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Home My WebLink About07-1512! % IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM 4800 A Charles Road Mechanicsburg, PA 17050 KULSOOM ASLAM 4800 A Charles Road Mechanicsburg, PA 17050 Plaintiff(s) & Address(es) No. 0^1 - Civil Action - (XX) Law ( ) Equity EDWARD M. SAVAGE 22 Cherokee Drive Mechanicsburg, PA 17050 Defendant(s) & Address(es) PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue A Writ of Summons in the above-captioned action. X Writ of Summons Shall be issued and forwarded to ( )Attorney ( heriff W. Scott Henning. Esquire 1300 Linglestown Road Harrisburg, PA 17108 Signature of Attorney (717) 238-2000 Supreme Court ID NoV3298 Name/Address/Telephone No. of Attorney Date: March 14. 2007 versus it ? WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT(S): YOU ARE NOTIFIED COMMENCED AN ACTION AGAINST YOU. THAT THE ABOVE-NAMED PLAINTIFF(S) HAS/HAVE Prothonotary Date: cy-?^j by Deputy ( ) Check here if reverse is used for additional information PROTHON. - 55 ?- c f e ? rIJ w ? ? fT ? ?_J ?j rwte- _ i a w IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, V. EDWARD M. SAVAGE, Defendant. CIVIL DIVISION NO. 07-1512 PRAECIPE FOR APPEARANCE (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 GUTHRIE and SKEEL, L.L.P. Firm #911 SUMMERS, McDONNELL, HUDOCK, 1017 Mumma Road, Suite 300 Lemoyne, PA 17043 (717) 901-5916 #15441 II IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. (Jury Trial Demanded) PRAECIPE FOR APPEARANCE TO: THE PROTHONOTARY Kindly enter the Appearance of the undersigned, Kevin D. Rauch, Esquire, of the law firm of Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P., on behalf of the Defendant, Edward M. Savage, in the above case. JURY TRIAL DEMANDED Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, 4L.P. By: vin D. Rauch, Esquire unsel for Defendant CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing PRAECIPE FOR APPEARANCE has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 2ND day of May, 2007. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By: Ketin D. Rauch, Esquire Counsel for Defendant .-?_i 1y ?_ Y x??? 5 s W ? {?. _3 yi `? ? '? .,-y,+ _ ../;_? ?? 46 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, CIVIL DIVISION NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. PRAECIPE FOR RULE TO FILE COMPLAINT (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, L.L.P. Firm #911 1017 Mumma Road, Suite 300 Lemoyne, PA 17043 (717) 901-5916 #15441 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. (Jury Trial Demanded) PRAECIPE FOR RULE TO FILE COMPLAINT TO: The Prothonotary Kindly rule the Plaintiffs, Muhammad C. Aslam and Kulsoom Aslam, to file a Complaint in Civil Action within twenty (20) days. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By: 11!1!L/A M:? V-K D. Rauch, Esquire ounsel for Defendant 46 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing PRAECIPE FOR RULE TO FILE COMPLAINT has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 2"d day of May, 2007. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By:_ `jEf'WTw,--- Kevin D. Rauch, Esquire Counsel for Defendant 41. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. (Jury Trial Demanded) RULE AND NOW, this day of N?zj 2007, upon consideration of Defendant's Praecipe for Rule to File a Complaint, a Rule is hereby granted upon Plaintiffs to file a Complaint within twenty (20) days of service, or suffer judgment Non Pros. Rule issued this R-G (-day of _(,q. , 2007: Distribution to: W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P. 1017 Mumma Road, Suite 300 Lemoyne, PA 17043 r, tl- -n r-'- W ! ?C 4__ s 4 W. Scott Henning, Esquire I.D.#32298 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorney for Plaintiff Fax : (717) 233-3029 E-mail: Henning@HHRLaw.com MUHAMMAD C. ASLAM and KULSOOM ASLAM, his wife Plaintiffs V. EDWARD M. SAVAGE, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 07-1512 CIVIL ACTION - LAW NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyer Referral Service 4th Floor, Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 AVISO USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accibn dentro de los pr6ximos veinte (20) dias despu6s de la notificaci6n de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accibn como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reciamaci6n o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyer Referral Service 4th Floor, Cumberland County Courthouse Carlisle, PA 17013 (717) 240-6200 HANDLER, HENNING & ROSENBERG, LLP By: L'-- V I W. Scott Henning, Esq F:\WP Directories\AGR\Complaints\MVA\Rear End\Aslam, Muhammad - Complaint.wpd W. Scott Henning, Esquire I.D.#32298 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-20000 Fax: (717) 233-3029 E-mail: Henning@hhrlaw.com Attorney for Plaintiffs MUHAMMAD C. ASLAM and KULSOOM ASLAM his wife Plaintiffs V. EDWARD M. SAVAGE, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 07-1512 CIVIL ACTION - LAW COMPLAINT AND NOW, come the Plaintiffs, Muhammad C. Aslam and Kulsoom Aslam, by and through their attorneys, HANDLER, HENNING & ROSENBERG, LLP, by W. Scott Henning, Esq., who makes the within Complaint against the Defendant, Edward M. Savage, and aver as follows: 1. Plaintiff, Muhammad C. Aslam, is a competent adult individual currently residing at 4800 A Charles Road, Mechanicsburg, PA 17050. 2. Plaintiff, Kulsoom Aslam, is a competent adult individual currently residing at 4800 A Charles Road, Mechanicsburg, PA 17050. 3. Defendant, Edward M. Savage, is an adult individual currently residing at 22 Cherokee Drive, Mechanicsburg, PA 17050. 4. At all times material hereto, Plaintiff was insured under an automobile insurance policy with State Farm Insurance Company and was covered by the full-tort option. 5. At all times material hereto, there were no adverse weather or road conditions. 6. On or about April 16, 2005, Plaintiff, Muhammad Aslam, was lawfully operating his vehicle at the intersection of Trindle Road and Center Road in Mechanicsburg, Cumberland County, PA. 7. At approximately that same time and place, Defendant, Edward Savage, failed to operate his vehicle in a safe and lawful manner, and caused a collision with Plaintiffs vehicle suddenly and without warning. 8. As a direct and proximate result of the negligence of the Defendant, Edward Savage, Plaintiff, Muhammad Aslam sustained injuries as set forth more specifically below. COUNT I - NEGLIGENCE MUHAMMAD ASLAM v. EDWARD SAVAGE 9. Paragraphs 1-8 are incorporated herein as if fully set forth below. 10. The occurrence of the aforementioned collision and all the resultant injuries to Plaintiff, Muhammad Aslam, are the direct and proximate result of the negligence, carelessness, and/or recklessness of the Defendant, Edward Savage, generally and more specifically as set forth below: (a) In driving his vehicle in careless disregard for the safety of persons or property in violation of 75 C.S.A. § 3714; (b) In failing to keep a proper lookout for vehicles lawfully upon the 2 roadway; (c) In failing to be reasonably vigilant to observe the Plaintiff's vehicle lawfully upon the roadway; (d) In following another vehicle more closely than was reasonable and prudent, in violation of 75 Pa. C.S.A. § 3310(a); (e) In failing to properly regulate the speed of his vehicle so as to prevent a collision; (f) In failing to operate his vehicle in such a manner that would allow him to apply the brakes and stop before striking the Plaintiff's vehicle; (g) In failing to operate his vehicle at a speed at which he could stop within the assured clear distance ahead, in violation of 75 Pa. C.S.A. § 3361; (h) In failing to have sufficient control of his vehicle, which would have allowed the vehicle to be stopped before doing injury to any person or thing likely to arise under the circumstances; and (1) In failing to be continuously alert, in failing to perceive any warning of danger that was reasonably likely to exist, and in failing to have his vehicle under such control that injury to persons or property could be avoided. 11. As a direct and proximate result of the negligence of the Defendant, Edward Savage, Plaintiff, Muhammad Aslam, has suffered personal injuries, including, but not limited to, injuries to his back. 12. As a direct and proximate result of the negligence of the Defendant, Edward 3 M. Savage, Plaintiff, Muhammad Aslam, has undergone continuing medical care for aforesaid injuries. 13. As a direct and proximate result of the negligence of Defendant, Edward M. Savage, Plaintiff, Muhammad Aslam, has suffered a loss of income and will in the future continue to suffer a loss of income and/or earning capacity. 14. As a direct and proximate result of the negligence of Defendant, Edward M. Savage, Plaintiff, Muhammad Aslam, has suffered great physical pain, discomfort, and mental anguish, and he will continue to endure the same for an indefinite period of time in the future, to his great physical, emotional, and financial detriment and loss. 15. As a direct and proximate result of the negligence of Defendant, Edward M. Savage, Plaintiff, Muhammad Aslam, has been compelled, in order to effect a cure forthe aforesaid injuries, to spend money for medicine and/or medical attention, and will be required to spend money for the same purposes in the future, to his great detriment and loss. 16. As a direct and proximate result of the negligence of Defendant, Edward M. Savage, Plaintiff, Muhammad Aslam, has suffered a loss of life's pleasures, and he will continue to suffer the same in the future, to his great detriment and loss. 17. As a direct and proximate result of negligence of Defendant, Edward M. Savage, Plaintiff, Muhammad Aslam, has been, and will in the future be, hindered from attending to his daily duties and chores, to his great detriment, loss, humiliation, and embarrassment. 18. Plaintiff, Muhammad Aslam, believes and, therefore, avers that his injuries 4 are permanent and serious in nature. WHEREFORE, Plaintiff, Muhammad Aslam, seeks damages from Defendant, Edward M. Savage, in an amount in excess of the compulsory arbitration limits of Cumberland County, exclusive of interest and costs. COUNT II - LOSS OF CONSORTIUM KULSOOM ASLAM v. Edward M. Savage 19. Paragraphs 1-18 are incorporated herein as fully set forth below. 20. As a result of the negligence of the Defendant, Edward M. Savage, the Plaintiff, Kulsoom Aslam, has suffered a loss of consortium, society, and comfort from her husband, Muhammad Aslam, and she will continue to suffer a similar loss in the future. 21. As a result of the negligence of the Defendant, Edward M. Savage, the Plaintiff, Kulsoom Aslam, has been compelled, in order to effect a cure for her husband's injuries, to spend money for medicine and medical attention and will be required to spend money for the same purposes in the future, to her great detriment and loss. WHEREFORE, Plaintiff, Kulsoom Aslam, seeks damages from Defendant, Edward M. Savage, in an amount in excess of the compulsory arbitration limits of Cumberland County, exclusive of interest and costs. Respectfully submitted, HANDLER, HENNING &,gOSENBERG, LLP Date: 5 `,? By: W. Scott Henning, El I.D. No. 32298 1300 Linglestown Ro,- Harrisburg, PA 17110 (717) 238-2000 Attorney for Plaintiffs 5 VERIFICATION The undersigned hereby verifies that the statements in the foregoing document are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of this lawsuit. The language of the document is of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the document are that of counsel, I have relied upon my counsel in making this Verification. The undersigned also understands that the statements made therein are made subject to the penalties of 18 Pa. C.S. Section 4904, re ing to unsworn falsification to authorities. Muhammad C. Aslam Date: S _C) q_ HANDLER, HENNING & ROSENBERG, LLP W. Scott Henning, Esquire ID #32298 1300 Linglestown Road Harrisburg, PA 17110 717-238-2000 MUHAMMAD C. ASLAM and KULSOOM ASLAM, his wife Plaintiffs V. EDWARD M. SAVAGE, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 07-1512 CIVIL ACTION - LAW CERTIFICATE OF SERVICE On May 24, 2007,1 hereby certify that a true and correct copy of Plaintiffs' Complaint with Notice to Defend was served upon the following by depositing in US certified mail, return receipt requested: Kevin D. Rauch, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel, LLP 1017 Mumma Road Suite 300 Lemoyne, PA 17043 Date: May 24, 2007 Respectfully Submitted, HANDLER, NNIN I By: W. Scott Henning,! ERG, LLP C"f rNa P C c' A ' ' m t1F1 ?a? of IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, CIVIL DIVISION NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. TO: Plaintiffs You are hereby notified to file a written response to the enclosed Answer and New Matter within twenty (20) days from service hereof or judgment may be 9Atpre^air you. Suffigv6fe!Mcgonne1l, Hudock, Guthrie & Skeel, L.L.P. ANSWER AND NEW MATTER (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, L.L.P. Firm #911 1017 Mumma Road, Suite 300 Lemoyne, PA 17043 (717) 901-5916 #15441 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. (Jury Trial Demanded) EDWARD M. SAVAGE, Defendant. ANSWER AND NEW MATTER AND NOW, comes the Defendant, Edward M. Savage, by and through his counsel, Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P., and Kevin D. Rauch, Esquire, and files the following Answer and New Matter and in support thereof avers as follows: 1. After reasonable investigation, the Defendant has insufficient information as to the truth or falsity of said averments, therefore said averments are denied and strict proof thereof is demanded at the time of trial. 2. After reasonable investigation, the Defendant has insufficient information as to the truth or falsity of said averments, therefore said averments are denied and strict proof thereof is demanded at the time of trial. 3. Denied. To the contrary, Defendant, Edward M. Savage, is an adult individual currently residing at 222 Cherokee Drive, Mechanicsburg, Pennsylvania 17050. 4. After reasonable investigation, the Defendant has insufficient information as to the truth or falsity of said averments, therefore said averments are denied and strict proof thereof is demanded at the time of trial. 5. Admitted. 6. Paragraph 6 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 7. Paragraph 7 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 8. Paragraph 8 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. COUNT I - NEGLIGENCE MUHAMMAD ASLAM v. EDWARD SAVAGE 9. In response to paragraph 9, the Defendant reiterates and repeats all his responses in paragraphs 1 through 8 as if fully set forth at length herein. 10. Paragraph 10 and its subparts state legal conclusions to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 11. Paragraph 11 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 12. Paragraph 12 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 13. Paragraph 13 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 14. Paragraph 14 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 15. Paragraph 15 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 16. Paragraph 16 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 17. Paragraph 17 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 18. Paragraph 18 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. WHEREFORE, Defendant, Edward M. Savage, respectfully requests this Honorable Court enter judgment in his favor and against the Plaintiffs with costs and prejudice imposed. COUNT II - LOSS OF CONSORTIUM KULSOOM ASLAM v. EDWARD SAVAGE 19. In response to paragraph 19, the Defendant reiterates and repeats all his responses in paragraphs 1 through 18 as if fully set forth at length herein. 20. Paragraph 20 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. 21. Paragraph 21 states a legal conclusion to which no response is required. To the extent, however, that a response is deemed necessary, said averments are denied generally pursuant to Pa.R.C.P. 1029(d) and (e). Strict proof thereof is demanded at the time of trial. WHEREFORE, Defendant, Edward M. Savage, respectfully requests this Honorable Court enter judgment in his favor and against the Plaintiffs with costs and prejudice imposed. NEW MATTER 22. The motor vehicle accident in controversy is subject to the Pennsylvania Motor Vehicle Financial Responsibility Law and this Defendant asserts, as affirmative defenses, all rights, privileges and/or immunities accruing pursuant to said statute. 23. Some and/or all of Plaintiffs' claims for damages are items of economic detriment which are or could be compensable pursuant to either the Pennsylvania Motor Vehicle Financial Responsibility Law and/or other collateral sources and same may not be duplicated in the present lawsuit. 24. To the extent that the Plaintiffs have selected the limited tort option or are deemed to have selected the limited tort option then this Defendant sets forth the relevant provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law as a bar to the Plaintiffs' ability to recover non-economic damages. 25. This Defendant pleads any and all applicable statutes of limitation under Pennsylvania Law as a complete or partial bar to any recovery by Plaintiffs in this action. WHEREFORE, Defendant, Edward M. Savage, respectfully requests this Honorable Court enter judgment in his favor and against the Plaintiffs with costs and prejudice imposed. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.F1 By: n D: Rauch, Esquire nsel for Defendant VERIFICATION Defendant verifies that he is the Defendant in the foregoing action; that the foregoing ANSWER AND NEW MATTER is based upon information which he has furnished to his counsel and information which has been gathered by his counsel in the preparation of the lawsuit. The language of the ANSWER AND NEW MATTER is that of counsel and not of the Defendant. Defendant has read the ANSWER AND NEW MATTER and to the extent that the ANSWER AND NEW MATTER is based upon information which he has given to his counsel, it is true and correct to the best of his knowledge, information and belief. To the extent that the content of the ANSWER AND NEW MATTER is that of counsel, he has relied upon counsel in making this Affidavit. Defendant understands that false statements herein are made subject to the penalties of 18 Pa.C.S. §4904, relating to unsworn falsification to authorities. Date: Edward M. Savage #15441 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing ANSWER AND NEW MATTER has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this ---- day of June, 2007. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, ".P. By: (Cevin D. 'Rauch, Esquire Counsel for Defendant r-.3 W. Scott Henning, Esquire I . D.