doses     □ Rx written for Supartz -Need Authorization from insurance company
□   Rx written for Synvisc One (Hylan GF-20)                              □ Rx written for Synvisc -Need Authorization from insurance company


□ NEW CERTIFICATE OF PROFESSIONAL CARE COMPLETED AND GIVEN TO PATIENT, PT COUNSELED ON RESTRICTIONS (SEE CERTIFICATE
FOR WRITTEN RESTRICTIONS)and RETURN TO WORK/SCHOOL.
□ Continue previous restrictions.
□ Military Profile written
□ DECLINED Certificate of Professional Care (work or school restrictions) by Patient or Parent




___________________ COMPLETED BY STEVEN B. LARSON, M.D.                                       DATE: _________2012



Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11
                AMERICAN ORTHOPEDICS & SPORTS MEDICINE, PLC
                                                                          Follow Up Visit
PAGE 7 of 7
PATIENT NAME:_____________________________MR#_______ DATE:____________-2012
                                                                TO BE COMPLETED BY DR. LARSON ONLY

PLAN – continued.:
PATIENT TO RTC: ____DAYS ____WEEKS ____MONTHS                                        □ PRN       □ AFTER TEST.           □ AFTER CONSULT
RTC DATE:___________ /2012                  □ After Brace Approved □ When brace arrives, bill patient when brace picked up
□ ASAP for New Problem evaluation □ PRE OP H&P                         □ POST OP              □ SURGERY DATE SCHEDULED: ____________/2012
□ NEW PROBLEM: □ R □ L
□ DIFFERENT PROBLEM: □ R □ L
□ Patient counseled to return to clinic sooner if any significant worsening in patient’s conditions occurs or patient wants to change the treatment plan.
RADIOGRAPHIC STUDIES ON RETURN TO CLINIC:
□   NONE
□   NO X-RAYS, PATIENT IS IN A SKILLED NURSING FACILITY___________________________________
□   Check with Dr. Larson first when patient returns back to clinic.
□   ORDER X-RAYS BELOW ONLY IF PATIENT STILL HAVING PAIN.
□   ORDER X-RAYS BELOW ONLY IF PATIENT REPORTS DOING WORSE.
□   ORDER X-RAYS BELOW ONLY IF PATIENT NOT HEALING AS EXPECTED OR NOT BETTER.
□   ORDER X-RAYS BELOW ONLY IF MORE THAN □ 3 MONTHS                       □ 6 MONTHS      ___ MONTHS
□   SHOULDER □ L □ R 3 VIEWS - AXILLARY, AP OF AC JOINT, OUTLET VIEWS
□   SHOULDER □ L □ R             2 VIEWS - INTERNAL AND EXTERNAL ROTATION VIEWS
□   SHOULDER □ L        □ R 2 VIEWS - AP OF AC JOINT, SUPRASPINATUS OUTLET VIEW                      □ IN BRACE/ IMMOBILIZER
□   SCAPULA      □ L    □ R □ LATERAL SCAPULA VIEW                   □ IN BRACE/ IMMOBILIZER
□   ELBOW       □ L □ R □ 2 VIEWS                  □ OOC      □ IN CAST □ OOB □ IN BRACE              □ IN SPLINT □ OOS
□   WRIST        □ L □ R □3 VIEWS               □ 2 VIEWS □ AP □ LAT □ CTV □ OBLIQUE OOC                     IN CAST OOB     IN BRACE
□   HAND         □ L □ R □ 3 VIEWS               □ 2 VIEWS □ AP □ LAT □ CTV □ OBLIQUE OOC                    IN CAST OOB     IN BRACE
□   FOOT         □ L □R           □3 VIEWS      □ 2 VIEWS          OOC        IN CAST    OOB    IN BRACE
□   ANKLE        □ L □ R         □3 VIEWS        □ 2 VIEWS         OOC        IN CAST    OOB    IN BRACE
□   KNEE-3       □ L □ R         □ 3 VIEW(AP,LAT,LAURIN) □ 3 VIEWS(STANDING AP, LAT, LAURIN)
□   KNEE-2      □ L □ R          □ 2 VIEWS; □ AP/LAT □ LAT, LAURIN □ LAURIN, SUNRISE □ LAT, Unilateral Standing AP □OOC □ IN CAST □OOB
□   KNEE-B      □ BILATERAL STANDING AP OF KNEES
□   HIP            □ L     □ R       2 VIEWS(AP & LAT) 2VIEWS [□ LATERAL VIEW and (STANDING AP: □ UNILATERAL □ BILATERAL ) ]
□   ELBOW       □ L □R            2 VIEW – AP & LAT         □ IN CAST □ OOC         □ IN SPLINT    □ OOS
□   PRE-OP TOTAL JOINT WITH OSSIMETER                 □ LEFT □ RIGHT          AP/LAT VIEWS          □ KNEE □ HIP          □ SHOULDER
_____OTHER:___________________________________________________________________________________________
SPECIAL STUDIES/CONSULTS TO BE ORDERED:
□ NONE
□ EMG/NCV: □ DR: Acosta □ Dr. Cruz
□ BONE DENSITY TEST
□ MRI: □ Left □Right BODY PART: □ SHOULDER □ KNEE □ HIP □ ANKLE □ WRIST □ OTHER:________________
□ NEED MRI/CT IMAGES ON CD BY THE TIME PATIENT RETURNS BACK TO CLINIC.                                □ CD Reminder slip given
    After Dr. Larson has reviewed the MRI images and the radiologist’s report, final diagnosis will be made and the final recommendations for treatment.
□ Does patient have claustrophobia? □ Yes □ No Valium Rx written for claustrophobia □ Yes □ No
□ Metal in body not securely attached to bone? □ Yes □ No
□ MRI offered as diagnostic option, patient declined after counseling               □ MRI recommended, patient declines after counseling

