DATE OF INJURY _______________ DATE OF SURGERY__________
DIAGNOSIS/HISTORY______________________________________________
THERAPY BEGIN DATE___________ FREQUENCY/DURATION___________
DATE OF NEXT SCHEDULED OFFICE VISIT______________
_AROM ______________ _AAROM _____________ _PROM/JOINT MOBILIZATION __________
_PERCUSSIVE DESENSITIZATION _FRICTION MASSAGE _SENSORY REEDUCATION
_WOUND CARE
_REMOVE POSTOP DRESSING
_WHIRLPOOL
_REMOVE REMAINING SUTURES AFTER _____ WEEKS POSTOP
_DEBRIDE WOUND AT THERAPIST'S DISCRETION
_EDEMA CONTROL _SILICONE SHEET SCAR DRESSING _ELASTOMER MOLD SCAR DRESSING
_ADL _JOBST MEASUREMENT _ARTHRITIS PROGRAM
_RSD / STRESS LOADING PROGRAM
SPLINT FABRICATION
_I _M _R _S MALLET
_I _M _R _S PIP RINGS: ALLOW FLEXION, BLOCK EXTENSION PAST _______ O
_I _M _R _S HAND BASED PROTECTIVE POSITION (MP@80O, IP'S@0O)
_I _M _R _S DISTAL PHALANX PROTECTIVE AQUAPLAST CAP, DIP FREE
_I _M _R _S HAND BASED ANTICLAW (MP 60 DEGREES, IP JOINTS FREE)
_WRIST 30 DEGREE DORSIFLEXION SPLINT
_HAND BASED ABDUCTION THUMB SPICA, LEAVE IP FREE
_FOREARM BASED THUMB SPICA, IP FREE, ALLOW PENCILGRIP
_3 FOREARM STRAP WITH 2 Dia X « Thick FELT DISK OVER ECRB
_NIGHTTIME SOFT ELBOW FLEXION BLOCK SPLINT
_CYLINDER SPONGE PEN/PENCIL BUILDUP
MODALITIES
_HOT/COLD PACK _FLUIDOTHERAPY _WHIRLPOOL _ULTRASOUND/PHONOPHORESIS _EMG BIOFEEDBACK _TENS _FUNCTIONAL ELECTRICAL STIM OF __________________
_ADDITIONAL MODALITIES AT THERAPIST'S DISCRETION
_ COMPLEXITY OF PROBLEM REQUIRES TREATMENT BY A CERTIFIED HAND THERAPIST
PLEASE CONTACT ME IMMEDIATELY
IF THERE ARE ANY QUESTIONS REGARDING THIS PRESCRIPTION
IF THE PATIENT DOES NOT FOLLOW THERAPY GUIDELINES
IF THIS IS A WORKER'S COMPENSATION CASE, NOTIFY THE ADJUSTOR IMMEDIATELY
IF THE PATIENT DOES NOT FOLLOW THERAPY GUIDELINES
IF THE PATIENT DOES NOT COME TO SCHEDULED APPOINTMENT FOR ANY REASON