#32298 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorney for Plaintiff Fax: (717) 233-3029 E-mail: Henning@hhrlaw.com MUHAMMAD C. ASLAM and IN THE COURT OF COMMON PLEAS KULSOOM ASLAM CUMBERLAND COUNTY, PENNSYLVANIA his wife Plaintiffs V. NO. 07-1512 EDWARD M. SAVAGE, CIVIL ACTION - LAW Defendant PLAINTIFFS' REPLY TO NEW MATTER AND NOW, comes the Plaintiffs, Muhammad C. Aslam and Kulsoom Aslam, by and through their attorneys, HANDLER, HENNING & ROSENBERG. LLP, by W. Scott Henning, Esquire, and reply to Defendant's New Matter as follows: 22. Denied. The allegation set forth in Paragraph 22 is a conclusion of law to which no responsive pleading is required, however, to the extent that the Honorable Court deems a response necessary, the Plaintiffs acknowledge that they will be bound by any provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law that the Honorable Court deems properly applicable to the subject cause of action. 23. Denied. The allegation set forth in Paragraph 23 is a conclusion of law to which no responsive pleading is required, however, to the extent that the W Honorable Court deems a response necessary, the Plaintiffs acknowledge that they will be bound by any provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law or Collateral Source rules that the Honorable Court deems properly applicable to the subject cause of action. 24. Denied. The Plaintiffs selected the Full Tort option, and hence, the Defendant's allegation as set forth in Paragraph 24 is irrelevant. 25. Denied. The allegation set forth in Paragraph 25 is a conclusion of law to which no responsive pleading is required, however, to the extent that the Honorable Court deems a response necessary, it is denied that the Plaintiffs' claims may be barred in whole or in part by the applicable Statute of Limitations, and proof to the contrary is demanded at the trial in this matter. WHEREFORE, Plaintiffs, Muhammad C. Aslam and Kulsoom Aslam, respectfully request judgment to be entered against the Defendant, Edward M. Savage, for the relief set forth in their Complaint. Respectfully submitted, ? - /,?- DATE HANDLER, HENN & ROSENBERG, LLP W. Scott Henning, si I.D. #32298 1300 Linglestown Harrisburg, PA 17110 717-238-2000 Attorney for Plaintiffs 2 re MUHAMMAD C. ASLAM and IN THE COURT OF COMMON PLEAS KULSOOM ASLAM CUMBERLAND COUNTY, PENNSYLVANIA his wife Plaintiffs V. NO. 07-1512 EDWARD M. SAVAGE, CIVIL ACTION - LAW Defendant CERTIFICATE OF SERVICE On the 13th day of June, 2007, 1 hereby certify that a true and correct copy of Plaintiffs' Reply To New Matter was served upon the following by depositing in U.S. Mail; Kevin D. Rauch, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel, LLP 1017 Mumma Road Suite 300 Lemoyne, PA 17043 DATE Respectfully submitted, HANDLER, HENNI & ROSENBERG, LLP W. Scott Henning, Esi I.D. #32298 1300 Linglestown RJ Harrisburg, PA 17110 717-238-2000 Attorney for Plaintiffs VERIFICATION PURSUANT TO PA R.C.P. NO. 1024 (c) W. SCOTT HENNING, ESQUIRE, states that he is the attorney for the party filing the foregoing document; that he makes this affidavit as an attorney, because the party he represents lacks sufficient knowledge or information upon which to make a verification and/or because he has greater personal knowledge of the information and belief than that of the party for whom he makes this affidavit; and that he has sufficient knowledge or information and belief, based upon his investigation of the matters averred or denied in the foregoing document; and that this statement is made subject to the penalties of 18 Pa C.S. §4904 relating to unsworn falsification tg-.puthorities. Date: W. SCOTT HE IN & E QUIRE r C',' 1,77 %1 1 C - SHERIFF'S RETURN - REGULAR CASE NO: 2007-01512 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND ASLAM MUHAMMAD C ET AL VS SAVAGE EDWARD M KENNETH GOSSERT Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon SAVAGE EDWARD M the DEFENDANT , at 1720:00 HOURS, on the 22nd day of March at 22 CHEROKEE DRIVE MECHANICSBURG, PA 17050 by handing to EDWARD SAVAGE a true and attested copy of WRIT OF SUMMONS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Postage Surcharge 31 3G/a7 (?;_ 2007 So Answers: 18.00 11.52 .39 10.00 R. Thomas Kline .00 ,"'39.91 03/23/2007 HANDLER HENNING ROSENBERG Sworn and Subscibed to By: before me this day of A.D. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. MOTION TO COMPEL REIMBURSEMENT OF IME EDWARD M. SAVAGE, NO-SHOW FEE Defendant. (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, L.L.P. Firm #911 1017 Mumma Road, Suite 300 Lemoyne, PA 17043 (717) 901-5916 #15441 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. (Jury Trial Demanded) EDWARD M. SAVAGE, Defendant. MOTION TO COMPEL REIMBURSEMENT OF IME-NO SHOW FEE AND NOW, comes the Defendant, Edward M. Savage, by and through his counsel, Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P., and Kevin D. Rauch, Esquire, and files the following Motion to Compel Reimbursement of IME No-Show Fee and in support thereof avers as follows: 1. This matter arises out of a motor vehicle accident which occurred on April 16, 2005. 2. As a result of the accident, the Plaintiff filed a Complaint sounding in negligence asserting claims for personal injuries. 3. As the Plaintiff has placed his physical condition in controversy, the Defendant scheduled an Independent Medical Examination pursuant to Pennsylvania Rule of Civil Procedure 4010. 4. On May 8, 2008, Defendant's counsel informed Plaintiffs' counsel that an examination of his client had been scheduled with Walter C. Peppelman, Jr., D.O., of the Pennsylvania Spine Institute for Thursday, August 14, 2008. A true and correct copy of the correspondence between the parties dated May 8, 2008, is attached hereto as Exhibit "A." 5. Also enclosed in the May 8, 2008, letter was Dr. Peppelman's rescheduling and cancellation policy, which indicated a $500 fee would be charged if Mr. Aslam failed to attend the examination. A true and correct copy of Dr. Peppelman's scheduling policy is attached hereto as Exhibit "B." 6. At no time did the Plaintiff or Plaintiffs counsel object to the examination or the medical examiner's cancellation policy even though they were both aware of the possibility of being responsible for any fees for nonattendance. 7. On July 29, 2008, Defendant's counsel forwarded a letter to Plaintiffs counsel reminding the Plaintiff of the Independent Medical Examination. A true and correct copy of the correspondence between the parties dated July 29, 2008, is attached hereto as Exhibit "C." 8. The Plaintiff failed to attend his August 14, 2008, examination with Dr. Peppelman. As a result, the Defendant incurred a no-show fee of $500 in accordance with Dr. Peppelman's cancellation policy. A true and correct copy of Dr. Peppelman's invoice is attached hereto as Exhibit "D." 9. On September 2, 2008, Defendant's counsel forwarded a letter to Plaintiffs' counsel requesting reimbursement of the $500 no-show fee. A true and correct copy of the correspondence between the parties dated September 2, 2008, is attached hereto as Exhibit "E." 10. Defendant's counsel again requested reimbursement on October 17, 2008; however, to date, the Defendant has yet to receive any response from Plaintiffs' counsel. 11. Accordingly, pursuant to Pennsylvania Rule of Civil Procedure 4019, the Defendant respectfully requests this Honorable Court to enter an Order directing Plaintiffs' counsel to reimburse Defendant's counsel $500 for the no-show fee associated with the failed attendance of Muhammad Aslam. 12. Public policy dictates requiring the Plaintiff to pay the $500 no-show fee. If the Plaintiff is not required to pay the fee, then a Plaintiff can unfairly drive up litigation costs. 13. Counsel for Defendant certifies that he has attempted to contact with Plaintiffs' counsel as set forth above to resolve this dispute. Despite such attempts by Defendant's counsel, Plaintiffs' counsel has yet to reimburse Defendant's counsel. 14. Counsel for Defendant certifies that no Judge has ruled upon any other issue in the same or related matter. 15. Opposing counsel does not concur in this motion. WHEREFORE, Defendant, Edward M. Savage, respectfully requests this Honorable Court enter an Order compelling Plaintiffs' counsel to reimburse Defendant's counsel $500. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By: Kevin D. Rauch, Esquire Counsel for Defendant May 8, 2008 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Aslam v. Savage Our File No. 15441 Dear Mr. Henning: Please be advised that I have scheduled an Independent Medical Examination of your client. This examination will take place on Thursday, August 14, 2008, at 2:15 p.m. with Walter C. Peppelman, Jr., D.O., of the Pennsylvania Spine Institute, which is located at 805 Sir Thomas Court, Harrisburg, Pennsylvania 17109. Enclosed please find Dr. Peppelman's [ME policy. Kindly note his rescheduling, cancellation, and no-show provisions. Should your client fail to comply with these provisions, you will be responsible for the penalty fees associated with the same. Should you have any questions or concerns regarding the above, please feel free to contact me. Thank you. Very truly yours, Seth T. Black STB:Iat Enclosure PENNSYLVANIA SPINE INSTITUTE 7 ..i?J.. Walter C. Peppelman Jr., D.C., FACOS William J. Beutler, M.D., FRCS To Whom It May Concern: All Independent Medical Examinations/Impairment Rating Examinations to be scheduled for Walter C. Peppelman, D.O., Pennsylvania Spine Institute, will require a pre-pavineat at the current rate of $1,200.00. If medical records :received for review are over 2" (two inches), there will be an additional charge of $500.00. The payment is to be received 48 business hours in advance for the scheduled IME/IRE. Effective July 1, 2005, a no-show fee of $500.00 will be withheld if the patient fails to arrive for their appointment and a fee of $500.00 will also be withheld if a 48 hour cancellation notice is not received. Our office policy is not to allow Audio taping during an Independent Medical Examination. ou for Your this matter. Sincerely, Walter C. Peppelman, D.O. Patient Appointment Tax ID#: 23-2189809 805 Sir Thomas Court - Harrisburg, FA 17109 • (717) 540-3993 9 Fax (717) 652-2630, www.paspineinstitute.com July 29, 2008 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Aslam v. Savage Our File No. 15441 Dear Mr. Henning: Please allow this letter to serve as a reminder of your client's upcoming Independent Medical Examination in the above-referenced matter. This examination will take place on Thursday, August 14, 2008, at 2:15 p.m. with Walter C. Peppelman, Jr., D.O., of the Pennsylvania Spine Institute, which is located at 805 Sir Thomas Court, Harrisburg, Pennsylvania 17109. 1 previously provided you with Dr. Peppelman's IME policy. Should your client fail to comply with his rescheduling, cancellation, and/or no- show provisions, you will be responsible for the penalty fees associated with the same. Should you have any questions or concerns regarding the above, please feel free to contact me. Thank you. Very truly yours, Seth T. Black STB:Iat 28/08 -.per: .7-.H ski i_ N IDN GROUP IRS # 232189809 ASLAM, MOHZ timKT'D 4800 A CHARLES ROAD MECHANICSBURG,PA 17050 .. . Statement THE ARLINGTON GROUP PO Box 6507 805 SIR THOM HARRISBURG, PP. 17112 Tel: "717/652--9015 Acct: 10110437-1. /TM 201627033 Pat : AsLAM,NOHV'JMAD 02/05/47 Tel: 717/555-5555 Page: J_ Da`CG Diag Ref C.P.T Qt Procedure Pl Prv Amt Sal ------------- 08/73/08 0 ---------- 99456 ---- 1 ------------------------ WORK/MED DISABILITY I ---- IM -- O ---- WP ----------- 1200.00 ------- 0.00 1)8113/08 IMEP IME PAYMENT 0 WP -1200.00 STATE FARM 113251339) 08/18/08 RCNS REMOVE CHARGE NO SHOW O WP -1-200.00 08/18/08 CTPT CREDIT TRANSFER PATIE 0 WP 1200.00 08/14/08 0 170 1 NO SHOW IM 0 TN7P 500.00 500.00 08/20/08 0 99456 1 WORK/MED DISABILITY I IM O WP 1 .200.00 0.00 11/20/08 IME 08/18/08 CRFkv' CREDIT FORWARD O WP -1200.00 FROM 081308 IME Next appointment: 11120108 1:45p DR PEPPELMAN HBG OFFICE Regular Balance: $ 500.00 September 2, 2008 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Aslam v. Savage Our File No. 15441 Dear Mr. Henning: Enclosed please find an invoice in the amount of $500 for the fees associated with your client's missed IME appointment. Kindly forward payment in the amount of $500 to my office at your earliest convenience. Should you have any questions or concerns regarding the above, please feel free to contact me. Thank you. Very truly yours, Seth T. Black STB:Iat Enclosure CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing MOTION TO COMPEL REIMBURSEMENT OF IME NO-SHOW FEE has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 4th day of November, 2008. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By: Z?? cvz' Kevin D. Rauch, Esquire Counsel for Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, CIVIL DIVISION NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. AND NOW, TO WIT, this (Jury Trial Demanded) ORDER day of 2008, it is hereby ORDERED, ADJUDGED, and DECREED that counsel for Plaintiff, Muhammad Aslam, shall provide counsel for Defendant, Edward Savage, $500 for reimbursement of the no- show fee for the Independent Medical Examination of Muhammad Aslam within thirty (30) days of this Order. Distribution to: BY THE COURT: Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Skeel, L.L.P. 1017 Mumma Road, Suite 300 Lemoyne, PA 17043 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 J. ?,7 _= _ ) " 7? '.. •--4 ?} R ..., r". rvv MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs vs. EDWARD M. SAVAGE, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-1512 CIVIL : JURY TRIAL DEMANDED IN RE: DEFENDANT'S MOTION TO COMPEL REIMBURSEMENT OF IME-NO SHOW FEE ORDER AND NOW, this iy day of November, 2008, a brief argument on the defendant's motion to compel is set for Thursday, December 4, 2008, at 2:30 p.m. in Courtroom Number 4, Cumberland County Courthouse, Carlisle, PA. ?" . Scott Henning, Esquire For the Plaintiffs evin D. Rauch, Esquire For the Defendant : rlm y BY THE COURT, S ???? ?? 4?????? a "? ?`° ?, ,`? ?,? -??: MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs VS. EDWARD M. SAVAGE, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-1512 CIVIL JURY TRIAL DEMANDED IN RE: DEFENDANT'S MOTION TO COMPEL REIMBURSEMENT OF IME-NO SHOW FEE ORDER AND NOW, this q0 day of December, 2008, the defendant's motion to compel reimbursement of IME-No Show fee is DENIED. BY THE COURT, W. ZScott Henning, Esquire For the Plaintiffs /Seth T. Black, Esquire For the Defendant :rlm 04 t?E r» 7 t l c? I __.l.1?1 Kevin Al 'Hess, J. ?? :g wv S- 331 WZ A3i?+vvd 3Ni ?0 MUHAMMAD C. ASLAM and IN THE COURT OF COMMON PLEAS OF KULSOOM ASLAM, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs, NO. 0 7 - 1512 20 v. EDWARD M. SAVAGE, Defendant. RULE 1312-1 The Petition for Appointment of Arbitrators shall be substantially in the Following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Kevin D. Rauch , counsel for the defendant in the above action (or actions), respectfully represents that: 1. The above-captioned action (or actions) is (are) at issue. 2. The claim of plaintiff in the action is $ The counterclaim of the defendant in the action is 0 The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: None WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respectfully submitted, ie,- D 4"e-- ORDER OF COURT AND NOW, petition, Esq., and captioned action (or actions) as prayed for. 200 , in consideration of the foregoing Esq., and _ Esq., are appointed arbitrators in the above By the Court, EDGAR B. BAYLEY Fl LED-C, 11-TIC, E OF THEE PRCTHI-I OTARY 1009 JUN 10 P 1: 3 0 CtlFrOB *a4.oo Po A'rT`f C A& ai 58 Rr* aal.5i s MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, V. EDWARD M. SAVAGE, Defendant. RULE 1312-1, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA The Petition for Appointment of Arbitrators shall be substantially in the Following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Kevin D. Rauch , counsel for the defendant in the above action (or actions), respectfully represents that: 1. The above-captioned action (or actions) is (are) at issue. 2. The claim of plaintiff in the action is $ The counterclaim of the defendant in the action is p The following attorneys are interested in the case(s) as counsel or are otherwise disqualified to sit as arbitrators: None WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respectfully submitted?,? NO. 07 - 1512 20 ORDER OF COURT AND NOW, petition, Esq., and captioned action (or actions) as prayed for. , 200____, in consideration of the foregoing Esq., and Esq., are appointed arbitrators in the above By the Court, EDGAR B. BAYLEY n tol CLA# qjo -4A QAtao CU lft-vv? t t OF THE PROTHONOTARY 2009 JUN 10 Pfd 1: 30 cur, ' .. "' NTY FLP,;P 3?1..VANIsA. F1LE? f3 ?Y 20(19 JU?'1 6 ?t P? 2= E-,; ' k. a.4.00 Po A 1 ar JIS& A44-/ Its . aac.s?g 6 40, K..? o y{ q, y y .. rA b? r?71 . M IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, V. EDWARD M. SAVAGE, Defendant. CIVIL DIVISION NO. 07-1512 JOINT STIPULATION (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, L.L.P. Firm #911 100 Sterling parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #15441 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, V. NO. 07-1512 EDWARD M. SAVAGE, Defendant. CIVIL DIVISION (Jury Trial Demanded) JOINT STIPULATION AND NOW, come the Plaintiffs, Muhammad C. Aslam and Kulsoom Aslam, by and through their counsel, W. Scott Henning, Esquire, and the Defendant, Edward M. Savage, by and through his counsel, Kevin D. Rauch, Esquire, and do hereby stipulate and agree as follows: 1. The parties have agreed to compulsory arbitration of this matter. 2. This matter may be listed for arbitration by the Prothonotary upon receipt of a Petition for Appointment of Arbitrators from either party. HANDLER, HENNING & ROSENBERG, LLP BY W. Sc nnii Counsel for Pla 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By: ire Kevin D. Rauch, squire Counsel for Defendant 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing JOINT STIPULATION has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this day of , 2009. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, L.L.P. By; Kevin D. Rauch, Esquire Counsel for Defendant '71 cz, 7 Z: r7 ??_ ,.sue IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, CIVIL DIVISION NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. MOTION TO COMPEL AFFIDAVIT (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, P.C. Firm #911 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #15441 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, V. EDWARD M. SAVAGE, Defendant. CIVIL DIVISION NO. 07-1512 (Jury Trial Demanded) MOTION TO COMPEL AFFIDAVIT AND NOW, comes the Defendant, Edward M. Savage, by and through his counsel, Summers, McDonnell, Hudock, Guthrie & Skeel, P.C., and Kevin D. Rauch, Esquire, and files the following Motion to Compel Affidavit and in support thereof avers as follows: 1. This matter arises out of a motor vehicle accident which occurred on April 16, 2005. 2. As a result of the accident, the Plaintiffs filed a Complaint sounding in negligence asserting claims for personal injuries. 3. The Complaint was pled in excess of the compulsory arbitration limits. 4. On April 23, 2009, Defendant's counsel suggested a trial date during the September 21, 2009, Civil Trial Term. 5. On May 13, 2009, Plaintiffs' counsel suggested compulsory arbitration. A true and correct copy of the correspondence between the parties dated May 13, 2009, is attached hereto as Exhibit "A." 6. Defendant's counsel had no objection to compulsory arbitration and proceeding with filing an executed Joint Stipulation referring this matter to compulsory arbitration. 7. The Joint Stipulation was filed with the Prothonotary on July 16, 2007. 8. Shortly thereafter, the Honorable Edgar B. Bayley requested that the Plaintiffs file an Affidavit indicating that they are only seeking damages within the compulsory arbitration limits. 9. On July 27, 2009, August 25, 2009, and September 25, 2009, Defendant's counsel requested that Plaintiffs' counsel file the requested Affidavit and advised that a Motion to Compel the same would be filed with the court. A true and correct copy of the letters dated July 27, 2009, August 25, 2009, and September 25, 2009, are attached hereto as Exhibit "B." 10. Despite these attempts, the Affidavit has yet to be filed. 11. Counsel for Defendant certifies that he has attempted to contact with Plaintiffs' counsel as set forth above to resolve this dispute. Despite such attempts by Defendant's counsel, the Affidavit has yet to be filed. 12. Opposing counsel does not concur in this motion. WHEREFORE, Defendant, Edward M. Savage, respectfully requests this Honorable Court enter an Order compelling Plaintiffs' counsel to file the Affidavit requested or enter an Order referring this matter to Arbitration. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. By. D-Z Kevin D. Rauch, Esquire Counsel for Defendant II dlar, nning& osanbarg,«P ATTORNEYS AT LAW May 13, 2009 Seth T. Black, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel, LLP 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 RE: Muhammad C. Aslam v. Edward M. Savage 07-1512 Dear Seth: W. Scott Henning Henning@hhrlaw.com I acknowledge receipt of your recent communication inquiring about listing this case for the September Jury Trial Term in Cumberland County. In view of the nature and extent of the injury in this case, I believe the case may be better served by proceeding with Compulsory Arbitration. Please advise whether your client is agreeable with proceeding with Compulsory Arbitration. If so, I will proceed to prepare and file the necessary Praecipe. Very truly yours, I :S---q Lt I HANDLER, HENNING & ROSENBERG, LLP WSH/tgd cc: Muhammad C. Aslam B Y: -------------------- Handler, Henning & Rosenberg, LLP 1300 Linglestown Road, Harrisburg, PA 17110 Phone: 717-238-2000 * Fax 717-233-3029 * Toll Free 1-800-427-2224 www.hhriaw.com Carlisle Office 717-241-2244 * Lancaster Office 717-431-4000 * York Office 717-845-7800' Hanover Office 717-630-8200 July 27, 2009 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Aslam v. Savage Our File No. 15441 Dear Mr. Henning: I am in receipt of Judge Bailey's letter requiring that an Affidavit executed by your clients be filed with the court prior to this matter being scheduled for arbitration. Should your clients have a problem with this requirement, please advise me of the same. Otherwise, kindly file the Affidavit as soon as possible so that we may continue to move this matter forward. Should you have any questions or concerns, please feel free to contact me. Thank you. Very truly yours, Seth T. Black STB:Iat August 25, 2009 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Aslam v. Savage Our File No. 15441 Dear Mr. Henning: have yet to receive a copy of the Affidavit executed by your client as required by Judge Bailey in the above-referenced matter. Kindly file the same with the court so that this matter can be listed for arbitration. Should you have any questions or concerns, please do not hesitate to contact me. Thank you. Very truly yours, Seth T. Black STB:Iat September 25, 2009 W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Aslam v. Savage Our File No. 15441 Dear Mr. Henning: In review of my file it appears that you have yet to provide the Court with an Affidavit signed by your client so that this matter may proceed to arbitration. Kindly file the same within the next two weeks or I will be forced to file a Motion to Compel the same. If for any reason you need additional time to have the Stipulation executed, please do not hesitate to contact me. Should you have any questions or concerns, please do not hesitate to contact me. Thank you. Very truly yours, Seth T. Black STB:kan CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing MOTION TO COMPEL AFFIDAVIT has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 24th day of November, 2009. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. By: //_ Kevin D. Rauch, Esquire Counsel for Defendant TAPY 2009 NIGV 25 PIN 2: ?. 6 FILED- -ri""E (.7 TFF ,; , " 2010 JA;IN 2 7 Gtl l., . 21 r Lj IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. PETITION FOR APPOINTMENT OF ARBITRATORS EDWARD M. SAVAGE, Defendant. (Jury Trial Demanded) Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, P.C. Firm #911 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #15441 464d 3W17 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. (Jury Trial Demanded) EDWARD M. SAVAGE, Defendant. PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Kevin D. Rauch, Esquire, counsel for the Defendant in the above-referenced action respectfully requests that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiffs in this action is for personal injuries in an amount below the compulsory arbitration limits per the Joint Stipulation filed on or about July 15, 2009. 3. The following attorneys are interested in the case as counsel or otherwise disqualified to sit as arbitrators: None. WHEREFORE, your petitioner prays your Honorable Court to appoint three arbitrators to whom the case shall be submitted. Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. By: DL-. Kevin D. Rauch, Esquire Counsel for Defendant CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing PETITION FOR APPOINTMENT OF ARBITRATORS has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this day of 2010. W. Scott Henning, Esquire Handier, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. By: -.? Kevin D. Rauch, Esquire Counsel for Defendant I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiffs, CIVIL DIVISION NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. (Jury Trial Demanded) ORDER AND NOW, this day of , 2010, in consideration of the foregoing petition, Esquire, Esquire, and Esquire, are appointed arbitrators in the above- BY THE COURT: J. Distribution to: .'Kevin D. Rauch, Esquire Summers, McDonnell, Hudock, Guthrie & Skeel, P.C. 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 '/W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 ties evla t LCL -n t Ui captioned action as prayed tor. R ?? - - 2010 h,F'R' 29 hH 10 . 52 Ct r ; iT' W. Scott Henning Attorney ID# 32298 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Fax : (717) 233-3029 E-mail: Henning@hhriaw.com MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiff V. EDWARD M. SAVAGE, Defendant Attorney for Plaintiff(s) IN THE COURT OF COMMON PLEAS CUMBERLAND COUNT, PENNSYLVANIA NO. 07-1512 CIVIL ACTION - LAW PRAECIPE RE: PLAINTIFF'S ARBITRATION EXHIBITS PURSUANT TO Pa.R.C.P. No. 1305 In accordance with Pennsylvania Rule of Civil Procedure 1305(b), the following documents are attached which the Plaintiffs intend to introduce into evidence at the time of the arbitration of this case: 1. Medical Records from Holy Spirit Hospital dated 4/16/2005; 2. Medical Records from Gadani Associates dated 4/25/2005 through 11/29/2005, 3. Medical Records from Dr. Ljubisa M. Stankovic dated 8/19/2005 to 8/23/2005; 4. Medical Records from Orthopedic Institute of Pennsylvania dated 1/5/2006 through 3/9/2006; 5. Medical Records from Healthsouth dated 12/13/2006 through 8/17/2006. Respectfully Submitted, HANDLER, HENNING & ROSENBERG, LLP Date: April 26, 2010 By c -tt ';Q PnrL n I?3Vj W. colt Henning, Esq. W. Scott Henning Attorney IDS 32298 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorney for Plaintiff(s) Fax : (717) 233-3029 E-mail: Henning@hhrlaw.com Muhammad C. Aslam and Kulsoom Aslam IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff(s) V. : NO. 07-1512 : CIVIL ACTION - LAW Edward M. Savage Defendant(s) CERTIFICATE OF SERVICE On April 26, 2010, 1 hereby certify that a true and correct copy of Plaintiffs' Arbitration Exhibits was served upon the following by depositing same in the United States Mail, in Harrisburg, Pennsylvania: Seth T. Black, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel, LLP 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Dated: 4/26/10 HANDLER, HENNING & ROSENBERG, LLP V C t ncr I&V W. Scott Henning (elHctl P," f-lealth Syswrn Camp Hill, PA 17011 PATIENT FACESHEET MR #I SURGERY DATE .,I L b. ll I P NU SE STA. RGOMIBEU AQ T T TIME H ?PT E CLINIC 201-61-703; 04/16/DE 15:09 saca E ER3 FIN CLASS AGE DBIRTH RACE 5EY, MS CHURCH / R. PREF AMBULANCE ADM RE_, DATE I TIME BEG BY T 8 U<:/UE/1997 3 td 1d tJGIQr PER PT NOD73 PER PT ^O 614!16/fl `_S 15:05 AGORUS t I" #J° ASLF+M MUiIAMl1AD VENDI LEE CORP 4800A CHARLES RD I•IECHFd1ICSBTJRG, PA ;f{ 17050 MECKANIC_SBIJRG, PA UFO CODE PHOTOID X OCCUPATION ASLMd MURAIDI.IAD MI 4800A CHARLES RD VENDI LEE CORP 111ECH:014TCS5tJRG, PA H 17050 MECHADITC'SBURG, PA 717 - 612-9579 - ' RELATIONSHIP S 201-62-7033 ?. .,,'.;'' AKHTEF. . ABDIJM V tt# 307 KAY RD MEC;-LPdTICSBJRG, P', RELATIONSHIP 9 RELATIONSHIP{ a, ?Y11 HON1E PHONE 7:17 737-4375 HOME PHONE - f WORK PHONE WORK PHONE 'ODE M3J INS CO A(rro INSUR3c /u PLAN PLAN CODE INS CO C ;. 1 POLICY fl a 38 f , POLICY # GROUP W GROUP 4 AUTHORIZATION ii AUTHORIZATION JI ADDRESS 0,,n' ;TAT" °AP1.1 DP: C0NCORDV7LLE PA 1433° ADDRESS PHONE N VERIFIED PHONE P VERIFIED SUE NAME ASLAId , trU)1A1,1I4AC- MI Y SUB, NAME: MI (r. REL TO PT PRIORITY REL TO PT PRIORITY PLAN CODE INS CO PLAN CODE INS CO 1:-.. POLICY Ji POLICY JI ?1 f II GROUP N ?f: GROUP I? \l Ifi . A111"HORIZATION W ? Y AUTHORIZATION It ADDRESS ADDRESS C.. PHONE fl VERIFIED P) UNE 11 VERIFIE'D' STUB NAME MI j SUB. NAME M1 REL TO PT PRIORITY REL TO P PRIORITY J. .L :Fc}.. I ;i i' .:A ?.- t.. ?'f•., i'q t?. ,r .l ?...}i ? ea; ro: J? s>a•!` ( DESCRIPTION ACC. DATE / TIME / IND. PRIVACY NOTICE P'17)./7,EPT NEC:(, '-AA, L SaOULDER U4/16/0`_` 17:00 A 04162005 01 ER? AW; COMMENTS - 1 PF:G NONE PEI;. F 7 NIRIS ?L•'R P". . ADMTTTNNC> D);. ADMITTING DR. 1 ATTENDING DR REFERRING DR 80C2c" P.D GRp;JP 113GO18 ED GROUP ADMITTING COMPLAINT ' BROUGHT EIY: AMBULANCE SERVICE: // ?J.vi[,GF'T PIECI'. AND ABD, LEFT SHO[iLDL:R PiiIIJ (:U)??TI'd i J? 1,? ??tJ V-P -? ER MEDICAL RECORD PT=T 542213 2532777 ASLAM ,MUHAMMAD 58 M TRAGE ACUITY: 1 2 3 4 5 Flame: Made val: QALS' DBLS' ?MC D POLICE Log in: Aye PCP: le female m F wn none _, LKED C!VJ/C DCARRIEU DOTHER Primary Language: n list DHard of hearing 00ther Interpreter Triaga: Room N IP* CHIEF COMPLAINT I WHAT BROUGHT YOU tF! TODAY? - - (j/1,??1f^ __ /---- / Onset (Detc/rlmo for nccltlonr) . +rour ? ays t7vieeks I(f f HPI? ? 111 Pktpl'liDFiY::GI pt:`denies {lmn; 080 Assess tivi, if; sovenly o' frs w4l JunaW to o answer ?EaG LnC Lorali.7tion:_ inrensiry: 0 1 2 a s s E 9 to l '. : u..', % R. ` { ! ? natant iiniermittent + Frequency: C C1r acler: + P /min ?? HT, ' // g Dull ClBurning FlAche FiPressure i°I EManual V min GreOar-, Uirr gular 7, Oral jt?anir. Rectal Axillary -h ech asalll?ringl.Js dot-retractions expiratoty grunl ?audible wheezes 01! ul.r?INRB 302 iUmin I f. ..um.r.a Jstafect LThrubbing IRadiatindCltdorrrad+ating Rapid Triage Sign tut i RN Time Whal relieves pain? Owning Clrest 0011her. t p UAalyeifo raid 'rlSev tlP:: tiGo»dla?u U*sPfJ. Y PASIm CI, atfv?t. CJdt D. Cppparetlve Awake-Alert ri W-Person E+fYr' d-Place drienied•Time ?lAgltated 1Uncooperative (GVerbally AbusiveLGontbalivc ,Anxious JGry inq L7Coniused C :1y 0Appropriate words response t_1Gonsoiable, inappropriate words UPersislenl rnappr2prialo crying, scrsamh.g DMoans to pain arm :OryClNorm. Color In Intact (visible) L'Cool LJDiaphorelic TJAbmsior, DRash EHol 'JTenting -3Ecchymosis Ebufn Epale 5i'lushed Ol'unctum Wwnd =1Ashen EModied ELaceratirnt! Avulsion C;Cyanotic C.Jaundice aep UPink I Moist !]Pate ECyanofic ?Dry ECrackeo ClBbedlln j , 'Drda 0clontrolled DNat Conlrolied Localwn: A`, Exiramdy Extr unity coiar,LIWN! OMoriled CiCyanow. Skin Temp LIWarm C10ool Dislai Pulses'IPrescnll7Nol palp. Edema LlYes ENo Deformity UYes ::7 Nu Ecch mosisDYas - o AM WORM HI M G}1Nd': = +; PMH Checklist: UNale, as staled by patient 0unabie to obtain into due to severity o1 pl r ? gym. Alryvay ONasal 00rEd U Side: DPVL` JPE CCarcer I OA00M DlmrnunosuP-ressed OW f DGAD 0 HF CCOPD DSeizures DOOM ETransplan :JGardiac Sient4- 1411 DAslhma I7hyroid 7Depressron JLiver Disease f7CABG CICVA CSmoker n- Arthritis DDemenlia '_JGERD condilionrunable to answer ' Exposure to moo "chickenpox, or 1 TB in past rnontf ive - s Advanaad Direc ves? ?nn ? ;ar?' !Fi?n111.ait.Jbtt'%- Other: _ ., c, anacil tc• '=J d --c- - L/ri3irt !G?r 4o rlti?` •'; pe r Strryeries, / u , y '.- Suspected duct 7 Child abuse: Jye; (ilV s see nurses .aofeS! 1 Last Tetanus Dora A1RG1ES, :__11/ P' Childhood Immunizations is-ov: J mYwtlmtmb. DOOM i IC'0wr RVtI ,CJ$piigt.' '\ LATEX ALLERGY? _1Y No ?IIITD CNoi IJTD Ounknovan (c1 LMP itrl:?avr.; flHysternctorny nUst OPationl 13f amAy 1-.1EMS Dbowe=. (-?Dosages unknown C!lduoS unknown DICAT1 N DOSE MEDICATION DOSE MEDICATION DOSE 7 n TRIAGE INTERVENTIONS Efte ' Elevation ?IgPD O',ptirr. JOressing CO i(R NSIVE TRIAG OMPL j1 )Palm 1Soe Physician orde sheet 11C-CxrNar Masked ESecurihy notified ?t TRIAGE NOTES _ - _HN _ r ..nc rns4c RP7 sirna u. Doty Cniie signalure (d appfrsnhbt pH FiR ME TRIAGE DISPO!LURGI C ER Occu alional Health -- prnnn J' R!•r srUnarure! - TI I 2, - t ?.?:1•_ Holy Spirit Hospital Damp Hill. PA 17011 John R. niet, ECU Nursing Assessment r i?APT 0-0'i 1 .?L r ril r, 1.ST„ml , mlylillbU6411) 5? IV, ::'U]_-67.-703 02",06;=997 Is17 GROUP ER3 54 22i3 09%16/05 25327776 Initial Lab & X-Ra r drders: Labs ( ) Acetaminophen ( I DOAS [ ( Tnrombolyli- Labs ( j Acetone (SAGE-) J ESR ( 1 Toy. Screen ( ] Alcohol (ALCO) I ) Glucose I ) Urine Tox Screer [ ] Arrrylase/Lipase ( j HOGS I ) TSHR ( 1 APTT ) HIV ( ) TYpe8Cross - u of units ( 1 BBH ( ) Livar (BOR) I j Blood GUltures Prollle ( J Type h Screen f 1 Bf AP 1 1 Lyres f( UA: I J DIP I I DIAG. I J GBCP ( J Phonobarb I) Urine C A S ( 1 CfJP ( 1 PTP t I Urine HCG } 1 CRP1 ) Salicytate ( 1 WC Breath Alco'tost ( ] Digoxin I ) Theo ) WC Drup Scroon ( ) Dilanhn ( I Other. Afldioil i Y ( I Alod/CiWr. Series { ) K ] Ankle R L (i,.45 Spine J Clavicle R L ( 1 Mandible k1_6'.rv. Spine Rt. ( Lat . i 1 Nasal J j Chest Rtn. ; Port !' TPA ( ) Orbil P. L ( ( Elbow R L ( ) Pelvis ( ) Facial l 1 PYelogram IVP (] Femur R L ( J Ribs R L ( J Finger F. L ( 1 Shoulder R L ( } Foot R L ( ) Skull J Forearm R L I ) Sternum ( J Hand R L I) T/Spine ( ] Hip R L [ I Tib / Fib R L (] Humerus R L [ 1 Toe R L O Knee R L ( J Wns1 R L ( j Other: Time/CRT/Inl. REASON: Special Procedures: Ultrasound: CT : (W=With contract; WO=Wlthoui) ( J Abdomen I J Abdomen/Pelvis W WO ( J VQ Scan ( ) Duplex Dopplar J J Brain/Head W WO ( i Ecito- ( 1 Gallbladder I ) Chest W WO cardiogram 1 J Polvo l 1 Spiral chnst for PE Transvnginal ( 1Other: Tima/CRTAnt. _ REASON: S_peclmens/Cultures ( ) Bela Slier, AG Rapid ( ) Stool G & S t Cervical/Genital I I Stool 0& P 1 Chlamydia ( ) Stool G, Difticlle GC Glliture ( ) Triclronionnc I j Monospot (rapid) I J Wound G% S l 1 Sputum C S S ( J Other: Billing Classlficatlon; y PHYSICIAN CHARGE l:AC1LI1'i CHARGE ( ) Level I I I Level I ( )AceKlenl ' Level 11 - ( 1 Level II ( ) Medical J Level III ( I Level III t i Gase I Level IV J I_r'vnl IV ) E%iended 1-05 1 Lave! V ) Level V Holy Spirit Hospital Camp, Hill, PA John R Dietz Emergency Genie( Physician Order Sheet Cardiac Respiratory ( ) MonlW ( 1 ABG's ( 1 EKG ( 1 Poak Flows BatoreiAho, Resp Tr.. ( 1 02 umin. ( ) Roepiratory Tr.. ( 1 02 Saturation Medications / JV's / Additional Drders Dalorfime Data/Time/Int. IV: NSS/ D5W/ LR/ D51.45NS/ MgNS WO/KVD/infuse at mile/hr j ] Obtain old ,records ( J Td [ J Protocol initiated tor: -r / Z' Initials: Signature: Initials: Signature: RNlMA RN/MA Dictated: Half I I Completed [ ) CRITICAL CARE; hrs. Diagnostic lmprossion: Consulting/Adti?tting physipl, r .II II ? ?f JJ Signature: MD/D0 RNP Dnte.=1_ J_l /mil Time: c u t1; 25327776 G/Q`J 5421.3 C11/= -1 n-11 ur--v term wun: Appearance: ntal Status: fReupiratory: Gastrointestinal rA Trauma 0 N)A ' G er ra1: r ch: JNL oi l warm r norrnal conscious t?uncooperalivb }?a€yrlmofncal UDanies pain lsymptonts L lelitargic Ocombalive nd uniabared Oneusee ?diarrhea r ?1rail Upale cool ?loud I (]confused Oanxioub Olabored Uvomiting Uconsfipahorl I Jabrasion: Dobese Oflushad h I Uslurred ?emaaated Oc anolic d Z1 lkative y ry mumbling Ujaundiced Udiaphorelic ? ? Gail: ?motllsU Orash ?haby / q(t ormal ?abnormal UPHA U led lo: Uhysterical O SOB OHernalemesis ?laceralion_ Jcough person Rasp so Stimuli Last Btvl^ Uecchymosis,.A;7 Uproduchve r ppropdatc OQ2 L -- DAbdomen tender__,,_- Udeformay A J via 1usion-how Udelayed -dislendad Uh rm Gsofl Uburns sheel Ubleeding tt'.-M/W ef-4?1? . . n - . . Oedema Ue h r -- e na Neuro a NIA UPERL R L d i U GU! GYN A Car lovascular: Odenies sls dank pain L I R oChesl pain denim J tdoni(wed rhythm Sae ac le hea Osliff neck. Size, ?freauency ?Radiating: area nursing Assessment _ '.)fleck pain Pinpoint U O Ourgency Severity `110 Severity _00 'Jpacar Otauaidroop Dilated U 'J ODysuria Dconstant Osharp Uederne.-.`__•. umbness: Fixed J U I OMurnaturia )urethral discharge Dntermillent Cidull J Sluggish 7 ? Orelenlion Ovaginal discharge Oburning Qheavy U calf tenderness R-, l l non-reactive O J >6a OOlher Ovagmal bleeding MOB :Ipleurilt,. Jwarmth Oreoness ucapillary refill Uloley present.. fi Unon-radiating _.trarlmlinr4 t _ Onausea Urapul Udolayed - OB R?'. 10 , SENT O denias sls LINIA Completed by mime tocol Initialed. EKG done Labs done X-ray dons Pr Ey 5 cars Nose Throat lurred viei i R Acuity: LOPain UR Uconyeslion ]sore o OCall bell within reach OSlde rails up x2 OCompanlon with patient Udouble visio I R_I_ Odischarge Odralnage Odrooling DER procadure explained OPholophobia L I R Owith lenses Llepistaxix L ! R Odysphagia 14URSING ASSESSMENT! l RN 5ignzture: Time. IV Therapy (mndoion codes: O=no InkammsttonicomWicalion i=edema 2oerytherm 3=c-cchyrrpsis Medications a=paht 5=nardness e=Warmth 7=leaking Dote; AM SolvUOn Stze Site Rnle Allampls ' cond Initial Dale, Drug Route Site lrueal Response Time Turn ?-----? /f _. - Dales Notes Date; j Notes Time Time I v / i G ATUR -- y? --J y?I /` ^ ? ? "' J ?// _ ADMIT /DISCHARGE ! T NS??F ? ,-?-L? , ? , ? ?-( 'r ?'?i/l? -. - ? ?mbulalory Jwlc ; lamlaulance to.=?3?rcSme Unursinti home UAIv1A UOR. go instructions given to s? d t ienl ""I" Oparenl ?other: --- ----------- - -- --- -- ,.-_ ?tr fe rred larOcansenl si ed Uold records) nt (loot U d if{q eel done ' Ip!/S? -i ? scharge OArjr6ssion 023hr Obs Room# i JReporl called @_ to Rfd!tPIJ - -- Condilion `c _ t - l ove : p in sa e,. RN : czI f f-loly opir HOSpftal !L Camp Hill, PA 17011 i John R. Diet ECU ,SL?ll9 ; I'•1LT}i ???Il?ti_li r ? F' bl Patient Observation l Assessment 1 Notes 201-G-''033 02b1997 -nS Loo 911,1' 10 ` R ,, t.LV-, ED CROUP 542212 C'9/1E; 05 15327776 T" Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 '(717),763-2600 PATIENT: M R#: SOC SEC: ORD DR: PT TYPE: DOB: LOCATION ASLAM, MUHAMMAD 542213 201-62-7033 THERESA W ILLIAMS,CRNP/ M.D. E 02/06/1947 ER3- DICTATION DATE: Apr 16 2005 7:21 P TRANSCRIPTION DATE: Apr 16 2005 7:21 P ADM DATE: 04/16/2005 ARRIVAL DATE: 04/16/2005 HOSP SERVICE: ER3 ***Final Report*** EXAMINATIOW LIS SPINE 72110 -0411612005 .COMMENTS: Indication: MVA '&rvical spine: Upright examination shows no signs of fracture, dislocation, localized soft Tissue swelling. Moderate 174t?generative disc changes at C5-C6 with bilateral neural fomminal encroachment this level and to a lesser extent at C4-C5. `- `Z6mbosacral spine: There are 5 true lumbar vertebrae and without fracture, dislocation, spondviolysis or spondylolisthesis. is Severe degenerative disc changes at L5 1. Numerous calcified gallstones. L; CONCLUSION: IMPRESSION: No signs of acute traumatic injury. Degenerative changes as above. Gholelithiasre. DICTATED BY: DAVID GREENBERG M.D. I PSC DATE OF EXAM: 04/16/2005 ;'? IGNED BY: DAVID GREENBERG M.D. tATE/TIME: Apr 16 2005 7:21P A2 Imaging Services Consultation page 1 Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Darrip Hill, Pennsylvania. 17011 (717) 763-2600 PATIENT: M R#: SOC.. SEC: ORD DR: PT TYPE: DOB: LOCATION ASLAM, MUHAMMAD 542213 201-62-7033 THERESA WILLiAMS,CRIqP/ M.D. E 02/06/1947 ER3- DICTATION DATE: Apr '16 2005 7:21P TRANSCRIPTION DATE: Apr 16 2005 7:21P ADM DATE: 04!1612005 ARRIVAL DATE: 04/1612005 HOSP SERVICE: ER3 'Final Report*" EXAMINATION: CERVICAL. SPINE 72050 - 0411612005 COMMENTS, Indication: MVA ' E&c,al spine: U,prJbbt examination shows no signs of fracture, dislocation, localized soft tissue swelling. Moderate 11 generative disc changes at C5-C6 with bilateral neural foramina) encroachment this level and to a lesser extent at C4-C5• O t `-?t6mbosacral spine: There are 5 true lumbar vertebrae and withoul fracture, dislocation, spondylolysis or spondylolisthesis. r'T§7T vere degenerative disc changes at L5-S1. Numerous calcified gallstones. 1. .J?.'.CONCLUSION: IMPRESSION: No signs of acute traumatic injury. _ __..Degenerative changes as above. Cholelithiasis. jlj E??i•ii 1 I ? .3/ DICTATED BY: DAVID GREENBERG M.D. ! PSC h,TE OF EXAM:. 04/16/2005 '.;j,0NED BY: DAVID GREENBERG M.D. s FIAT IME: Apr'16 2005 7:21P imaging Services Consultation Page 1 1.1IN1KRGENC' Clan PF,R URGi CF:NTF;R DISCHAR(E INSTRU:CT.IONIS ?I )LY `;3'TR!T HOSPIT;\I, (7171 76i -2,310 (717) 701-2424 I'll, r"J.1111; n ,r.;i uaauneu: Vr r hr rer•. vl Ir. the I-,ntergcncs Cartcr navt hu:? rendered nn Is cnlere!a¢•, bn>t, only, emd are not itncnded to I, a ,uh:diun•. dr r ;ni rl';rn u, pros cowple t t ,dww :.:1 h puu LI-eiop I r,, pn 1 i:nr. ui c:nuphe:uioil Cnawct ynta phyeielan of Ihn Gwcrcencc C.ent-r. POLI ?)U' 7•ltG IN:tiTRUC11C1h;5 t'H[l FJ i t }.:i_ 7t','. Patient Information: Patient Information Sheets Contain Important Information to Review and Keep . I ) P.uconlinal pain Cornael abrasion ( 1 Headache (1 Pain Managamenl I hit-alerlou Miscarnr,l.le i Alcohol rna^-hon ! ! Crouproronchilis t 1 Head Injury .) Pediatric Head Injury ) oolhache i. ) Allergic reaction 1) C Mtch walking ( ) HypenensioiI 1 Pediatric URI i I.IRI and Cold:; l 1 Asll Irna ) Diarrhea arld VomilinnlPed. Vomiting !) IrnrnunizaliornTelanus O PID/STD n and F'yeiclnepI:,tits ) BWA pain ) Dislouauon O Kidney Sloes O Pneumonia V/nunrl Recheck )Rites-l lurn,an/Animal/In sno l DrudrAlcohol abuse/addiction ( I Lablynlhilis )Flash ! 2a H•. Pharmcuae::: Burn (1 I ot•rile. Convulsion 1 Laceration (1 Seizure C that 1 Cheat Pain ) Fevor/Ped. Fover ) Nock, Strain ) Sore Throat 1 High putasmurn containing loods I (;onlunclivnts I Flu ) Nuseblued ( ) Sprains and Strains _ __, ) GC)PD Fracture (! Otitis Media l) Suture Cara & Removal WOUND CARE MEDICATIONS . ) May gently wash over wound in 2z hours '.viih suap and ',eater or ( ) Continue present medications except: _ ^_ Per;Jx.ide. ! CIlamge dressing _ limes dally, Redress with BacilracinlNeosporin and sterile dressing or leave it open it advised. I ) Keep wound clean, dry ( ) covered 1 1 uncovered SPRAINS, STRAINS, BRUISES, FRACTURES 16ldvate tyre injured pan for _ days to reduce swelling. (-•)?Applb Ice packs intennlllenuy for ( flays to raduce swelling. j ;1,.;-( / l ) Ace wrap for support for_days I Wear splint I. ) Al all times unl)I tallow-up. (? For activity as needed. ( ) Use sling for support. ( 1 Use outcries l ) As needed, weight bearing as tolerated. )At all times. NO WEIGHT BEARING NECK/BACK ( ) Weal cervical collar for support for _--_,days. ( ) Rest, avoid bending, lifting, strenuous activily,(Or _ days. t. ).Apply moial heat ???r?_L1 !,?'"-' minutes ?J-times dally beginning in 1-- --I r- hours. ) ? " ?? ADDITIONAL INSTFIUCT16NS ( ? Encourage fluid intake l ) Clear liquid diet. Advance lu regular diet as tolerated I Off worktschool iron, to Return to work on I. J Licht Duo/ until: ?- Restrictions: ( ) No gym/sports until ( ) Follow' instructions on Workman's Compensation Form. ( ) Wear eye patch for hours. ? If nose bleed recurs. pinch nose: firmly lot 5 minutes continuously, return if bleeding not controlled. ( 1 The: prescribed anlibioticimedicatlon, may reduce the effectiveness of medication you are currently taking. Check package instructions or consult with Pharmacist. ) The interpretation of your' X-Ray:; are preliminary leading. Your filnlS will be reviewed by n radiologist. You or your Physician will be contacted if there is a change in the diagnosis. I I ( ) Use Advil (Ihuprolen) or Tylenol as needed for pa n, level according to package instructions for age and weight etc. ( 1 Use the following medicines according to package instruction.: 1: 2: 3'. ( ) The following medicines may cause drowalness: DO NOT DRIVE OR O RATE MACHINERY WHILE TAKING: The prescribed entlblotic/mecilcaIIon, may ieauce. the effectiveness of madication you are currently taking. Check packagz instructions or consull wilh Pharmacist. FOLLOW-UP Thls is our recommendation for follow-up, If your insurance (HMO) requires a physician referral for specialty consultation. IT IS UR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. ((, ollow-up with: ( ) U*-Center ( ) Occ. Health/Company Doctor (`)"Family Doctor or it) t t days for: (L),T=alloy/-up ( ) Suture removal l ) Take the lollowing test results to your physician ) CBC l ) CMP ( ) EKG ( ) X-RAY REPORT t. ) OTHERS IF YOU DO NOT HAVE A FAMILY. PHYSICIAN4 CALL 763-2900 FOR PHYSICIAN REFERRAL. ( ) Call as soon as possible for appointment ( ) Pick up your X-Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ( !See vour physician or specialist if not improved in _ days. (; Return to Emergency Center if you lse?,youi condition is worsening, especially If ) I n ei I ?!ll /c::1 _I r ,i. ? i t'' l? .i, ill( ,L\ ( ) `four blood preSSUre was eledated Check wills your physician. P, copy of your dictated Emngency Roorn Report is availoMa to your Physician iron) Modica( Records (7 6 3-2 1560), If riot already sent. Clinical Impressions: 1 heraby acknowledge; receipt of these instructions and understand them understand that I have had omeryency treatment only and that I may be released belore all of rrt), medical problems are known or treated. I will arrange for follow-Up care as I have beau krstluclod. II is my usponslbllty lu not( my Prnnary Care Phy.'Iclan II?JIIr visit, SIGNATURE: J !' v L/-. - 11 A-!' ?X-'? `l - PI- Iy?iiltitlthMji. O;CR(JP SIGNATURF:.y _-__ PAtki0 PrF)esporislM6 Pnruopy ,! Uatc (/PATIENT/.Rt`?(abNSIEILK t'E?-ON VIZRB"(ZES%l1NDERSTANJi11NG,, SIGNATURE' "? _ i / Alum, RN xu; HOLI'• SPIRIT HC)Sf'1TA1, ,TURN R, DIR'1.Z L'fY1HItGENC r' Cls1?'1'EFt ,;03 NORTH 21ST STELM' C'ANIV 111I.,L, 1 A 1701 1-2 288 (7.171'763.2310 Thomas Aldoiu. 1,1T) 01 M75F. r Julu) I'. Judeuu, MI ) 039"01 E Da,id 7.iouncrmw,. ;SID U0 636F. Susan Nliller, NP 51'0(176'41'. Salcalurr Allanu. IOD 0 550_'L' h'II) I'hthr. tblunnin. NIL) 01':4) 13[ __ FLtrbari .Suor)F_ NI' VPW-46l7li l:nntr5l; Attila, NID OIG7271- Pu,hpu Mudan. MD 051511_ Relitc Abelson, 1N1' vl'I, 1G910li --' ?eresa Williams, NP 3'1'(A)Ci126k Jon Duhim. DO 000991L Lmcieuuc Paul. PAD 0395^_41- Pant Darden. NP SP006LI66N NilJ:i Wallace, NJ' 31006 7 1 313 Am•, 1 aiardo. N•1D '1200;= Howard Rudnick. N4D 040h631 NJIa)ic Celli., N I' ^L' I;mc Weneei. NP M'005'1?7}; .. .... _..-? C .r. _,..., i..ir.3 ormiAirV6, 51HAINS, BRUISES, FRACTU-rS 6l4vate the injured pan lor_ days to reduce swelling. -)*Apply ice packs intermittently lorJ?ays to reduce swelling. ( ) Ace wrap for support for _ days. ( ) VJaar splint ( j 'Al all limes until follow-up. ( ) Fur activity as needed. ( ! Use sling lot support. ( ) Use crutches' i ) As needed. weight bearing as tolerated. I )At all times. NO WEIGHT BEARING NECK/BACK ( ) Wear cervical collar for support [or-days. ( ) R.?cl, avoid bending, Iiilrngg, strenuous acliv?ty for __ days. (tl-ripply moist heatrJ?r "1- minutes 1?I times daily y' beginning in _ r hours. j t? ADDITIONAL INSTRUCTI NS ( ! Encourage fluid intake C,•lear liquid Biel. Advance to regular diet a:, tolerated ( ) ON woNschool from', to ( 1 Roturn to work on _ f ) Light Duty until _ Restrictions: ( ) 110 gym/sports until ( ) Follow instruntions on Workmen's Compensation Form. O Went eye patch for hours. ( ) If nose bleed recurs, pinch nose firmly lot 5, minutes continuously, return if bleading not controlled. ( ) The prescribed antibiotic/medication, may reduce the effectiveness of medication you are currently taking. Check parkage instructions or consult with Pharmacist. ( ! The interpretation of your X-Rays are preliminary reading Your films will be reviewed by a radiologist. You or your Physician will be contacted if [here is a change in the diagnosis. I ( (.1(i % J "i 4' it 1 ( i ;? !?'"I i , ' I 2. s: f )The following rnedlelnes may cause drowsiness: DO NOT DRIVE OR OP!RATE MACHINERY WHILE TAKING The prescribed antiblotle/medi c ation, may reduce the effectiveness of medication you are currently taking. Check pacl(age instructions or consult with Pharmacist. FOLLOW-UP This Is our recorn mend ation for follow-up. II your insurance (HMO) requires s physician referral for specialty consultation. IT I YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. (()-Follow-up will): ( ) U)Wi Cenlar i ) Occ. Health./Company Doctor (`ID Family Doctor or . in ---days foe F4l-wo, -up Suture removal ( )Tai;a the lollowing less rrjau is to you[ piiyslcian: ( ) CBC (1 CMP I ) EKG ( ).A-RAY REPORT ! ) nTl-IERS IF YOU DO NOT HAVE A FAIAIL1'' PHYSICIAN CALL 763-2900 FOR PHYSICIAN REFERRAL. ( 1 Cell as soon as possible lot- appointment 1 Pick up your X-Hays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready, See yew physician or specialist if not improved in days, ( ) Relum to Emergency Center it you teel,youi condition is worsening, especially it 1 I I• I i }"' i. i tr `l ( ) Your blood pressure was ele> ated. Check with your physician. A copy of your dictated Emegeincy Room Report is available to your Physician from Medical Records (763-2660), it not already sent. Clinical Impressions: I hereby acknowledge receipt of these instructions and understand there. I understand that I have had emergency treatment on and that I may be released before all of my medical problems are known or treated. I will arrange for follow-up care as I have been instructed. 11 is my responsibility to noli my Primary Care Phy icijn if Isr visit. r ! f SIGNATURE: I-/ J. ;y_ _ ?R_• SIGNATURE: _ -')`_`. SIGNATURE: Pri rson;? DERSTANpING HOI.A' SPIRIT HOSPITAL JOHN R, WETZ ENTRRGFNC1' CENTER 503 NORTH 215'1' STREET CAW' HILL,, PA 170(1-2288 (717) 763.23 16 Thumas Aldous, MD 017075E r) - .lohn P. Judson, MD 0383686 David Ziuunernran, 1.1D 005636E i ! Susan (Miller, NP SP(N 17624fi Salvatow )\)fan(.-. NID 025,5021 . foil) 7 Philip Maguire, tJMD (J15063f. - 13tuhara Strong. NP VP(H)361 713 Raman, Arum, NID O1 4'7F, ' 1'uslgr., Muclarl, 1vID 051514L Rencc. Abclsou. NP VP006910D t- Y") Crew Williams. NP "fYlNl(il?(iH Ion Dublin, DO 0069911- ) Lawrence Paul. 191) 0:495241- Pont Darden, NP 91:101606(iR Nikki Wallace, NP TP00671811 rim', lal;ridu MI) 41119.12 Hnward Rudhhrl, 1.11) 0408ii 2l. Namlic Gillis, NP"' i lanc Wenger. NT' SP(X)592-1B Kmarz,na Fcu;uo, NID! 4179-s6F Raniana Sharma, NID 031265F. bl[c) Hat Nhklip.n Guucr. 111) 0167241, Christine Sheridan. IN-) O(19 i7 t licve anc 511001. Matlvy .less or. MD 0125_;31 - Alan 'I rpfis, ivlf) 03POI81 ltti nni NI' UPI. iV I I + r" ' f j I . DA ] F I S :iDC;l•i;ifLiltF ff?Y ? 1?%)i? .--.` ? ? )I I '---- ?) Af I) /P) OJN1?) i)I?i ? -( - r- . . ? _ ]tF.F1LL ' - Tll\9frti IN l)ROEN FOI? A URAN17 t: y,;yI"P. I'RODLCT 'fU 11E UISPEh'SF,1). lliC - PIU_Sr 81011, h111STI-IiilsD 1 I,I'IE'Hi:a,'VIJ MEI)Ir AI )J !:CCSSAR) IN TlIt! SPACG, NF rLS5:rR1t)lz "BRAND nLLr)w. (,I A :... ?,sL:>?rn , r1TTxhJ>Ify>1?r"", , ?h r1 201 6 2-'/Oi' 02;nr,i1997 n LA 1311 ?Si!L15'I'IT l'TIO?r I'LRht CiS1RI_C En GROUP E1'i3 54,2213 G11;'?5i'(T5 25377776 • a a m 9 D dl`s E : --- G --- ---- - ??i<<il Sins Wt._ CurrCiit IvICCL; 71 L1111i?y 1Ix uC: 7. ` DIvl/I [HP/CA Iiub (2 fast 114 o l'. >!/ UM/11131'H A I IL`I.:N.(. c_. v 1' n i Ivl - S/Juints? CNS C'lutn ?cd "I'c?dt?: Ci l J Syst? m ------------- - - UI Iwi; Other - Social I-Ix ul Ti? sts planned. 1 12. ZnvW cZ V)i 11 t) U ? ruo rj 4U)-0/(,,- ol (?,) I -La { F f?? r- ? GNIJANI 3 hady Lane Enola, PA J-7025 Mar 22 06 11:0Ga Prav Oadani 717732 31 P.2 Name: DA-rl? t t ; ?tt - - 9s?. ? ?e? It r`'I ??d (,l(? , 1 t tt 1• ?I?y I? ?? ._ _, ? •,: , _ , __ , . ,., _.__ cz? t114l)' I x u1 III:I ICI ('C,?c?X )tlwc ?r I rol if Ill k I1g: \? itk: ul,t,,:,, ?) - ?- VI(:J ?t, t, S1 t (?f lir. .I; I :! 1 7 i r%t?' I I. 1 - ?_ttfr?ltt t?,t?:?l, ?t,1,?<<'tl?: - I?atntl j Ii..a'•. DIvI1 I B 'ILA n ?- ? III I •. l•,J • I .,. ? N' ? ?••?---''z'...r ,- C? t I t ? _ _ _ ?`"? ?' 'Ilk it CUllll'_C_/( (IM _ Mar 22 06 11:07a Prav. Gadani 717732 31 P.5 MIC IMA NETIC IMAGING CENTER RE: ASLAM, MUHAM AD DATE: 08/31/2105 j 4800 Charles Roa I Apt 1 APS#: 40901 Mechanicsburg, P 17050 DOB: 02/06/1947 SS#: 201-62-7033 KK STUDY: MRI of the lumbar spine REFERRING PHYSICIAN: Pravin Gadani, MD CLINICAL HISTORY: Low back pain. PULSE SEQUENCES: T2, T1 sagittal; PD, T2 axial COMMENTS: Them is mild straightening of the lumbar I rdosi s hich could be secondary to muscle spasm of atient pos itioning. Discogenic endplate changes a e noted L5-S1 level. A hemangioma is pres en within the body of L2. Axial images were obtained thr ugh the intervertebral discs from L1- throu gh L5-S1 levels. A right paracentral disc bulge is present. It indents the ventral theca) ac. T (ne entral spinal canal is normal. Mild righ neural foraminal narrowing. 1-2-3: Normal. 1-3-4: Normal. 1-4-5: Small circumferential disd/disc osteophyte complex and bilate I fac 't j int disease. Bilateral ligamentum flavum thickening. The central spinal c l nal is n rmal_ Mild bilateral neural foraminal narro ing. L5-S1: The disc space is nearly) completely obliterated. There is asy metric circumferential disc osteophyte complex and bilateral facet joint dise se. M;Id ilateral ligamentum flavurn thickening, The central spinal canal is normal. S vere tiilat ral neural foraminal narrowing. i{ The conus ends at the L2 level bnd is normal in configuration. CONCLUSION: Degenerative disc disease Cat L5-S1 d 4-5 level . Severe bilateral neural foramin I narrowing at the L5-S1 level and m Id bila?eral neural foraminal narrowing at the L4-5 evel. 11 1 Multi level degenerative disc dis ase. CONTINUED ON PAGE 2 Mar 22 06 11:08a Prav. Gadani 717732 31 P.6 rlix* M I C IAGNETIC IMAGING CENTER Page 2 ASLAM, MUHAMMAD 08/31/2005 CLI-2)evei. A small right paracentral disc b Ige a Thank you for referring this patient to us. Sincerely, Kiran Kapadia, M.D. KK /jp f. , l Name L h rm? - : i C1 ?l Age: a S.S.#: Date: ?lllgl05 WGT: I "7'z.- BP: REASON FOR VISIT:,P- *-A YLu lv,,v f / PHYSICAL ASSESMENT:H- qvkrj-; ?-ft '? rho I hSrl f? 1. d/dL?Erd A- LABS : 17' 20-? MIS C? I, _,PP? ??. ???t? /cam.--,, ?s ? ?X ?., ?- -- GCJ?avLCT C ? . `ice VZ?GL Date: h'/a3/Q 5 WGT: IA? BP: l/fib P: R:_ TEMP: 6 9,0 REASON FOR VISIT: '4?G PHYSICAL AS SESMENT:{?,„? shy i LABS: Vi'vo (m 6a v,,?? 8.3(c? S - ISC. MEDS : Date: - WGT: BP: P: R: TEMP : REASON FOR VISIT: PHYSICAL ASSESMENT: LABS: MEDS: DX TEMP: HT: _ (IEDS? 0?-a0 f- - Wf SSa Q 3 x MIS C HIP A. Forward Flexion (00-100°) Right Left 100° Right Left Right Left 50° B. Backwarc Right SPINE Cervical Re; A. Lateral Right i Extension (00-300 Left >,ion Flexion (00-400) .r Left ,/?]\: LEFT ?1? RIGHT k i f, SPINE Y??JWtbtXCiG??CLGVI?L 'd,ICI(K Lumbar Region A. Flexion-Extension (00-900) b -7o ° D. Abduction (:00-;400) Eight Left E. Adduction (00-200) Right Left B. Flexion (00-300) D. Rotation (00-450) C.. Extension KOo-300.) Right Left ao° 3CP 00 450 Extension ; Flexion Neutral Po:ltion B. Lateral Flexion Righto -I C) `Left .20° n rr i? ANKLE A. Dorsi-Flexion (00-200) (00-200) Right Left B. Plantar-Flexion (00-400) Right Left 0° planfor. 20` flexion 40" Clar51- ?y flexion / HIP' _ A., Forward Flexion (00-7.000) C. 1;vta.tton-=lnte,- or cc --A 00) Right Left 'Right Left 0. 100° B. Flexion (00-300) C, Extension (00-300) 50' U B, Backward Extension (00-300) D. Abduction (0°=400.) E. Adduction (0°-20°) Right Left Sight Left Right Left SPINE Cervical Region A. Lateral Flexion .(00-400) Right Left p° :.?.t?: LEFT 1/" RIGHT SPINE ?M r Y I l (?ln.C???? lr?/V l Lumbar Region 00 13 A. Flexion-Extension (00-900.) Extension ; Flexion Neutrol Position Roiat t.on--C-xt-.r o r (Op-?C, Right Left D. Rotation (00-450) Right Left 0° ~ s ? 45° ANKLE A. Do.rsi-Flexion (00-20°) B. Lateral Flexion (0o-200) Right Left Right O ^(O Left a - 6 B. Plantar-Flexion (00-400) yp° Right Left h o° planlar? 20° flexion y ?- t ? d0? dorsi- ?\ flexion Jones,,15784 GE OF MOTION CHART - (HINTON 'LA) This Chart is to,be used an conjunction with your report, either as a guide or for separate completion. if you choose to complete -the '.ROM Chart, complete the blank to show the degree at which motion stops. SHOULDER A. Forward Elevation (00-1500) Right Left ELEVATION Iso* B. Abduction (0°-150°) Right Left %ABDUCTION C.. Adduction (00-300) Right Left D,...Inter.nal Rotation (0°-400) Right Lef t ?.q E. External Rotation (0°-90°) Right Left. ELBOW a A: Flexion-Extension ,(00-1500) B. Supination (00=800) C. Pronation (00-80o) Right Left Right Left Right Left rso? ? C' ?\ . `-... . _ 00 'Boo V(?1.S A. Dorsiflexion (0°-60°.) B.. PalrTiar Flexion (.00-700) Right Left Right' Le'ft C. Radial Deviation -(0°-20°) 'Right Left D. 'Ulnar Deviation Neutral Position. Right Left KNEE -80° A. Flexion-Extension (0°-1200) Right Left 10.t111?Sup1notion a° 7120` Pronai ion ORTHt-..FDIC INSTITUTE OF PENNSYLV.---,IA (717) 761-5530 Patient: Muhammad C. Aslam Chart ##: 25060928 DOB: 02/06/47 SSN: 201 62 7033 Page # 1 ------------------------------------------------------------------------------ 1/05/2006 THOMAS J. YUCHA, M.D. OFFICE VISIT Poplar Church Road Office CHIEF COMPLAINT: I saw Muhammad in consultation today at your.request with the chief complaint of a problem with his low back. HISTORY OF COMPLAINT: Muhammad Aslam is a 58-year-old cashier for Gas, Inc. on the Carlisle Pike. He mentions that on April 16, 2005, he was a restrained driver at a stop sign when he was hit from behind by a larger vehicle than he was driving. He said the vehicle probably was a Ford Explorer. It pushed his trunk, caved it in, and totaled the car. He said he did not have any low back problems prior to that accident. He said right now he still has some discomfort in the low back, and at the end of the day he has "heavy legs" more on the left than the right. He does not complain of any significant redness, increased heat or swelling about the low back. There are no significant paresthesias. He has recently been taking Oxycodone for pain, about two or three a day. He is not taking non-steroidal anti-inflammatory medication. He says his back pain is worse than his leg pain. Also, on October 16, 2005, he suffered a significant injury when he was working at Exxon on the Carlisle Pike. He was stabbed five or six times by a perpetrator and they life-lined him to Hershey Medical Center. He is still being treated at Hershey. he has been out of work because of that incident. His roots are in Pakistan. He has been in this country for 15 years. REVIEW OF SYSTEMS: Review of systems, past medical history, family history and social history have been recorded and reviewed. PHYSICAL EXAM: The skin is warm and dry and there is no evidence of any redness, swelling or slain lesions. He flexes only to about 60 degrees and extends 5 degrees. The neurological examination of the lower extremities shows him to be non-tender over the sciatic notches. He is able to walk on the heels and toes without any problems. There is a normal gait. The deep tendon reflexes for the patellar tendon and the Achilles, tendon are normal and equal bilaterally. There are no sensory or motor losses. Straight leg raises are negative bilaterally. The FABER'S test is negative bilaterally. DIAGNOSTIC TESTS: A report of x-rays that were taken on April 16, 2005, mentioned that there is "severe degenerative disc changes at L5-Sl". An MRI taken on August 31, 2005, mentions there is "degenerative disc disease at L5-Sl and at the L4-5 level with severe bilateral neural. foraminal narrowing at the L5-Sl level. There is mild bilateral neural foraminal narrowing at L4-5 with multiple level degenerative disc disease. There is a ORTH(_ DIC INSTITUTE OF PENNSYLVi,.1 :IA (717) 761-5530 Patient: Muhammad C. Aslam Chart #: 25060928 DOB: 02/06/47 SSN: 201 62 7033 Page # 2 --------------------------------------------- - -- 1/05/2006 THOMAS J. YUCHA, M.D. -CONTINUED- OFFICE VISIT small right paracentral disc bulge at L1-2. DIAGNOSIS: I told Muhammad that I feel his problem is that of a traumatic aggravation of some previous existing degenerative disc disease at L5-S1 and throughout the lower lumbar spine. PLAN: I gave him instructions to have formal physical therapy three times a week for the next four weeks. He will see me back here in the office at that time. He certainly could take a non-steroidal anti-inflammatory medication of choice in the hope that he would not have to rely on the Oxycodone. I will see him back here in four weeks and will make sure that he has the detailed instructions in good back mechanics to help to prevent any recurrences in the future. TJY/tjs Letter to Ljubisa Stankovic, M.D. and Pravin Gadani, M.D. CORRESPONDENCE (Ref) STANKOVIC 2/06/2006 OFFICE VISIT M.D. LJUBISA THOMAS J. YUCHA, M.D. Poplar Church Road Office CHIEF COMPLAINT: Pain in the back and the left leg. HISTORY OF COMPLAINT: Muhammad mentions that he feels like when he has physical therapy he is better for about 2 or 3 hours and then the pain recurs. He takes Aleve, two twice a day, and this does not give him any significant relief. He has not tried any Ibuprofen. His left leg bothers him more than his back pain. He has problems down in the hamstrings posteriorly. There is no redness, increased heat, swelling or paresthesias. There are no right-sided problems. He doesn't complain of any hip problems. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history, and social history have been re-evaluated and reviewed. PHYSICAL EXAM: The skin is warm and dry and there is no evidence of any redness, swelling or skin lesions. He flexes only to 70 degrees. The neurological examination of the lower extremities shows him to be non-tender over the sciatic notches. He is able to walk on the heels and toes without any problems. There is a normal gait. The deep tendon reflexes for the patellar tendon and the Achilles' tendon are normal and equal bilaterally. There are no sensory or motor losses. Straight leg raises are negative bilaterally. The FABER'S test is negative bilaterally. DIAGNOSTIC TESTS: None obtained today. DIAGNOSIS: Traumatic aggravation of pre-existing degenerative disc disease at ORTHL-.EDIC INSTITUTE OF PENNSYLVI-.4IA (717) 761-5530 Patient: Muhammad C. Aslam Chart #: 25060928 DOB: 02/06/47 SSN: 201 62 7033 Page # 3 ------------------------------------------------------------------------------ 2/06/2006 THOMAS J. YUCHA, M.D. -CONTINUED- OFFICE VISIT L5-Sl and throughout the lower lumbar spine. PLAN: He feels he is benefitting from formal physical therapy, and I would like him to continue with that. I have also ordered epidural steroid injections for him. I will see him back here in about four weeks. He could switch to Ibuprofen instead of the Aleve. TJY/tjs cc: Ljubisa Stankovic, M.D. and Pravin Gadani, M.D. via fax 2/07/2006 THOMAS J. YUCHA, M.D TEL/MESG-MESSAGE TO CHART T I faxed Muhammad's records and x-ray reports to Susquehanna Valley Pain Management for his epidural steroid injection on February 10, 2006. tDs 2/15/2006 THOMAS J. YUCHA, M.D. PHYSICAL THERAPY Sherry called from LIealthsouth Physical Therapy at Country Meadows stating Muhammad had been discharged but prior to that he had been ill and had missed several physical therapy visits so they saw him on February 9, 2006, for one last visit. She said unfortunately his script had expired, and she asked if they could have a script to cover that one last visit on February 9, 2006. The script was faxed to her at 214-2907. tjs 3/09/2006 THOMAS J. YUCHA, M.D. OFFICE VISIT Poplar Church Road Office CHIEF COMPLAINT: Pain in the bac]c and the left leg. HISTORY OF COMPLAINT: Muhammad said he had one epidural steroid injection about a month ago and said that helped considerably. He said it helped him about 50 or 60 percent. He said the pain is in the left leg more than the back. There is no redness, increased heat, swelling, radiation of pain or paresthesias. He does not feel he is ready to return to work yet. REVIEW OF SYSTEMS: The patient's review of systems, past medical. historv, family history, and social history have been re-evaluated and reviewed. PHYSICAL EKAM: The skin is warm and dry and there is no evidence of any redness, swelling or skin lesions. Flexion of the low back is 85 degrees, extension 15 degrees and lateral bending 20 degrees to each side. The neurological examination of the lower extremities shows him to be non-tender over the sciatic notches. He is able to walk on the heels and toes without any problems. There is a normal gait. The deep tendon reflexes for the patellar tendon and the Achilles' tendon are normal and equal bilaterally. There are no sensory- or motor losses. Straight leg raises are negative ORTHt,_. FDIC INSTITUTE OF PENNSYLV.,_:.,IA (717) 761-5530 Patient: Muhammad C. Aslam Chart #: 25060928 DOB: 02/06/47 SSN: 201 62 7033 Page # 4 ------------------------------------------------------------------------------ 3/09/2006 THOMAS J. YUCHA, M.D. -CONTINUED- OFFICE VISIT bilaterally. The FABER'S test is negative bilaterally. DIAGNOSTIC TESTS: None obtained today. DIAGNOSIS: We know that Muhammad had the significant discogenic disease. His x-rays from last year showed the severe disc changes at L5-Sl. He also has multi-level degenerative disc disease. PLAN: I told Muhammad that he is coming along much better. He and I both realize that he should get another epidural steroid injection. He is going to have that, and I. will see him back here in four weeks. He should continue to take the Ibuprofen. If he feels he is ready to go to work, he can go to work before being seen by me. TJY/tjs cc: Ljubisa Stankovic, M.D. via fax Pravin Gadani, M.D. via fax 4/06/2006 THOMAS J. YUCHA, M.D. MISSED APPT LETTER (Pat) ASLAM, MUHAMMAD C. NO SHOW NOTE Muhammad did not show up for his appointment today. A letter was sent. tj s ORTHC DIC INSTITUTE OF PENNSYL% ;IA (717) 761-5530 Patient: Muhammad C. Aslam Chart #: 25060928 DOB: 02/06/47 SSN: 201 62 7033 Page # 4 ------------------------------------------------------------------------------- 3/09/2006 THOMAS J. YUCHA, M.D. -CONTINUED- OFFICE VISIT bilaterally. The FABER'S test is negative bilaterally. DIAGNOSTIC TESTS: None obtained today. DIAGNOSIS: We know that Muhammad had the significant discogenic disease, His x-rays from last year showed the severe disc changes at L5-Sl. He also has multi-level degenerative disc disease. PLAN: I told Muhammad that he is coming along much better. He and I both realize that he should get another epidural steroid injection. He is going to have that, and I will see him back here in four weeks. He should continue to take the Ibuprofen. If he feels he is ready to go to work, he can go to work before being seen by me. TJY/tjs cc: Ljubisa Stankovic, M.D. via fax Pravin Gadani, M.D. via fax 4/06/2006 THOMAS J. YUCHA, M.D. MISSED APPT LETTER (Pat) ASLAM, MUHAMMAD C. NO SHOW NOTE Muhammad did not show up for his appointment today. A letter was sent, tjs -4/.27/2006 THOMAS J. YUCHA, M.D. REQUEST FOR RECORDS Office notes copied, billed by Quadramed and mailed to HANDLER, HENNING & ROSENBERG, LLP, ATTORNEYS AT LAW. jef . --- HEALTHSOUTH Rehab of Mecha ' nicsburg NWGmb Add C 1 1 r ry ` a ?!1 a i ' 1 i l / I V 00 COMP OUTPATIENT WORKERS cantor H n ,y j CHAR TICKET - 880 I18 . 895 884 A SL AM+ .HUIJAM.NAD C MAP 31 ( 7 SpdAfd LIFE HI Hrshy 1 Date f 885 8B6 888 891 / / u .b / 1 9 4 7 ¢ ? P Ix . ?{ V? 8 M WA .: Lebn gal Cara Therapist Number 892 894 L 1' N G t.4 "D s -SC O I f CX N/S R/S p ' ty Q A 19 I f 9 ?r`. tr Rx Expires: I DAILY NOTE i` SUBJECTIVE: ? Unremarkable ? No ew complaints Z ? Increased/Decrees d pain alter last visit ? Patient pain level @/ ' Patient a rts: A 4 1 7 V I- --" - al c ?? G c OBJECTIVE: /V11) V G Area Treated: Swelling: Ecchymosla: ROM: L r Q Strength: Function: Comments: Cx ?'>?f_ ,/ -?. EATMENT CONSISTED OF THE FOLLOWING MODALITIES AND PROCEDURES: SvcCd Description SvcCd Descriplion Svc d Description zm(;A DescdoWn 50119 PT Evel - 114 Hr 50167 Isokinetlc Test -112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval.- 1/4 Hr 50165 Isokinetic Training - 114 Hr 50168 Home Eval - 1/4 Hr 50029 Wheelchair Evel -1/4 Hr 50077 CS Traction: Static _ Inl -_ Ibs on _ lips off _ min _ 50169 Job She Eval -1/4 Hr 50170 Seating Eval -1/4 Hr 50130 LS Traction: Prone _ Supine _ Ibs an _ Ibs off _ min _ 50016 ADL - 114 Hr 50015 Community Mob Aasmt -1/4 Hr 50036 Ultrasound Single eonUpulse _W/cm, _min 50030 Sensorimotor -114 Hr 50163 Ultrasound Comb eont/pulso _Wlcn _min 50020 Cog Retraining - 1/4 Hr 50156 Home PgmlFamlly Ed -1/4 Hr 50035 lontophoreels -15 Min IM _MA/Mln S M L 50187 Comrnun Re4nteg - 1/4 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3).1/4 Hr 50024 Neuromusc Re-Ed -1/4 Hr 50128 Moist Heat X Min 50164 Neuromusc Stlm -114 Hr 50010 Cold Pack! Ice Massage X Min 50012 Ru]dotherapy -1/4 Hr 50163 Adjustment 50014 WP 0 _ FX _min 50028 OT Indlvki - 114 Hr 50050 Splint - Simple 50005 Sterile WP ® _ FX _min 50125 OT Group - 1/4 Hr 50050 Splint - Complex 50028 PT -1 /4 Hr 50017 PT Indivld -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thor -1 /4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage .114 Hr 50112 PT Wrk Read] Eval - 112 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive Ex - 114 Hr 50127 Elac Slim 50113 PT Wrk Readl -1/4 Hr 50112 OT Wrk Readi -114 Hr 50166 Home Pgm/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed -1/4 Hr 50012 Fluldolherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASE3SMENT; A STG Current: / Cam( ?_ Met: Yos / No LTG Current : /c.- Met: Yes /No Reset: In: Weeks Reset: In: Weeks ? Patient tolerated treatment well ? Home Exo a Program reviewed ? T e Exerclea Pro ram advanced as-per flow shoal PAN El upgrade a tiles as tolerated /per protocol Dischar a from Therapy Comment: THERAPIST SIGNATUF ? THERAPY MINUTES TOTAL UNITS: Remo HFALTHSOUTH Rehab of Mac OUTPATIENT WORKERS' COMP CHARGE TICKET Dare Therapist Number CX NIS RIG Rx Expires: comik Hand NwCmb 880 882 t96 884 Spr(Md LIFE ChmN/ Hrshy 886 886 888 891 DAILY NOTE SUBJECTIVE ? Unremarkable Q-14a new complaints Patient Reports: t l p L-vn (E) Z,?,o ?ou, ii. 00010115.8 tx?f , A 5l, A X, M UN.A;Mo4t* p ty Lebn ae/Gwu /? 892 894 ? O 4 7 0 RQ 0)@ M VA 010CH 11110, Sr, OT T X96 ? Increased/Decreased paln after last visit atlant pain level a 110 r <; 9 v -- tic) a i -,c>a. 1 a?4 U LO i4 OBJECTIVE: 5--")l Area Treated: ) Swelling: Ecchymosis: ROM: _ u Strength: i 4 yy ?7 LQa olCFfncx ?lsCt-?Cd Function: / i Comments: SvcCd Description ay2u Description Svc Desabtton vcCd Description 50119 PT Eval -114 Hr 50167 Isokinetic Test -1/2 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eves -114 Hr 50029 Wheelchair Eval -114 Hr 50165 Isoklnstic Training -1/4 Hr 50168 Home Eval 114 Hr 50029 Wheelchair Evai -114 Hr 50077 CS Tractlon: Static- Int ! lbs on _ Ibs o8_ min _ 50169 Job Site Eval - 1/4 Hr 50170 Seating Evai -114 Hr 50130 LS Traction: Prone _ supine _ lbs on _ Ibs off _ min_ 60016 ADL -1/4 Hr 50015 Community Mob Assmt -114 Hr 50036 Ultrasound Single cont/pulse-_ Wlcm _min 50030 Sensodmolor -114 Hr 50163 Ultrasound Comb cont/pulse ,_ W/cm _min 50020 Cog Retraining - 114 Hr 50166 Home Pgrn/Famlly Ed - 114 Hr 50035 lontophoresis - 15 Min Q !MA/Min 5 M L 50167 Commun Ra-Integ -114 Hr 50165 Patient Ed - 114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2.3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Stim -114 Hr 50010 Cold Pack I Ice Massage X Min 50012 Fiuldotherapy . 1/4 Hr 50163 Adjustment 50014 WP Q ^ FX _min 50028 OT Indlvld -1/4 Hr 50050 Splint - Simple 50005 Sterile WP ® ____ FX ^ min 50125 OT Group -1/4 Hr 50050 Splint - Complex 50028 PT -114 Hr 50017 PT indivld - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT' Group Thar - 1/4 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 1 /4 Hr 50112 PT Wrk Readl Eva) -112 Hr 50111 OT Wrk Readl Evel -112 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Slim 50113 PT Wrk Readl -1/4 Hr 50112 OT Wilk Reedi -1/4 Hr 50166 Home Pgm/FamRy Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed -114 Hr 50012 Fiuldotherapy 50174 PT Wrk Hard . 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath STG Current: _ Jl (yyC? j Met: Yes/ No LTG Current: _ 0/Z?7Gr"Y- Re at, In: Weeks Reset: J In: lvPatlent tolerated treatment well Cl Home Exercise Program reviewed ? The Exercise Program advanced as per Row sheet PLAN: grade activities as tolerated /per protocol ? Discharge fromTherapy Comment: Met: 'Yes/No Weeks THERAPIST SIGNATURE: MINUTES: TOTAL UNITS: eme Hd U24100 HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP CHARGE T CKET Date Therapist Number CX NIS RIS Rx Expires: DAILY NOTE Patient Reports: ? No new Area Treated: ROM: Strength: Function: Comments: Cantor Han ntryMd C Nwcmb 880 895 88 884 SpdMd UFE CWHI Haby 885 886 888 891 Latin eal Care 892 594 ?00101,,10 umnl SL .x l" , M UiN ?M14i0 C 710611967 011 06 M V-A LYNCH *01 Scott 60604141 after last Wish ? Patient 114 el.` 110 Ecchymosls: Lys-u es rl I n BE& Description a2994 D lion SycQd Description 50119 PT Eval - 1/4 Hr 50167 lsoklnellc Test -1/2 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eval -1/4 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 isoklnetic Training -114 Hr 5016B Home Eval -1/4 Hr 50029 Wheelchair Eva) -1/4 Hr 50077 CS Traction: Static -„_ Int _ lbs on _ lbs oft _ min! 50169 Job Site Eval -114 Hr 50170 Seating Evai -114 Hr 50130 LS Traction: prone _ Supine _ Ibs on _ lbs off _, min _, 50016 AOL -114 Hr 50015 Community Mob Assmi -114 Hr 50036 Ultrasound single cont/pulse _ Wlcm _min 50030 Sensodmotor -114 Hr 50163 Ultrasound Comb cant/pulse ._ W/an -min 50020 Cog Retraining -1/4 Hr 50166 Home PgnVFamhy Ed -114 Hr 50035 iontophoresis - 15 Min C _MAIM[n S M L 50167 Commun Re-Integ -1/4 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3) .114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heal X Min 50164 Neuromusc Sttm - 114 Hr 50010 Cold Pack I Ica Massage X Min 50012 Fluldotherapy -1/4 Hr 50163 Adjustment 50014 WP 0 - FX _min 50028 112 OT Individ -114 Hr 50050 Splint - Simple 50005 Sterile WP 0 _ FX _ min 50125 OT Group - 1/4 Hr 50050 Splint - Complex 50028 PT -114 Hr 50017 PT Indivld -1 Hr (Aqua) 50011 Paraffin Bath _ 50126 PT Group Ther - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Read[ Eval -1/2 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Stlm 50113 PT Wrk Reach -114 Hr 50112 OT Wrk Reach -114 Hr 50166 Home Pgm/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hra 50024 Nouromusc Re-Ed -1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT: STG Current: Met: Yes 1 No LTG Current: Met: Yes/No Reset: In: Weeks Reset: n. Weeks ? Patlant rated rsatmont/ a Exerc va rogram reviewed ? The Exercise Program advanced as per how sheet PLAN: gra each a as tolerated lper tocol ? Discharge from Therapy Comment: THERAPIST SIGNATUR THERAPY MINUTES: TOTAL UNITS: .? ? evlee a HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Cann), Heed 1NwCrnb CHARGE TICKET 880 882 884 SprIMd LIFE ChmH1 Hrahy Date 885 886 868 891 AU101N? M{?M1AMNi1?) r. 1 O Lean as) Caro i r V b/ i Te/ ? 4 R Y Theraplsi Number 892 894 ., VA CX NIS R/S 1 ?w W #1 j ?:iY i Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable l5?Tvo new/?,impla? Tintsr ? IncreasedlDecreased pain after last visit ? Patient pain ievei C /10 Patient Reports: ?,I? LU C L-7 ,1 ,0 -h 01A- Svccd Description SvcCd D a tl S-Qd pesciatton SvcCd Description 50119 PT Eval -1/4 Hr 50167 leokinetlc Teat - 1/2 Hr 50118 OT Eva] - 114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isoklnatic Training -114 Hr 50168 Home Eval -1/4 Hr 50029 Wheelchair Eval - 114 Hr 50077' CS Tradlon: Stauc _ Int _ Ibsen - lbs oR _ min_ 50169 Job She Eval -114 Hr 50170 Seating Eval -114 Hr 50130 LS Traction: Prone, Supine _ his on _• Ibs off _ min - 50016 ADL - 1/4 Hr 50015 Community Mob Aasml - 114 Hr 50036 Ultrasound Single cont/pulse _ Wlcm _min 50030 Sensorlmotor -114 Hr 50163 Ultrasound Comb cant/pulse _ W/cm _min 50020 Cog Retraining -114 Hr 50166 Home PgnVFomhy Ed -114 Hr 50035 lontophoresis - 15 Min a _MA/Min S M L 50167 Common Re-Intel; -114 Hr 50165 Patient Ed -114 Hr 50037 Phonophoreais 50013 Jobst Compression 50125 Group (2.3) -114 Hr 50024 Neummusc Re-Ed -114 Hr 50128 Moist Heat X Min 5D164 Nouromusc Slim -114 Hr 50010 Cold Pack I ice Massage X Mi n 5DO12 Fluldotharopy -114 Hr 50183 Adjustment 5OD14 WP @ _ FX _min 5D028 ^ OT Indivld • 114 Hr 50050 Splint - Simple 50005 Sterile WP _ FX - min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT • 1/4 Hr 50017 PT Indlvid -1 Hr (Aqua) 50011 Paraffin Bath _ 50126 PT Group Thor - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wrk Resdi Eval -112 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive Ex - 1/4 Hr 50127 Eisc Slim 50113 PT Wrk Readi -114 Hr 50112 OT Wrk Readl -114 Hr 50168 Home PgmlFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Nouromusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrh Hard - 1 Hr 50180 OT WrkHard- 1 Hr 50011 Paraffin Bath ?.aacaomci? ? : .gym STG Currant: Met: Yes/ No LTG Current: ?i Met: Yes I No Reset: In; Weeks Reset: LI) -J In: Weeks 6-Patent lotsra treatme ??r,`?-oCmat rciso Program reviewed ? The Exercise Program advanced as per now shoe( PLAN; p o e vib oralad lper p cd Discharge from Therapy Comment: THERAPIST SIGNATURE: S/J THERAPY MINUTES: TOTAL UNITS n4 rat f 5-l° Funcbon: Comments: HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP cantor Hand CnlryMd NwCmb CHARGE TICKET 880 882 885 B84 1 SprWif LIFE ChMNI HrshY 00-0101158 it 11145 Date p 885 886 888 891 d SL A d s N U14 A.11*4 4 4 f 0 Latin Bal Care Y fiM R Therapist Number 892 894 1/06/1947 0 0 CX NIS R/S 058 9 WA V V Rx Expires: L Nb 'C" 001 SC.O t t DAILY NOTE O 40 11114 t 4 SUBJECTIVE: ? Unremarkable 'El No new complaints 13 Increased/Decreeaed paln after last visit ? Patient pain iwo a Patient Reports: p7' IU Qi /n e1,(,1 ce .? 1-0 Y-A-tom -/tYrik OBJECTIVE: Area Treated: Swelling Ecchymosis: ROM; I'M 7r --Veil I/ 'q V tn" ga L. (?(. . -go Strength: - /71 J, ? 7 31Yt 7 Function: Comments; C la* SvcCd Description SvcCd D c llon vc d Description 9vCCd Description 50119 PT Eval -1/4 Hr 50167 Isoklneilc Test -112 Hr 50118 OT Eval -1/4 Hr 50119 OT Re-Eva) -114 Hr 50029 Wheelchair Eva[ -1/4 Hr 50165 Isokinetlc Training -114 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Eval -114 Hr 50077 CS Traction: Static- in( - IN on _ Ids on! min ! 50169 Job Site Evai -1/4 Hr 50170 Seating Eval -114 Hr 50130 LS Traction: Prone,_ Supine r Ibs on _ Ilia off _ min _ 50016 ADL • 114 Hr 50015 Community Mob Assmt-114 Hr 50036 Ultrasound Single conupulse_ W/cm _min 50030 Sensodmotor-1/4Hr 50163 Ultrasound Comb contipuise ! W/cm _min 50020 Cog Retraining - 1 /4 Hr 50156 Home PgmlFamhy Ed -114 Hr 50035 lontophoreals -15 Min 0 -_MAIMin S M L 50167 Commun Re-Integ - 114 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophorests 50013 Jobst Compression 50125 Group (2-3).114 Hr 50024 Neuromusc Re-Ed - 1/4 Hr 50128 Molst Heat X Min 50154 Neuromusc Shm -1/4 Hr 50010 Cold Pack I Ice Massage X Min 50012 Fluldotherepy -1/4 Hr 50163 Adjustment 50014 WP 0 _ FX _min 50028 OT Indfvld -1/4 Hr 50050 Splint - Simple 50005 Stadia WP 0 ____ FX _ min 50125 OT Group - 1/4 Hr 50050 Splint - Complex 50028 Pi -1/4 Hr 50017 PT Individ - 1 Hr (Aqua) 50011 Paraffin Bath _ 50126 PT Group Thar -1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Readi Eval - 112 Hr 50111 OT Wrk Readl Eva) -112 Hr 50164 Progressive Ex -114 Hr 50127 Else Stim 50113 PT Wrk Read! -114 Hr 50112 OT Writ Readl - 1/4 Hr 50166 Horne Pgrn/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - i Hr 50011 -Paraffin Bath ASSESSMENT: STG Currant Met: Yes / No LTG Current: Mst: Reset ?7 In: Weeks Reset: In: _ ? Patient tt?tole??rated((tr//s1``1almmentt well LL ? Home Exon; ?rogram reviewed ? The-Exerolso Program advanced as per now sheet PLAN: aa?Upgrarll?a IV[iss E. l r?r proloco ?V? '?- pe Discharge from Therapy Comment: Yes INo Weeks THERAPIST SiGNATUR ITHERAPY MINUTES: TOTAL UNITS: e se HEALTHSOUTH Rehab of Mac OUTPATIENT WORKERS' COMP CHIA GET KET Date a Therapist Number CX N/S R/5 Rx Expires: DAILY NOTE SUBJECTIVE ? Unremorlo3b Patient Reports: OBJECTIVE: Area Treated: ROM: Strangth: Function: Comments: erg F ? ... __ .- NwC mh Canto, Hand 7Ct.111d 880 882 884 ?jt ' f 1Q 7 SprWd LIFE ChmHI Hnhy 885 886 888 891 S •? Latin BCare ^ ` ^ i 9 V ?1 lr A ] V Tf V 892 894 ONO M W A Y404 MD., No new mplalnts ? Increaspd/Decreased pain after last visit ? Patten pain ievel ® 110 Swelling: Ecchymosls: SvoCd Description SvcCd Description vc Description 50119 PT Eval -114 Hr 50167 Isokinedc Test - 112 Hr 50118 OT Eval -1/4 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isokinetlc Training -1/4 Hr 50168 Home Eval - 114 Hr 50077 CS Traction: Static ^ Int - Ibs on _ Ibs off _ min, 50169 Job Site Eva] - 1/4 Hr 50130 LS Ttacson: Prone _ Supine _ Ibs an _ his off ` min - 50016 AOL - 114 Hr 50036 Ultrasound Single conllpulse_Wlcm _min 50030 Sensohmotor- 1/4 Hr 50163 Ultrasound Comb conllputas -Wien _min 50020 Cog Retraining -114 Hr 50035 lontophoreals -15 Min C _MA/MIn S M L 50167 Commun Re-Ineg • 1/4 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3) -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Slim -1/4 Hr 50010 Cold Pack / Ice Message X Min 50012 Fluldotherapy -114 Hr 50014 WP .6 _ FX ____min 50028 ?OT Individ -114 Hr 50005 Stadia WP C _ FX + min 50125 OT Group - 114 Hr 50028 PT -1/4 Hr 50017 PT Indlvid - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thor -1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Read] Eval - 1/2 Hr 50111 OT Wrk Readl Eval - V2 Hr 50164 Progressive Ex -114 Hr 50127 Elec Stim 50113 PT Wrk Readi - 1/4 Hr 50112 OT Wrk Readi -114 Hr 50166 Horne PgnVFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed -114 Hr 50012 Fluldotherapy 50174 PT Writ Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath A??ESSMENT: ? ? STG Current: Met: Yas / No LTG Current: Met: Yes/No Reset: In. Weeks Reset: In: Weeks ? Pallent tolerated lra ent we El Home Exorcise Program reviewed 0 The Exercise Program advanced as per flow sheet )ALAN: ra"erUpgrade acINI ee as tolamtad /per protocol ? Dlscharga from Therapy Comment: THERAPIST SIGNATUR THERAPY MINUTES: _T`? TOTAL UNITS: ov+se vc d Description 50119 OT Re-Eval - 1/4 Hr 50029 Wheelchair Evai -1/4 Hr 50170 Seating Eval - 14 Hr 50015 Community Mob Asamt - 114 Hr 50166 Home PgrnfFamlly Ed -114 Hr 50165 Patient Ed -1/4 Hr 50024 Neuromusc Re-Ed -114 Hr 50163 Adjustment 50050 Splint - Simple 50050 Splint - Complex OUTPATIENT WORKERS' COMP CHAR E TICKET Date ?-I? Therapist Number CX Vbe NIS Rx Expires; DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Reports: Area Treated: ROM: Strength: Function: Comments: Cantor Hand CnlryMd NWCmb 880 882 895 884 SpriMd LIFE Charm Hrshy 885 886 888 891 Labn Rai Cam 892 894 R/S ? No new complaints ? A-, , ) _1 7u 1' / l ?OMN 0001015.8 2/06/1947 ORO 0:8 M MA LYNCH got I.CGFt pain after last visit swelling: i 1?- :cwt xrp. ? Patleni pain level 110 // _ ? i+ ,, .1 Ecchymosis: SycCd Description svcCd Description SvcCd assgttiop vc d Description 50119 PT Eval - 114 Hr 50167 Isoldnatic Test - 112 Hr 50118 OT Eva[ -114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Evai -114 Hr 50165 Isohlnetlc Training -1/4 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50077 CS Traction: Stolle- Int ! Ibs on _ the off _ min, 50168 Job Site Eval -114 Hr 50170 Seating Eval -114 Hr 50130 LS Traction: Prone-Supine_ Ibs on _ Ibs o8 _ min _ 50016 ADL -1/4 Hr 50015 Community Mob Asaml -114 Hr 50036 Ultrasound Single conllpulse _ W/crn ., _min 50030 Ssnaodmotor -1/4 Hr 50163 Ultrasound Comb conYpulse _ W/cm _min 50020 Cog Retraining -114 Hr 50166 Home Pgm/FamNy Ed -114 Hr 50035 lontophoresis -15 Min Q _MAIMin S M L 50167 Commun Re-Intag -1/4 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophoresia 50013 Jobst compression 50125 Group (2.3) -114 Hr 50024 Neuromusc Re-Ed - 114 Hr 50128 Moist Heat X Min 50164 Neuromusc Slim -1/4 Hr 50010 Cotd Pack 1 ice Massage X Min 50012 Fluldotherapy -114 Hr 50163 Adjustment 50014 WP a - FX _min 50028 OT Indivld -1/4 Hr 50050 Splint - Simple 50005 Sterile WP 0 _ FX _ min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT -1/4 Hr 50017 PT indlvld -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thor -114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 1/4 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Slim 50113 PT Wrk Read4 -114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home Pgrn/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hm 50024 Neuromusc Re-Ed -1/4 Hr 50012 Ruldothempy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk hard -1 Hr 50011 Paraffin Bath STG Current Met; Yes I No LTG Current: Reset: In: Weeks Reset; ? Patient tolerated treatment well ? Home Exercise Program reviewed PLAN: ? Upgrade actiNA)es as tolerated /par protocol ? Dlscharge fmm Therapy Comment: THERAPIST SIGNATURE Mat: Yes I No In: Weeks ? The Exorcise Program advanced as per flow sheet THERAPY MINUTES: TOTAL UNITS! ??--= ov se OUTPATIENT WORKERS' COMP CHARGE CKET Date 7a Therapist Number CX NI5 Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable Area Treated: ROM: Strength: Function: Comments: cenfor 880 spr" 885 R/S No now complaints ?0*s HmC CntryMU ',"b t ` 0001U 4t . g• ??. JKt 882 895 1 884 11113 V M Ji LIFE Chmlif Hrshy 886 888 891 1? Q 6/ 1 Q 4 7 040 Labe aal Gars Sp k WA ?It 892 894 LYhC.M AD* scot? UDOt> 410, ? Increased/Decreased pain after last visit CI Patient pain level G tic c L) Swelling: Ecchymo, Is: SvcCd Description vcC Description SwCd DeacriptIOD SvcCd Descrioyg8 50119 PT Eval -114 Hr 50167 Isokinetlc Test - 112 Hr 50118 OT Eval - 1114 Hr 50119 OT Re-Fuel • 1!4 Hr 50029 Wheelchair Eval -114 Hr 50165 isakinetic Training -114 Hr 50168 Home Eva[ -114 Hr 50029 Wheelchair Eval -1/4 Hr 50077 CS Traction: Static _-__ Int - Ibs on _ to$ off - min _. 50169 Job Site Eval -114 Hr 50170 Sesting Eval -114 Hr 50130 LS Traction; Prone ^ Supine tbs on _ The off _ min+ 50016 ADL • 1/4 Hr 50015 Community Mob Assmt -114 Hr 50036 Ultrasound Single conlipuise --W/cm _-min 50030 Sensodmotor-1/4 Hr 50163 Ultrasound Comb contlpuise ,-Wtcm _min 50020 Cog Retraining - 114 Hr 50166 Home Pgm/Famby Ed -114 Hr 50035 lontophomals -15 Min 0 _MAIMIn S M L 50167 Commun Re•integ • 114 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Mtn 50164 Neuromusc Stim - I/4 Hr 50010 Cold Pack t Ice Massage X Min 50012 Fluidotherapy -114 Hr 50163 Ad)ustment 50014 WP Q _ FX -min 50028 _ OT Indivld -1/4 Hr 50050 Splint - Simple 50005 Sterile WP a _ FX _ min 50125 OT Group -1/4 Hr 50050 Splint - Complex 5002B PT -114 Hr 50017 PT Indlvld -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther -114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Message -114 Hr 50112 PT Wrk Readl Evel - 112 Hr 50111 OT Writ Readl Eva[ - 112 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Slim 50113 PT Wrk Read! -114 Hr 50112 OT Wrk Readi -114 Hr 50166 Home Pgm/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hn 50024 Nourornusc Re-Ed -114 Hr 50012 Muldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT; STG Current: C C'L , Met: Yee I No LTG Current: ?1 / i/CTZ 5 Met: Yee /No R eat: l In: Weeks Reset: -? In: Weeks Patient tolerated treatment well -a-Horne Exercise Program reviewed ? The Exercise Program advanced as per flow sheet PLAN: H1 Upgrade activities as tolerated Iper protocol ? Discharge hnm Therapy Comment: Lc^ cu) THERAPIST SIGNATUR ?2?Ct-nl C THERAPY MINUTES: TOTAL UNITS: av se OUTPATIENT WORKERS' COMP CHARG TICKS Data w/ Therepl(s/ll Number CX N/S Rx Expires: DAILY NOTE SUBJECTIVE: 0 Unremarkable Patent Reports: 7 ) Cantor Hand Cahl'Md NwCm 880 882 895 884 5885 LIFE 85 888 888 891 8 888 891 ?} 1dY(I Latin Bar Cara 892 894 2/06/1447 040 ws a 58 M WA 04CN ND, SC0tI 00020eta5 4b No new complaints ? fncreasedlDacreased pain after last visit ? Patient pain levelit_/to OBJECTIVE: Area Treated: Swelling: Ecchymosis: ROM: -? Strength: nei-/Ir2r:Zt -1X Function: Comments: v Cd Dear n vcCd Dg3criotton 9M294 Description S-Cd Descrintion 50119 PT Eval - 114 Hr 50167 leokinatic Test - 112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eva[ - 1/4 Hr 50165 Isoklnatic Training -114 Hr 50168 Home Eval -1/4 Hr 50029 WheetchalrEval -114 Hr 50077 CS Traction: Statc _ Inl - Ibs on _ Ibs off _ min _ 50169 Job Site Eval -1/4 Hr 50170 Sealing Eval -114 Hr 50130 LS Traction: Prone, Supine _ Its on _ Ibs oft_ min _ 50016 ADL -1/4 Hr 60015 Community Mob Assmt -114 Hr 50036 Ultrasound Single cont/pulse „_ W/cm _min 50030 Senaodmotor -114 Hr 50163 Ultrasound Comb coinUpulse _ W/rm ,_min 50020 Cog Retraining -1/4 Hr 50166 Home PgnVFamlfy Ed -114 Hr 50035 Iontophoresis -15 Min C _MA1MIn S M L 50167 Commun Re-Integ -114 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2,3) -114 Hr 50024 Neummusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neummusc Slim - 114 Hr 50010 Cold Pack I Ice Massage X Min 50012 Fluldotherapy -1/4 Hr 50163 Adjustment 50014 WP 0 _ FX -min 5DD28 _ OT Indlvld - 114 Hr 50050 Splint - Simple 50005 Sterile WP C .___ FX , min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT -114 Hr 50017 PT Indivld -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar- 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wtk Readi Eval - 112 Hr 50111 OT Wrk Reedl Eval -112 Hr 50164 Progressive Ex - 114 Hr 50127 Elec Slim 501 13 PT Wrk Readi -114 4r 50112 OT Wrk Readl -114 Hr 50166 Home PgmlFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neummusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT: ---) 1 STG Current: Met: Yes / No LTG Current: Met: Yes 1 No Reset In Weeks Roset: In: Weeks O Patientt tolerated treatment well ? Home Exercise Program reviewed / ? The Exercise Program adva ad as er heel PLAN: 5l Upgrade actly a tolerated /par protocol Z Discharge from Therapy Contn??' THERAPIST SIGNATU THERAPY MINUTES: TOTAL UNITS: as /1/?? ?ON HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP aanntor and C885d NwBC6mmb CHARG TICKET SprlMd LIFE Dete 885 886 ChMK Hrshy 888 891 ( ?. 01111, 8 ,£ 1 Lebn 892 Bel Care 894 A S L A M , 14 VIf Mgt A..O "?, Therapist Number x wS R/s 2 /060e 194 7 ?t?{} c Rx Expires: 050 M VA 0 LY10G 4 Kw ?Q1 .. , .. ,.. DAILY NOTE SUBJECTWE: 00'4?0 41 9 I ....,., ....,.. ? Unremarkable ? No new complaints 0 ? Increased/Decreased pain after last visit allent pain level a- i Hrri ` Patient Reports: 4 Xf it" Area Treated: ROM: Strength: Function: Comments: Ecchymosls: arad Descrlotlon v d Descriatkin 50119 PT Eval - 1/4 Hr 50167 Isoklnotic Test-112 Hr 50029 Wheelchair Eval - 114 Hr 50165 IsokinstE Training -1/4 Hr 50077 C5 Traction: Static- inl _ Ibs on _ Ibs oR, • min 50130 L5 Traction: Prone _ Bupine _, its on _ lee on _ min 50036 Ultrasound Single mntipulse,_ Wlcm _min 50163 Ultrasound Comb conttpulse __ _W/cm _min 50035 lontophoresis -15 Min C !MA/Mln S M L 50037 Phonophoresis 50013 Jobst C preaslan 50128 Moist Heat X Min 50010 Cold Pack / ice Massage X Min 50014 WP 0 _ FX _m4n 50005 Studio WP tM ^ FX ^ min 50028 PT -1/4 Hr 50017 PT IndWld -1 Hr (Aqua) 50126 PT Group Ther -114 Hr 5017 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex - 114 Hr 0127 Elec Slim 50166 Hamm P im/Family Ed 50040 Tens Application 50024 Neuromusc Re-Ed -1 Hr 50012 Fluidatherapy 50011 Para Rn Bath SvCCd D n S-Cd Desolation 501 07 Eval -114 Hr 50119 OT Re-Eval -1 /4 Hr 168 Hann Eval -114 Hr 50029 Wheelchair Eval -1/4 Hr 50169 Job Site Eva{ -1/4 Hr 50170 Seating Eval -114 Hr 50016 ADL - 114 Hr 50015 Community Mob Assmt -1/4 Hr 50030 Semodmotor -114 Hr 5DO20 Cog Retraining - 1/4 Hr 50166 Home PgmtFamily Ed -1/4 Hr 50167 Commun Ra-intag - 1/4 Hr 50165 Patent Ed -1/4 Hr 50125 Group (2.3) - 1/4 Hr 50024 Neuromusc Re-Ed - 114 Hr 50164 Neuromusc Slim -114 Hr 50012 Ruldotharopy -114 Hr 50163 Ad)ustmenl 50028 OT Indivld -1/4 Hr 50050 Splint - Simple 50125 OT Group -114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50112 PT Wrk Readl Eval - 1/2 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl - 114 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 Hre 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT: j STG Current: Met: Yes / No LTG Current: Met: Yes / No Reset: In: Weeks Reset: in: Weeks ? Patient tolerated tmaimant well ? Homo Exercise Program reviewed ? The Exercise program advanced as per flow sheet PLAN: ? Upgrade actWltla s eraled Iper protoc ? D rge from harapy Comment: THERAPIST SIGNATURE: THERAPY MINUTES: TOTAL UNITS: evub. (Hd W24100 OUTPATIENT WORKERS' COMP CH RGE TICKET DO rnar? v o. per Cantor Hand Cnrry NWCmb 880 882 88 884 SpWd LIFE ChmHl Hrshy 885 886 888 891 LBbn 88) Corn 892 894 CX NIS R/5 Rx Expires: DAILY NOTE SUBJECTIVE: ? UnremarkajJ?g1 / CYNo new complaints Patient Reports: t jb k) 4 .O-0"x.59 it?ti.1101. A 4#4 a K1! 0414AD C zr06/iW 056 M LYNC14 140, 00.0 2041 qi 0R0 WA tCatt t7 Patient pain level ® ? Increased/Oscreased pain after last visit Area Treated: aw ung: ROM: ~ Strength: If y4V_f 4-7 M &-A Function: Comments; TREATMENT CONSISTED OF THE FOL SvcCd Description S-Cd Description 50119 PT Eval - 114 Hr 50167 isoklnetlc Test - 112 Hr 50029 Wheelchair Eval -1/4 Hr 60165 lsokinetic Training - 114 Hr 50077 CS Tracaom Stalic - W _, ibs on _ too oft _ min - 50130 LS Traction: Prone ! Supins _ Ibs on _ too off _ min _ 50036 Ultrasound Single contlputse _ W/cm -min 50163 Ultrasound Cortrb conupulse ___ W/cm ,min 50035 lontophomsis -15 Min a _MAIMIn 5 M L 50037 Phonophore65 50013 Jobst Compression 50128 Mast Heat X Min 50010 Cold Pack / Ice Massage X Min 50014 WP Q _ FX _min 414-0-y rv1Gh 50005 Startle WP Q _ FX , min 50028 PT -114 Hr 50017 PT tndivld - 1 Hr (Aqua) 50126 PT Group That - IA Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage -1/4 Hr 50164 Progres*a Ex - 114 Hr 50127 I Elec Stim 50166 Home PgMFamlly Ed 50040 Tens Application 50024 Neuromusc Re-Ed -114 Hr 50012 Fluidotherapy 50011 Paraffin Bath $VcOd Description 50118 OT Eval -114 Hr 50168 Home Eval -114 Hr 50169 Job She Eva[ - 114 Hr 50016 AOL -1/4 Hr 50030 Samorimotor -114 Hr 50020 Cog Retraining -1/4 Hr 50167 Commun Re-Integ -1/4 Hr 50125 Group (2.3) -114 Hr 50164 Neummusc Stim -114 Hr 50012 Fluidotharapy -1/4 Hr 50028 OT indlvid -114 Hr 50125 OT Group -1/4 Hr 50011 Paraffin Bath 5 min U ?? SvcCd DeRctlytion 50119 OT Rs-Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50170 Seattng Eval -114 Hr 50015 Community Mob Assort -1114 Hr 50166 Home PgrrVFamlly Ed -114 Hr 501 B5 Patient Ed -114 Hr 50024 Neuromuac Re-Ed -114 Hr 50163 Adjustment 50050 Splint - Simple 50050 Splint - Complex 50112 PT Wrk Readl Eval - 1/2 Hr 50111 OT Wrk Read1 Eval -112 Hr 50113 PT Wrc Readl - 114 Hr 50112 OT Wrk Readi - 114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs .50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT: STG Current: Met: Yes/No LTG Current: ,4 , R set: In: Weeks Reset: CCGG?'eek Reset: """ U Pedant tolerategra d treatment well ? Home Exorcise Program reviewed PLAN: ?Dp I as U_r gcotocd /?? Discharge lmm Therapy Comment: THERAPIST SIGNATURE' S (A y L j Im _ ? The Exercise Program advanced as per flow sheet THERAPY MINUTES: TOTAL UNITS: mMe Met: Yes I No Weeks ?t ?n 1 00 06 ?.? ?x? P j(t? SAS NEALTHSOUTH Rehab of Mec OUTPATIENT WORKERS' COMP CHARGE TICKET ?2 a3 0LP Date Therapist Number CenfOr Hand ffl Nwcmh 880 882 884 SprtMd UrE ChmHl Hrahy 885 886 8138 891 CX Nis R/S Rx Expires: DAILY NOTE SU8J€CTIVE: ? Unremarkabis o new complaints Patient Reports: OBJECTIVE: Area Trested: 1 •r1M: Strength. Function: Comments: Ecchymcs;W Yr rr1???T W1 ,rrj .l?'.? • r SvCCd Description §r&d pescrlotlon SvcCd Description SvrC Description 50119 PT Eval -114 Hr 50167 Isokinatlc Test -112 Hr 50118 OT Eva; - 114 Hr 50119 OT Re-Evai -114 Hr 50029 Wheelchair Evai • 1/4 Hr 50165 Isoldnetic Training - 1/4 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Eve1-114 Hr 50077 CS Tracllon: Static _ Ini , Ibs on _ Ibs off _ min - 50169 Job Site Eval -114 Hr 50170 Seating Evai -1/4 Ht 50130 LS Traction: Prone _ Supine _ Ibs on , Ibs off _ min - 50016 Apt -114 Hr 50015 Community Mob Aaemt -114 Hr 50036 Ultrasound Single conVpulse _ Wlcm _min 50030 Sensodmutor -114 Hr 50163 Ultrasound Comb contipulss _,_ _ Wicm lmin 50020 Cog Retraining -1f4 Hr 50166 Home PgmlFemNy Ed -114 Hr 50035 lontophoresis -IS Min ® -MA/MIn S M L 50167 Commun Re-lnteg - 114 Hr 50165 Patient Ed -114 Hr 50037 Phonophoreals 50013 Jobst Compression 5D125 Group (2.91- 114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Slim -114 Hr 50010 Cold Pack/ Ice Massage X Min 50012 Fluidotherepy -1/4 Hr 50163 Adjustment 50014 WP Q _ FX ___Mn 50028 _ OT Individ -114 Hr 50050 Splint - Simple 50005 Sterile WP ® _ FX _ min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT - 1/4 Hr 50017 PT Indlvld -1 Hr (Aqua) 50011 Paratfin Bath 50126 PT Group Thor - 1t4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50112 PT Wrk Readi Eval -112 Hr 50111 OT Wrk Readl Eval -1/2 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elea Stlm 50113 PT Wrk Readl -1/4 Hr 50112 OT Wrk Readl -114 Hr 50166 Home PgrNFamliy Ed 50040 Tens Applicatton 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hm 50024 Neuromusc Re-Ed -114 Hr 50012 Fluidotherepy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT: STG Curiem: ? ?y. f!/ i-r .rte ( Met: Yes/No LTG Current: _ Met: Yes I No ty 7 //Reset: o In: Weeks Reset: In: Weeks 13'f'attent tolerated treatment well ? Home Exercise Program reviewed CI The Exerctsp Program advanced as per low sheet PLAN: ? Upgrade activ1tlas as tolerated lper protocol ? Discharge from Theraov Comment: THERAPIST Latin Dar Cara 892 894 0001011S.8 twins ASLAN, 14"A,t."Ao C ar06ow GAO 0S4 R NA L YNGw Mp l, JC,01't ?Ot?201t4S ???: ? Increased/Decreased pain after last visll ? Pallent polrl•lavel _ TOTAL UNITS: .,me HEALTHSOLITH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Cantor nand cmryMd NWCmb CHARCtE TICKET 880 882 895 884 ?xy SpdMd LIFE ChmNI Hrshy .? W Wi llrwp) Dete 885 886 888 691 A L A K t+ M WA.1 14.4,(1 PC Leon Gel Caro /?, Therapist Number 892 894 > /U 4ll t 94 7 040 NIS R/S Q ?A4 ?c Rx Expires: L Y 14C H 140 tr $ it o t 1 00U24?0191r DAILY NOTE SUBJECTIVE: zLS;' i:;rxk:; ? Unremarkable ? No new complaints Increased/De esed pain after last visit ? Petienl.paln level ® 1 . '.- Patient Reports: Area Treated: ROM: Strength: Fundlon: Comments: Swelling: Ecchymosls: S-Cd Descdoticn SvcCd Description SvcCd Deacriptilon SvcCd Descdotlon 50119 PT Eval - 114 Hr 50167 Isokinalic Test - 112 Hr 501 OT Eval - N4 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50165 isokinegc Training - 11,4 Hr 5 68 Home EvM -1/4 Hr 50029 Wheelchair Eval - 114 Hr 50077 CS Tradlon: Static ^ Int _ Ins on, Ibs off - mm - 50169 Job Site Evai -114 Hr 50170 Seating Eva] - 114 Hr 50130 LS Traction: Proms_ Supine _ Ibs on _ tbs off _,_- min 50016 ADL -114 Hr 50015 Community Mob Assmt - V4 Hr 50036 Ultrasound Single contipulse _ W/cm !mitt 50030 Sensorlmotor -1/4 Hr 50163 Ultrasound Comb eont/puLna __ _Wicm .lmin 50020 Cog Retraining - 114 Hr 50166 Home PgmlFamNy Ed -114 Hr 50035 lontophoresis -15 Mln Q _-MA/Min S M L. 50167 Commun Re-Integ - 114 Hr 50165 Patient Ed -114 Hr 50037 Phonaphorssis 50013 Jobst ompresslon 50125 Group (2.3) - 114 Hr 50024 Neuromusc Re-Ed - 114 Hr 50128 Moist Heat X Min 50164 Neuromusc Stlm - 114 Hr 50010 Cold Pack I ice Massage X Mi n 50012 Fiutdotherapy -1/4 Hr 50163 Adjustment 50014 WP Q _ FX _min 50028 OT Indivld -114 Hr 5OD50 Splint -Simple 50005 SterNe WP a _ FX _ min 50125 OT Group -114 Hr 50050 Splint - Complex 5DO28 PT -114 Hr 50 PT Individ -1 Hr (Aquas 50011 ParaMn Bath 50126 PT Group Their -114 Hr 172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wrk Readl Eva) - 112 Hr 50111 OT Wrk Read[ Eval -112 Hr 50164 Progressive Ex -114 r 50127 Elec St[m 50113 PT Wrk Readi • 114 Hr 50112 OT Wrk Reads • 114 Hr 50166 Home PgnvFam Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc -Ed - 114 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin th A38ESSMENT: STG Curtank Met, Yes I No LTG Current: Mal: Yes I No Re t; in. Weeks Reset: In: Weeks ? P ent tolerated ireatmanl well ? Home Exercise Program reviewed ? The Exercise Program advanced as per flow shoal PLAN: ? Upgrade adlvhles as t ated /per protocol ? Discharge from Therapy Comment: THERAPIST SIGNATURE: THERAPY MINUTES: TOTAL UNITS: o isc HEALTHSOUTH Rehab of Mechanicsburg C0011)( TIENT WORKERS' COMP wCmb and calryMd N }l ': 0 0 U /r OUTPA 0 0 884 895 862 a it 1r 88 CHARGE TICKET 88 Aap L A M * ? UMAf1MA SpRAfd LIFE CnmH! NrrAy Onto x 885 886 888 891 J? r U / ` 7 OR O V Lobo bal Care V } 9 J? W A Therapist Number 892 894 YN ?? SCOT 1 CX WS R/S I, Fix Expires: DAILY NOTE &BJECTIVE: ? Unremarkable ? No new complaints ? Increased/Dooreaead pain after last visit Cl Patient pain level lig " Patient Reports 0?}JECTIVE: SwelNng: Ecchymosls: Area Treated: ROM: Strength: ? nn 4 / let - ?CC Function: Function: l Comments: ' TREATMENT GONS{STED OF THE FOLLOWING MODALITIES AND PROCEDURES: v d Description SvcCd I)eecriptlon vc d D sc SvrC Description 50119 PT Eval - U4 Hr 50167 Isokinetlc Test - 112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eval -1/4 Hr 50029 Wheelchair Evai -114 Hr 50165 Isokinatic Training -1/4 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eva[ -114 Hr 50077 CS Traction: Static ___, Int,_ Ibs on _ Ibs oH_ min- 50169 Job Site Eval -114 Hr 50170 Seating Eval - 114 Hr 50130 LS Traction: Prone _ Supine ____ Ins on „ Ibs off _ min ` 50016 ADL - 114 Hr 50015 Community Mob Assmt -114 Hr 50036 Ultrasound Single conupulse_Wlcm., +mm 50030 Sensodmotor-1/4Hr 50163 Ultrasound Comb contipuise -_Wlcm _min 5002D Cog Retraining - 114 Hr 50166 Home Pgm+FamilyEd -1/4 Hr 50035 lontophoreais - 15 Min a ,MA/Min $ M L 50167 Commun Re-Integ -114 Hr 50165 Patient Ed - 114 Hr 50037 Phonophoresia 50013 Jobst compression 50125 Group (2.3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Slim - 114 Hr 50010 Cold Pack 1 Ice Massage X Min 50012 FluMatherapy -114 Hr 50163 Adjustment 50014 WP C _ FX _min 50028 OT Individ - 1/4 Hr 50050 Splint - Simple 50005 Sterile WP a _ Fx „min 50125 OT Group -114 Hr 50050 Spilm - Complex 50028 PT -114 Hr 50017 PT individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar -114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50112 PT Wrk Read[ Eval - 1/2 Hr 50111 OT Wrk Readl Evai -112 Hr 50164 Progressive Ex - 114 Hr 50127 Elec Stlm 50113 PT Wrk Read) -1/4 Hr 50112 OT Wrk Readi -1/4 Hr 50166 Home Pgm/Famlly Ed SOD40 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed -114 Hf 50012 Flu[dotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard - i Hr 50011 Paraffin Bath A33ESSMFMT: STG Current: Met: Yes/No LTG Current: t-C a L t' 1 Met: Yes/ No Reset: _ In: Weeks Reset: in: Weeks ? Patient tole ated treatment well ? Home Exercise Program reviewed ? The Exercise Program advanced as per flow ahoet r PLAN: lt ,} radea Mlles led or ro I ? on rg mTherapy Comment. THERAPIST SIGNATURE: THERAPY MINUTES: TOTAL UNITS: ?9a HEALTHSOUTH Rehab of Mac OUTPATIENT WORKERS' COMP CHARGE TICKET 0Z lC? o? Date a? Therapist Number CX N/S Rx Expires: DAILY NOTE SUBJECTIVE: X Unremarkable Patiard Reports: csurg C.MV, Hand CnrryMd NwCmb Q 0Q0j i P8 9 t 880 882 895 884 ??i/A M? A SL AM r MW14A141"AD C SpnMd UPE ChroHl WAY 885 886 888 891 x/06/1947 0-40 Lobn Isar Gerd n _ 892 894 LV YMCA! PD, $COT i WS C Q 0 t0 t i +l 0 i1 w, .,, .w,w, ? No now complaints ? Increased/Decreased pain attar last visit ? Patient pain level Q /10 4 OBJECTIVE: p Area Treated:Swelling: Ecchymosis: y- rjp*o ROM: ?RiPcM- [. ?- 44L 0---L 'el 11 11 el I Strength: y E (Z"U E 7 M 1. .?X ag >`. x f"" ?sw? Function: Comments: SvcCd Description S-Cd Description S-Cd Description v C Description 50118 PT Eval -114 Hr 50167 Isokinetic Test - V2 Hr 501`18 OT Eval - 114 Hr 50119 OT Re-Eval - 114 Hr 50029 Wheatchalr Eval -114 Hr 50165 Isokinetic Training -1/4 Hr 50168 Home Eve$ -114 Hr 50029 Wheelchair Evel -114 Hr 50077 CS Traction: Static- Inl M ibs on - Ibs o0_ min - 50168 Job She Evaf -114 Hr 50170 Seating Eval -1/4 Hr 5013D LS Traction: Prone _Supine _ Ibs on - Ibs of - min - 50016 AOL - 114 Hr 50015 Community Mob Assml -114 Hr 50036 Ultrasound Single contipulse _-_ _Wcm ,min 50030 Sonsodmotor -114 Hr 50163 Ultrasound Comb conllpulse _ Wlcm -min 50020 Cog Retraining - 114 Hr 50166 Home PgrWFamlly Ed -114 Hr 50035 lontophoreals -15 Min a _ __MA/Min S M L 50167 Commun Re-integ -1/4 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2.3) -1/4 Hr 50024 Neuromusc Ro-Ed - 114 Hr 50128 Moist Heat X Min 50164 Neuromusc Sfim - 1/4 Hr 50010 Cold Pack / Ice Message X Min 50012 Fluldotherapy -114 Hr 50163 Adlustment 50D14 WP a _ FX _rnin 50028 a OT Indivtd -114 Hr 50050 Splint - Simple 50005 Stertie WP a - FX _ mtn 50125 OT Group -1/4 Hr 50050 Splint - Complex 50028 PT - 114 Hr 50017 PT Individ - i Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar. 1/4 Hr 50172 PTGroup -1 Hr (Aqua) 50023 Massage -114 Hr 50112 PT Wrk Raadl Eval -112 Hr 50111 OT Wrk Readl Evol -112 Hr 50164 Progressive Ex -114 Hr 50127 Elec Stim 50113 PT Wrk Readl -114 Hr 50112 OT Wrk Readl - 114 Hr 50166 Home Pgm/Famlly Ed 50040 Tans Application 50173 PT FCE - 2 His 50179 OT FCE - 2 Kra 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath STG Current: Met: Yes I No LTG Current: Mel: Yes I No Reset: In: Weeks Resat: In: Weeks 2--Fa- ient tolerated treatment well _ G? Home Exercise Program reviewed El The Exercise Program advanced as per flow shoat C- ems.- Cpr°t Roc- PLAN: l2-Upgrade Ira4 vllles as tolerated iper protocol ? Discharge from Therapy Comment THERAPIST SIGNATURE OI r?J THERAPY MINUTES: 3 TOTAL UNITS: ___T"? ew HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP cantor mb Hand C NWC 884 8 (`.qj +?? ??'(t r+ 1M I)A A M M A D C A A A CHAR E TI E7 880 82 V ? ? q Date SpWd 885 DFE ChmM Hrahy 886 888 891 $ r U f 440 - Z I r w w A V Therapist Number Lobn aal Cara 892 894 .. L r?1c M OD a, $C O t - .,, y 0'44) Z04 Il 9 7 CX N15 R/S Rx Expires: 1 DAILY NOTE sU8J nremarkable Q No new complaints G3'll ? Increased/Decreased pain after last visit ? Patient pain level a to Patient Reports: OBJECTIVE: Aran Treated: -zy Swelling: Ecch meals; ROM: J ° ?( G Strength: t Function: Comments: 1.r- / fn - s' /F c. ?, /.y o tsit?lLJL_?. TREATMENT CONSISTED OF THE FOL v Cd Description Svc d Description 50119 PT Eval -114 Hr 50167 Isokinalic Test - 112 Hr 50029 Wheelchair Eval -114 Hr 50165 isoklnatic Training -114 Hr 50077 CS Tradtion: Static- Int ! Ibs on _ lbs off min _ 50130 LS Traction: Prone _ Supine _ Ibs an _ lbs off _ min 50036 Ultrasound Single conVpuise _Wkm lmin 50163 Ultrasound Comb congpulse _W1cm _min 50035 lontophoresis - 15 Min ® _ _MAIMIn S M L 50037 Phonophoreale 50013 Jobst Compression 50128 Moist Heat X Min 50010 Cold Pack 1 Ice Massage X Min 50014 WP ® - FA _min 50005 Sterile WP 0 _ FX _ min 50028 PT - 1/4 Hr 50017 PT individ - 1 Hr (Aqua) 50126 PT Group Thar - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1/4 Hr 50164 Progressive Ex -1/4 Hr 50127 Else Slim 50166 Home PgnVFamily Ed 50040 Tans Application 50024 Neuromusc Ra-Ed - 114 Hr 50012 Flu(dotherapy 50011 Paraffin Bath vc t n vc d D scr do 50118 OT Eval - 1/4 Hr 50119 OT Re-Eval -114 Hr 50168 Home Eval -1/4 Hr 50029 Wheelchair Eval -114 Hr 50169 Job Site Eval - IM Hr 50170 Seating Eval -1/4 Hr 50016 ADL - 1/4 Hr 50015 Community Mob Assmt -1/4 Hr 50030 Sensorimotor-114 Hr 50020 Cog Retraining - 114 Hr 50166 Home PgmlFamily Ed -114 Hr 50167 Commun Re-Integ - 114 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) - 114 Hr 50024 Neuromusc Re-Ed -114 Hr 50164 Neuromusc Slim -1/4 Hr 50012 Fluldotherapy -1/4 Hr 50163 Adjustment 50028 '2- OT Indlvld - tf4 Hr 50050 Splint - Slmpla 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50112 PT Wrk Rsadl Eval - 112 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl -1f4 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT: STG Current: Met: Yes I No LTG Current:._._ . Met: Yes 1 No Reset: In: Weeks Reset: In: VV&aks ? Patient tolerated tra nl well ? HDme Exercise Program reviewed _? T is?aaProg m li any far ow t PLAN: ?,gra Wp, ? Disc harge from Therapy THERAPIST SIGNATURTHERAPY MINUTES: TOTAL UNITS a a HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Canlor Hand CnrryA#d Nwcmb T CHARGE TIC K E 880 882 895 884 ? ?> / j /-11 ( SpAMd LIFE OnmH1 Hrshy Da 885 886 888 891 JC I Lobn Bet Gem Therapist Number 892 894 CX NI6 R/5 Rx Expiras; ;2 DAILY NOTE SUBJECTIVE: ? Unremarkable ? No new complaints ? Increas Arse Treated: ROM: Strength: Function: Comments: 000"0115:8 '4L AN, -10614AMMAD ?106/M 7 0 R-0 58 M MA LYNCH "D, SCOTT pain after last visit Patient pain level CA SvcCd Description vcCd Description 50119 PT Eval - 1/4 Hr 50167 Isoldnetic Test - 112 Hr 50029 Wheelchair Evai -114 Hr 50165 Isokinetic Training -114 Hr 50077 CS Trection: Static- Ink - Ibs on T, lbs off min 50130 LS Traclion: Prone _ Supin e V Ibs on lbs oll min 50036 Ultrasound Single eonl/pulae l Wlcm _min 50163 Ultrasound Comb conUpulse „ W/cm min 50035 kontophoresls -15 Min 0 _ __MA/Min 5 M L 50037 Phanophoresis 5OD13 Jabal Compression 50128 Moist Heat X Min 50010 Cold Pack / Ice Message X Min 50014 WP 0 _ FX _min 50005 Starke WP 0 ____ FX _ ,min 50028 PT -114 Hr 50017 PT Individ - i Hr (Aqua) 50126 PT Group That -114 Hr 50172 PT Group - 1 Hr (Aqua) f b ?E 7h L1, r.N....? ? Z?T u1? S-f-d Description SvCd Descrbtbn 50118 OT Eval -114 Hr 50119 OT Re-Eval -114 Hr 50168 Hamm Eval - 114 Hr 50029 Wheelchair Eval -114 Hr 50169 Job Site Evak -1/4 Hr 50170 Seating Eval -114 Hr 50016 ADL -114 Hr 50015 Community Mob Assmt -114 Hr 50030 Sensodmotor-114 Hr 50020 Cog Retraining - 114 Hr 50166 Home Pgmll amky Ed -1/4 Hr 50167 Commun Re-lateg -1/4 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) - 114 Hr 50024 Neuromusc Re-Ed -114 Hr 50164 Nouromusc Slim -114 Hr 50012 Fkutdot rapy -114 H 50163 Adjustment 50028 _*&LOT Individ -1/4 Hr 50050 SpIUd - simple 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50023 Massage - 1/4 Hr 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Readl Eva] -112 Hr 50164 Progressive Ex - 114 Hr 50127 ___L sac Stim 50113 PT Wrk Read) -1/4 Hr 50112 OT Wyk Readl -114 Hr 50166 Home Pgm/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuramusc Ra-Ed - 114 Hr 50012 Fluldotherepy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSE33MENT: r sTG Current. i Ms1: Yas ! No LTG Current: PLC' Met: Yes / No /Reset: br: Weeks Reset: In: Weeks t5Pedant tolerated treatment w ll e ? Home Exercise Progra m reviewed 0 The Exercise Prog ram advanced as per flow sheet PLAN: 0 Upgrade activit s t lera ed /per pro cot Dlsehargo from Therapy Comment: THERAPIST SIGNATURE: THERAPY MINUTES: 1- ?D TOTAL UNITS: Rd WZ4100 "se HEALTHSOUTH Rehab of Mechanicsburg ~ OUTPATIENT WORKERS' COMP CmID, Heed CMryMd NWUab :GRE TICKET 880 882 895 884 S 000"101115.18 12.111 j10$ , L ,\(W L ? fMd LIFE ChmHl Hrshy ` ` Dote 885 886 888 891 L e1 1lr Lebn SW Cam OR O Therapist Number 892 B94 CX N h 5 R1S L Y N C H w o, S-C 0 T t Rx Expires: 0 t r DAILY NOTE SUBJECTIVE: 110 0 unremarkable new complaints ? Increased/Decreased pain after last visit O Patient pain level Patient Reports: Area Treated: j^ ROM: Strength: Function: r Comments: Ecchymosis: S-Cd Descdptlgn SvcCd Description SvcCd Cigacrid 50119 PT Eval -1/4 Hr 50167 laokinatic Test - 112 Hr 50118 OT Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50165 Isokinetic Training -1/4 Hr 50168 Home Eval - 114 Hr 50077 CS Traction: Static Int - his on _ ms oh! min _ 50169 Job She Evol -1A Hr 50130 LS Traction: Prone ^ Supine _ the m _, Ibs oh- min- 50016 ADL -1/4 Hr 50036 Ultrasound Single conUpulse _ Wlcm lmin 50030 Sensorlmotor-114 Hr 50163 unrasound Comb cont/pulse _ Wicm 50020 Cog Retraining -1/4 Hr 50035 lontophoreals • 15 Min C _MA/Min 5 M L 50167 Commun Re-Integ - 1/4 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3) - 1/4 Hr 50128 Moist Heat X Min 50164 Neummusc Slim -114 Hr 50010 Cold Pack I Ica Massage K Min 50012 Fluidotherapy -114 Hr 50014 WP @ _ FX _min 50028 2- OT Individ • 114 Hr 50005 Sterile WP 0 _ FX `min 50125 OT Group -114 Hr 50028 PT - 114 Hr 50017 PT Indivld - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther - 1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 60164 Progressive Ex -1/4 Hr 50127 Elec shm 50113 50166 Home PgrNFamlty Ed 50040 Tens Application 50173 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldotharapy 50174 50011 Paraffin Bath ASSESSMENT: / J! i STG Currant: Met: Yes 1 No LTG Curmn ftaset'. In. Weeks Reset: / ? Patient tolerated treatment well ? Home Exercise Progra m reviewed PLAN: ado achy s as too, per tocol , r ?groe 1 herapy Comment: THERAPIST SIGNATURE: r S-Cd Description 50119 OT Re-Eval -114 Hr 50029 WheelchalrEval -1/4 Hr 50170 Seating Eval -114 Hr 50015 Community Mob Assmt -114 50166 Home PgrrYFamhy Ed -114 Hr 50165 Patient Ed -114 Hr 50024 Neuromusc Re-Ed - 114 Hr 50163 Adjustment 50050 Splint - Simple 50050 Splint - Complex PT Wrk Raadl Eval -1/2 Hr 50111 OT Wrk Read( Eval -112 Hr PT Wrk Readi -114 Hr 50112 OT Wrk Readi -114 Hr PT FCE - 2 Hrs 50179 OT FCE - 2 His PT Wrk Hard - 1 Hr 50180 OT Wik Hard -1 Hr Mot: Yes I No ln: Weeks The Exercise Program advanced as per now shoal THERAPY MINUTES: TOTAL UNITS'. aw / HEALTHSOUTH Rehab of Mechanicsburg ' GOMP OUTPATIENT WORKERS carver Hand cnkymd Nwcmb 895 884 • • 000101158 CHARG TICKET ? ' Y 880 882 ASLAM, MUMARNAQ C 0 Z-/ 2- 0 SprtMd LIFE ChmM Hraby pate 21? 885 886 888 891 2/0e/ 1947 DRO Lebo Bat Care 1W 4 a h ? N Therapist Number 892 894 E TSICH Wv, 4C.OTT / CX N/S _JL R/5 U O r Rx Expires: •',?,' ::r`, t? DAILY NOTE SUS.[E?TIYE: - ? Unremarkable O Na na com plaintts Inc reased/Docreased pain after last visit ? Pallent pain level ® 110 Patient Reports: OBJECTIVE: Area Treated: Swelling: Ecchymo3d: ROM: Strength: Funcllon: Comments: vcCd Description vcC Description amc& pes vcC cri on 50119 PT Eval -1/4 Hr 50167 isokinetic'Test -1/2 Hr 50118 OT oval • % Hr 50119 OT Re-Eval - 114 Hr 50029 Wheelchair Eval - 1/4 Hr 50155 lsokinetlc Training -114 Hr 50158 W6 me Eval -114 Hr 50029 Wheeiehalr Eval - 1/4 Hr 50077 CS Traction: Static _ Int _ Ibs on _ Ibs off _ min, 50169 Job Site Eva[ -114 Hr 50170 Seating Eval -1/4 Hr 50130 LS Traction: Prone _ Supine Ibs on - We off _ min„ 50016 AOL - 1/4 Hr 50015 Community Mob Assmi -1/4 Hr 50036 Ultrasound Single conUpulse _ W/cm _min 50030 -Sensortmotor - 1/4 Hr 50163 ultrasound Comb cont/pulse _ W/cm _min i 511020 Cog Retraining -1/4 Hr 50186 Home PgmlFamlly Ed -1/4 Hr 50035 lontophoresis -15 Min ® ^MA/MIn S M L 50167 Commun Rednteg • 1/4 Hr 50155 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression,,,/' 50125 Group (2-3).1/4 Hr 50024 Neuramusc Re-Ed -114 Hr 50128 Moist Heat X Min l 50164 Neuramusc Stlm -114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluldotherapy -114 Hr 50163 Adjustment 50014 WP a _ FX _min j 50D28 OT Indivld - 114 Hr 50050 Splint -Simple 50005 Sterile WP _ FX _ min ' 50125 OT Group - 114 Hr 50050 splint - Complex 50028 PT - 114 hr 5DD17 i PT Indivld - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther - 114 Hr 50172 PT Group -1 Hr (Aqua) J ! 