□ NEW CONSULT: DR:________ _______ CONSULT SPECIALTY: _____________________ LOCATION:_____________
□ NEW CONSULT: DR:________ _______ CONSULT SPECIALTY: _____________________ LOCATION:_____________
□ Consult offered as diagnostic option, patient declined after counseling □ Consult recommended, patient declines after counseling.
□ OTHER:____________________________________
□ SCHEDULE PRE-OP H&P, SURGERY:                          Surgery:_________________________________________________
□ See pre-op order sheet for procedure                          _________________________________________________
□ Patient told to bring Rx list for next visit, Pre op H & P

SPECIAL PATIENT INSTRUCTIONS/PLAN COMMENTS:
□   NEED PRE-OP H & P WHEN PATIENT RETURNS TO CLINIC FROM PREVIOUS SURGERY.
□   Supartz next visit: □ #1 □#2              □ #3 □ #4           □ #5
□   Cortisone Arthrocentesis to be considered at next visit, if still having pain.
□   MRI to be considered next visit, if not better after physical therapy and NSAID’s.
□   NEW YELLOW SHEETS (ALLERGIES, SOCIAL, FAMILY, PAST MEDICAL HISTORY, REVIEW OF SYSTEMS) NEEDED ON RETURN TO CLINIC.
□   DOCTOR’S ORDERS FOR NURSING HOME/SNF GIVEN, SEE COPY IN MEDICAL RECORDS.
□   All of Patient’s questions answered. Pt appears to agree with and understand treatment plan and seems willing to comply with carrying out the treatment plan.

___________________ COMPLETED BY STEVEN B. LARSON, M.D.                                                                        DATE: _________2012
Please see AOSM Approved Abbreviation List for acronyms and abbreviations used in this medical record.

Created on: 03/03/12 15:11:00 A11/P11 - D:\Docstoc\Working\pdf\63b15fc7-d746-4b82-9a4f-2b3ca992cf19.doc
Last modified on: 11/04/12 15:11:52 A11/P11

								
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