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Whether you’re a physical therapist documenting a shoulder evaluation, an occupational therapist assessing hand function, or a physician examining lower back pain, this comprehensive guide will equip you with the knowledge and tools to create effective soap notes for musculoskeletal assessments. This is a great resource for learning how to code and bill a visit. He reports the pain right on top of the knee, that feels deep and worse after he has been sitting
He denies any trauma or recent injury It contains a health summary page for a detailed history and plenty of space to write exam findings in addition to the somatic dysfunction table He has been gardening, but now must stop because he has difficulty being on his knees
He takes motrin occasional ly for pain and it seems to help.
We evaluated his knees that show bilateral knee arthritis, right greater than the left The patient has had injections for these in the past and is requesting another. This example demonstrates a comprehensive orthopedic soap note that includes all the essential elements while focusing on the specific needs of an orthopedic patient. 2) on examination, the patient has limited range of motion, strength, and functional mobility of the left knee
She requires assistance with transfers and ambulation. Knee pain seek immediate medical attention if you develop any chest pain, shortness of breath, severe leg or calf pain, or swelling Refer to physical therapy, to evaluate and treat (friedberg & d’hemecourt, 2024). We had done a knee scope on him several years ago
His exam today shows him walking without any ambulatory aid
He has got a cane at home, but he is reticent to use it He has significantly diminished hip motion, in rotation especially, compared to the right He can flex up to about 100 degrees He can get full extension.
Patient’s knees appear swollen, they are also tender to touch Limited range of motion in both knees There is an audible click heard when patient performs the mcmurray maneuver Healthcare professionals face documentation challenges daily, from selecting appropriate formats (soap notes vs
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