50023 Massage- 1/4 Hr // 50112 PT Wrk Readl Eval • 1/2 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive Ex - 1/4 Hr 127 Eioc Slim 50113 PT Wrk Readl -114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home PgmlFamlly Ed 50040 Tans Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 His 50024 Neuromusc Ro-Ed - 4 Hr 50012 Ruldolherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT / STG Current: Met: Yes 1 No LTG Current: Resat: In: Weeks Reset: ? Patient t sled treatment wall ? Home Exerciao Program reviewed PLAN: 43 Upgrade activities as tuieral / protocol ? Discharge frur Therapy Comment THERAPIST SIGNATURE, Met: Yes/ No in: Weeks ? The Exercise Program advanced as per flow sheet THERAPY MINUTES: 07 TOTAL UNITS: ease z OUTPATIENT WORKERS' COMP CI TiQKET Date _213 Therapist Number GX N/S Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable CTIVE: tROMA: Re reated:KIM th: on: Comments: ?ON -,- Cantor Had Ln7ryMd Nwcmb 880 882 895 884 000101158 12/1 Wo! SprMb LIFE ChmH1 Herby A UA M' y.U R A O NA D C 885 886 886 891 RIS ..w Labn eat care ?/06/1947 `O R O 892 894 0! 6 M WA LYNCH "Cis SCO r ,,1wir ? increased/Decreased pain attar last visit ?Patlent pain leveP6 ?k .. . Ecchymosis: vc d Description SvaCd Description vc d Description a-cd Description 50119 PT Eval - 114 Hr 50167 taokinetlc Test -112 Hr 50118 OT Eval -1/4 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval - 114 Hr 50165 Isokinetic Training - 114 Hr 50166. Home Eval -1/4 Hr 50029 Wheelchair Eval - V4 Hr 50077 CS Traction: Static _ Int , ibs on _ Ibs off - min - 50169 Job She Eva) -114 Hr 50170 Seating Eva( -114 Hr 50130 LS Traction: Prone _ Supine_ Ibs on _ lbs off _ min _ 60016 AOL - 94 Hr 50015 Community Mob Asamt -1/4 Hr 50036 Ultrasound Single contlpulse _ Wlcm _,mm 50030 Sensorimotor -114 Hr 50163 ultrasound Comb mnt/pulss.+ Wlan min 50020 Cog Retraining -114 Hr 50166 Home Pgrnfamlly Ed -114 Hr 50035 iontophoresis -15 Min @ _ _MAIMM S M L 50167 Commun Re4ateg - 114 Hr 50165 Patient Ed - 114 Hr 50037 Phonophoresls 50013 Jobst Compresslon 50125 Group (2-3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X -Min 50164 Neuromusc Stim -114 Hr 50010 Cold Pack / Ica Massage X Min 50012 F)uldotherapy -1/4 Hr 50163 Adjustment 50014 WP 0 _FX ___-,min 50028 ? OT Indlvld - 114 Hr 50050 splint - simple 50005 Sterile WP Q _ FX , min 50125 OT Group -1/4 Hr 50050 Splint - Complex 50028 PT -1/4 Hr 50017 PT lndlvld -1 Hr (Aqua) 50011 Paraffin Bath - 50126 PT Group Ther - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wrk Readl Evai - 112 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive Ex -1/4 Hr 50127 Elec Stim 50113 PT Wrk Read! - 1/4 Hr 50112 OT Wrk Readl - 1/4 Hr 50166 Home PgrNFamiiy Ed 50040 Tens Application 50173 PT FCE - 2 His 50179 OT FCE - 2 Hm 50024 Neuromusc Re-Ed -1/4 Hr 50012 Fluidotherapy 50174 PT Wrk Hard - I Hr 50180 OT Wrk Hard -1 Hr 50011 Para Bath ASSESSMENT: STG Current: 1, /! Re lX•r anent id lot PLAN; THERAPIST SIGNATUI Met: Yes / No LTG Current: In: Weeks Reset: will /? Home Exercise Program reviewed /perpro)qol 9plschergetomrherapy Comment: Malt Yes/ No /I Of In: Weeks ? The Exercise Program advanced as per Bow sheet THERAPY M(Nl1TES: TOTAL UNITS: eWne HEALTHSOUTH Rehab of Mecl OUTPATIENT WORKERS' COMP CHAfjGE TIC ET 1 Dale 77 ( )-/r1/ Therapist Number Cx 1?1s, ws _ Rx Expires: 'J DAILY NOTE SUBJECTIVE: ? Unremarkable ? No Patient Reports. ConfOr Hand CntryMtl NwCmb 880 882 895 884 SprtMd UFE "' CMd i?l Hrstn 885 886 888 891 Lebo Bal Cam 892 894 0001.^,'';$ 12/14!43 kS,16 AM, HUNA1111I*#A$ C ?/D6/1$47 ORO 058 " MA. LYNCH K. ,C.01Y w00i04 90 3111 pain after last visit ? Patten pain level Q l10 OBJECTIVE: Area Trasted. Swelling: Ecchymosis: ROM: Strength: Function: Comments: TREATMENT CONSISTED OF THE FOLLOWING MODALITIES AND PROCEDURES: vcCd Descriotion SvcCd Description SvcCd Description S-Cd Description 50119 PT Eval -114 Hr 50167 leokinetic Test - 112 Hr 50118 OT Evel - 114 Hr : 50119 OT Re-Eva) -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isokinetlc Training -114 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval-114 Hr 50077 CS Traction: Static , Int _ his on - Ibs oft _ min _ 50169 Job Shp Eval -114 Hr 50170 Beating Eval -1/4 Hr 50130 LS Traction: Prone _ Supine Ibs an _ Iris off _ min _ 50016 AOL-114 Hr 50015 Community Mob Assmt -114 Hr 50036 Ultrasound Single contlpulse _W/cm _ -_min 50030 `Senaorlmotor -114 Hr 50153 Ultrasound Comb contipuise _Wlcm __ _min 50020 Cog Retraining -1/4 Hr 50166 Home PgnUFamlly Ed -114 Mr 50035 lontophoresis -15 Min Q _MA/Min S M L 50167. Commun Rednteg - 114 Hr 50165 Patient Ed -114 Hr 50037 Phonophorests 50013 Jobst Compression 50125 Group (23) -114 Hr 50024 Neuromusc Re-Ed -1/4 Hr 50128 Moist Heat X Min 50164 Neuromusc Stim -114 Hr 50010 Cold Pack I Ice Massage X, Min 50012 Fluldotherapy -114 Hr 50163 Adjustment 50014 WP Q ` FX _min 50028 OT Indlvld - 114 Hr 50050 Splint - Simple 50005 Sterile WP 0 _ FX _min 50125 OT Group - 114 Hr 50050 Splint - Complex 50028 PT -114 Hr 50017 PT indlvtd - 1 Hr (Aqua) 50011 _ Paraffin Beth 50126 PT Group Thar - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex -114 Hr 50127 Eiec Sum 50166 Home Pgm/Famlly Ed 50040; Tans Application 50024 Neuromusc Re-Ed - 1/4 Hr 5QO12 Fluldotherapy 50011 Paromn Bath 50112 PT Wrk Readl Eval -1/2 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl - 114 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 Mrs 50179 OT FCE - 2 We 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT: i? STG Current: / Mat: Yes / No LTG Current: Reset: In: Weeks - Reset: J ? Patient tolerate eatment well ? Home Exercise Program reviewed PLAN: ? grade activities as toleratod er protocol ??Micharge fro Tt)erapy Comm nl: THERAPIST SIGNATURE: / L Met: Yes / No In: Weeks ? The Exercise Program advanced as per now sheet THERAPY MINUTES: TOTAL UNITS: eels OUTPATIENT WORKERS' CDMP CHARGE TICKET aer Therapist Number Px Expires: CX mup? DAILY NOTE SUBJEQ E: nremarkable Patient Reooft; ? Area Treated: ROM: Strength: Function: Comments: GantDr Hang CmryM NwCmh 880 882 895 884 SwWd LIFE ChmNl Nrthy 885 886 888 891 Lela! aw Cam 892 894 Pis CYNo new complaints ? 0 0 0 ,10 11,58 12 t l? 1? A,SL AM a MUHAME40 1/0VIW ORO 05& M NA l.r?fCr1 M0a SCOTT F 0401Q41'4$ ..... ,?. pain after last visit ? Patient pain level ® !to EcchymoaW r S-Cd Oescriotlon SvcCd tion Svc d Description Svc Description 50119 PT Eval - 114 Hr 50157 Isakinetlc Test -112 Hr 50118 OT Eval -1/4 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval - 114 Hr 50165 Isaklne8c Training - IA Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eve) - 114 Hr 50077 CS Traction; Static Int _ Ibs on _ too off - min _ 50169 Job Site Eva( -114 Hr 50170 Seating Eval -1/4 Hr 50130 LS Traction: Prone Supine - Ibs on - Ibs ON _ min - 50016 ADL - 1/4 Hr 50015 Community Mob Assmi -114 Hr 50036 Ultrasound Single conl/pulse -_ Wlcm lmin 50030 Sonsodmotor -114 Hr 50163 Ultrasound Comb condpulse -- Wlcm 50020 Cog Retraining - 1/4 Hr 50166 Home Pgm/Famlly Ed -114 Hr 50035 lantophoresis -IS Min Q _MAIM)n S M L 50167 Commun Re-integ -114 Hr 50165 Patent Ed -1/4 Hr 50037 Phonaphoresis 50013 Jobst Compression 50125 Group (2.3) -114 Hr 50024 Neummusc Re-Ed - 114 Hr 50128 Moist Heat X Mtn 50164 Neuromusc S8m - 114 Hr 50010 Cold Pack / Ice Massage X Mi n 50012 Fluldotherapy - 114 Hr 50163 Adjustment 50014 WP C, FX _min 50028 OT Indlvid . 114 Hr 50050 Splint - Simple 50005 sterile WP a _ FX amin 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT - 1/4 Hr 50017 PT Individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther- 114 Hr 50172 PT Group- i He (Aqua) 50023 Massage - 1/4 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Readi Eva) -1/2 Hr 50164 Progressive Ex - U4 Hr 50127 Elec Slim 50113 PT Wrk Readi - 114 Hr 50112 OT Wrk Readi -114 Hr 50166 Home PgrWFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hm 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Rutdotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraflln Hath ASSESSMENT. STG Current: Met: Yes I No LTG Current Met: Yes/No Reset: In: Weeks Reset: In: Weeks ? Patient tolerated treatment well ? Homo Examiso Program reviewed ? The Exercise Pro gram advanced as per Bow sheet PLAN: 6-10 red. activities arato i er 1 ? Discharge from Therapy Comment : r G THERAPIST SIGNATU E: _ THERAPY MINUTES: TOTAL UNITS: erlae HEALTHSOUTH Rehab of Mec OUTPATIENT WORKERS' COMP CHAR TICK 7 / ,2v UCp Dees Therapist Number Rx t 5 Rx Expires: DAILY NOTE Area Treated: ROM: Strength: Function: Comments; Can(Dr Hand UyMd NwCmb 880 882 895 884 SpdVd LIFE ChmH1 Hrjhy 885 886 868 891 Lebn Be) Care 892 894 R/S ? No new complain?/ ? (? /) 000-1011sa A SL A M , MUMA*mo C 1`/06/190 000 056 N WA LY,iCm ion, r ttOTt ?0{?z?1a1t1? ??? <pain after last visit ^ ? Patienttpaln level 0 110 Ecchymosls: a vc Description SvcCd Description vcCd Deschatlon Svc Description 50119 PT Eval -1/4 Hr 50167 Isokinetlc Test -1/2 Hr 50118 OT Eval -1/4 Hr 50119 OT Re-Eva) - 114 Hr 50029 Wheelchair Eval - 114 Hr 50165 isakinatic Training -1/4 Hr 50168 Home Eval - 1/4 Hr 50029 Wheelchair Eval -114 Hr 50077 CS Traction: Static _, lnt _ Ibs on _ Ibs off _ min _ 50169 Job Site Eval • 114 Hr 50170 Seating Eval -114 Hr 50130 L5 Tradlon; Prone _ Supine _ Ibs on _ Ibs off _ min _ 50016 ADL -114 Hr 50015 Community Mob Assmt -114 H 50036 Uthmound Smgteconuputse_W/cm _min 50030 Sansortmotor- 1/4 Hr 50163 Ultrasound Comb contlpuise _Wicm _-min 50020 Cog Retraining -114 Hr 50166 Home PgmlFamlly Ed -1/4 Hr 50035 iontephoresis - 15 Min ® _MA/Min 5 M L 50167 Commun Re-Irdep • 1/4 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophoresls 50013 Jobat Compression 50125 Group (2-3) -1/4 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Slim- 114 Hr 50010 Cold Pack I Ice Massage Y, Min 50012 Fluldotharapy -114 Hr 50163 Adjustment 50014 WP a FX min 50028 ?- ?`2 z" ?j _ _ . OT Indivki -114 Kr, 50050 Splint - Simple 50005 Sterile WP 0 _ FX -,_ ,min 50125 OT Group -114 Hr 50050 Splint - Complex 5002B PT -1/4 Hr 50017 PT Indlvld -1 Hr (Aqua) 50011 Parallin Bath _ 50126 PT Group Ther -1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr / 50112 PT Wrk Readi Eval - 1/2 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive I-% - 114 Hr 50127 Elec Stim 501 13 Pi Wrk Read! -1/4 Hr 50112 OT Wrk Readl - tl4 Hr 50166 Home PurwFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Kra 50024 Neuromusc Re-Ed -114 Hr 50012 Fluidotherapy 50174 PT Wrk Hard -I Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath I A53ESSMENT? STG Current: Met: Yes l No LTG Cunent: Met: Yes I No Reset: r in: Weeks Reset: In: Weeks r _ ? Patient loierat aament well ? Hama Exercise Progr I reviewed ? The Exercise Program advanced as per flow sheet PLAN: Upgra a activ s a?toletatd /par protocol harge (roTherapy Comment: THERAPIST SIGNATURE: THERAPY MINUTES TOTAL UNITS: ?/ ev m rrII R C? LY Z/ i? 7 ?f ti f? LL • L.C ?(.. cal t y /' L/? c -?J /, . ?. A ?? 58 Oaf`? NE i LTI SOUTN Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Hand 8" Q ?) N 884o ? N S L A M, n ttri A 14M AD C CHARG TICKET 8 882 ?/06/1947 B R O SprfMd LIFE CWHI Hr$hy Oate 885 886 886 891 0 50 M WA y Lxbn 001 taro L r lw C H 040 • S C O T T Therapist Number 892 894 CX S R/S Rx Expires: ,:? DAILY NOTE BUS ECTIV : nremarkable ? No new complaints ? IncreasedfUscreased pain after last visit ? Patient pain level ® /10 Patient Reports: P OBJECTIVE: Area Treated: Swelling Ecchymosis: ROM: ? ono .7 -J4 47 Ile. ;:j Strength: Function: Comments: W9, Oesedption SvcCd Description SvCd Description vr:Cd a ed on PT Evai - 114 Hr 50167 Isokinatic last - 112 Hr 50118 OT Evai -114 Hr 50119 OT Re-Eval -1114 Hr r Wheelchair Eval -1/4 Hr 50165 Isokinatlc Training -114 Hr 50168 Home Eval -114 Hr 50029 Whealchak Eval -114 Hr CS Traction: Static - Int - Ibs on _ lbs off _ min J 50169 Job Site Eval -114 Hr 50170 Seating Eval -114 Hr 5030 LS Traction: Prone _ Supine _ Ibs on _ Ibs off _ min 50016 ADL • i!4 Hr 50015 Cpmrnunity Mob Assml • V4 Hr 50036 Ultrasound single conupulse --- W/cm _min 50030 Sensorknotor - V4 Hr 50153 Ultrasound Comb conupulse _W/cm _mfn 50020 Cog Retraining -114 Hr 50166 Home PgMFamily Ed -1/4 Hr 50035 lontophoreals - 15 Min C MA/Mln 8 M L 50167 Commun Re-tnteg - V4 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3) -1/4 Hr 50024 Neuromusc Re-Ed -1/4 Hr 50128 Molst Heat X Min 50164 Neuramusc Shm -1/4 Hr 50010 gold Pack 1 Ice Massage X Min 50012 Fluldotherapy -114 Hr 50163 Ad{ustmant 50014 WP ® _ FX ____min 50028 OT tndivid -114 Hr ; 50050 Splint - Simple 50005 Sterile WP @ _ FX _ min. , 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT -114 Hr 50017 PT Indlvid -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther -114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Readl Eval - 112 Hr 50164 Progressive Ex -1/4 Hr 50127 Elec Slim 50113 PT Wrk Readi - 114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home PgrNFamlly Ed 50040 Tens Application 50173 PT FCE - 2 His 50179 OT FCE - 2 Hrs 50024 Neummusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - i Hr 50011 Parailin Bath ASSESSMENT: r STG Cunem Met: Yes/No LTG Current: Met: Yes I No Reset: in: Weeks Reset: In: Weeks ? Paeerit tolerat d treatment well ? Home Exercise Program reviewed ? The Exercise Program advanced as per now sheet PLAN; ,, ??ade?activllles stated /per cat of ? scharga from Therapy Comment: THERAPIST SIGNAT RE a? THERAPY MINUTES: TOTAL UNITS: 9vi{ OUTPATIENT WORKERS` COMP CHARGE TICKET oars 2-19 Therapist Number CX Rx Expires: _ DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Reports: _ N/S Alas csburg CenlDr Hand nhy NwCmb 880 882 895 884 R 1 SprfMd LIFE ChmHl Hrshy 01D01011 8 885 886 888 891 A 5 R y N U01N M Ai D C Lobo 921 Care eat e94 r 10 ?t / 7 oRa ws 056 X M A -- ?raa k 00, SCO" ooax???a? 316 No new complaints ? incressedlD9creased pain after last vish ? Patient pain level C /10 Area Treated: // SW WT ROM: lc?dr // a? _V?•l ?n Strength: l- /- Function: ?-?77/'?? t?7 TTl _ L Comments: / •I? / t!1 /] }? e? SvcCd Desc ilon vcCd Description S-Cd Description SycCd Description 50119 PT Eval - 1/4 Hr 50167 Isoklnetic Test - 112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eval - 114 Hr 50029 Wheelchair Eval - 114 Hr 50165 13oldnetic Training -114 Hr 50168 Horne Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50077 CS Traction: Static- Int _ Ibs on _ Ibs o8_ min _ 50169 Job Site Eva( -114 Hr 50170 Beating Eva1.114 Hr 50130 LS Traction: Prone _ Supine _ Ibs on _ Its off- min _ 50016 ADL -1/4 Hr 50015 Community Mob Aasrit -114 Hr 50036 Ultrasound Single conupulse _W/cm - ___min 50030 Sensarimotor- 1/4 Hr 50163 Ultrasound Comb conupuise _W/cm _min 50020 Cog Retraining -114 Hr 50166 Home Pgm/Famlly Ed -114 Hr 50035 iontophorasls -15 Min a _MA/Mln 5 M L 50167 Commun Re-intag -1/4 Hr 50165 Patient Ed -114 Hr 50037 Phonaphoresls 50013 Jobst Compression 50125 Gmup (2-3) -1/4 Hr 50024 Neuromusc Re-Ed - 1/4 Hr 50128 Moist Heat X Min 50164 Neuromusc Sum -1/4 Hr 50010 Cold Pack / Ice Message X Min 50012 Fluldotherapy - 1/4 Hr 50163 Adjustment 50014 wP , FX _min 50028 OT IndIvId - 114 Hr 50050 Splint - Simple 50005 Sterile WP Q ^ FX _ min 50125 OT Group - 1/4 Hr 50050 Splint - Complex 50028 PT -114 Hr 50017 PT IndIvId - 1 Hr (Aqua) 50011 Paraffin Bath _ 50126 PT Group Ther -114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Read] Eval -112 Hr 50111 OT Wrk Readl Eval - 112 Hr 50164 Progressive Ex - 114 Hr 50127 -4-Elec sum 50113 PT Wrk Readl - 114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home Pgm/Famlly Ed 5OD40 Tens Application 50173 PT FCE - 2 His 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluidotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath ASSESSMENT; / STG Current: Met: Yes / No LTG Current: Reset: In: Weeks Reset: ? Patient tolerated treatment wall L1 Home Exorcise Program reviewed PLAN: TT)lpgrade sctlvl as Iq d7p ,p tocol ? Discharge from Therapy Comment: THERAPIST SIGNAE TUE ??RE / Met: Yes t No In: Weeks ? The Exercise Program advanced as per how sheet THERAPY MINUTES: TOTAL UNITS; ev e HEALTHSOLITH Rehab of Mec OUTPATIENT WORKERS' COMP CHA E TIC ET Date Therapist Number CX N/S Rx Expires: DAILY NOTE SUBJECTIVE; ? Unremarkable Patient Reports: ? No new complaints ? Increased/Decreasad painlafter last ? Patient pain love{ a /1D Area Treated: Swelling: Ecchymosls: ROM', Strength: v? Function: Comments: SvcCd Description SvcGd Description Svcod DeacrioWn vc Description 50119 PT Eval - 114 Hr 50167 tsokinetlc Teal - 112 Hr 50118 OT Eval - 114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Evai -114 Hr 50165 Isokinetic Training - 1/4 Hr 50168 Home Eval -1/4 Hr 50029 Wheelchair Eval -1/4 Hr 50077 CS Traction: Stalk int _ IDs on _ Ibs off , min _ 50169 Job Site Eval = 114 Hr 50170 Seating Eval -114 Hr 50130 LS Traction: Prone Supine! Ibs on - Ibs oft - min _ 50016 ADL - 114 fir 50015 Community Mob Assmt -1/4 Hr 50036 ultrasound single conUputse _ Wicm _Min 50030 Sensor fi!tM. -1/4 Hr 50163 Ultrasound Comb conuprdse „ Wlcrn 50020 CogrRetraining -114 Hr 50166 Home PgmfFemlty Ed -1A Hr 50035 lontophoresis -IS Min ® _MA/Mln S M L 50167 ,Commun Re-Irdeg -1/4 Hr 50165 Patient Ed -114 Hr 50037 Phonophoreals 50013 Jobsi Compression 50125 Group (2.3) - 114 Hr 50024 Nauromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 t4wromusc SUM -114 Hr 50010 Cold Pack / Ice Massage X Min 50012; Fluldotherapy -114 Hr 50163 Adjustment 50014 WP a _ FX ^mtn 50928 OT tndivkl -114 Hr 50050 Splint - Simple 50005 Sterile WP a ! FX ____Mtn 56125 OT Group - 114 W 50050 Splint - Complex 50028 PT - 114 Hr 50017 PT individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thor -114 Hr 50172 PT Group - 1 Hr (Aqua)' 50023 Massage -114 Hr 50112 PT Wrk Readi Eva) -112 Hr 50111 OT Wrk Readi Eval • 112 Hr 50164 Progressive Ex- 114 Hr 50127 Elec Stim 50113 PT Wrk Read] - 114 Hr 50112 OT WrX Readl-114 Hr 50166 Home Pgrn/Famliy Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromuse Re-Ed - 114 Hr 50012 Fluidotha'rapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath r ASSESSMENT: STG Current: Mot: Yes/No LTG Current: Met: Yes/ No Rasat: in: Weeks Reset: In: Weeks ? Patien t tolerated treatment well ? Home Exercise Program reviewed ? The Exercise Program advanced as per flaw sheet PLAN: ? Upgrade activities as tolerated7per p oc I O Ischarge Irom T rapt' Comme nt: THERAPIST SI GNATURE: C- 4 r THERAPY MINUT E-K TOTAL UNITS ae ws t/ GentDr Hand IryWd NwCmb 00 0 ? S 8 880 882 895 1 884 7yL (? a J J ASt,NM, MUMANMAD C SprlMd LIFE Hrahy 885 886 888 891 7/ O W9 4 7 OR* