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Pt ID
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Pt ID assign auth
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Organization EOC unique ID
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Federal employer tax ID Organization
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Name Facility
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Date of first visit
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{mm/dd/yyyy}
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Provider First name
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Provider Last name
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National provider ID:ID:Pt:Provider:Nom:
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Provider role
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Diagnosis.primary:Imp:Pt:^Patient:Nom:
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Dx.secondary
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Movement system dx
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Primary health cond
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Other health condition
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Body function ICF code
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Body structure ICF code
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Activities and participation ICF code
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Clinical presentation status
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Medication documentation status
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Prescriptions
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Prognosis for rehabilitation
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Glob meas of phys function Pnl APTA
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Condition-spec function Pnl APTA
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Self-care and mobility Pnl APTA
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PT goals Pnl
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Planned intervention or services Pnl
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Intervention or services provided pnl
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Billing info pnl
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Planned interv +or serv dur time frame
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wk
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Instructions provided
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PT goal
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Planned interv +or serv dur visits
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{#}
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Airway clearance technique perf
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PT goal attain dur - time frame
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wk
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PT goal attain dur - visits
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{#}
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Planned interv +or serv visit freq
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Assistive technology prov
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Biophysical agent used
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Instructions plan
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Functional training perf
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Airway clearance technique plan
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Integ repair protect technique
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Assistive technology plan
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Manual therapy technique used
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Biophysical agent plan
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Motor function training perf
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Functional training plan
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Integ repair protect technique plan
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Ther exercise perf
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Manual therapy technique plan
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Other intervention or service provided
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Motor function training plan
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Reason for referral:Find:Pt:^Patient:Nar:
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Ther exercise plan
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Other intervention or service plan
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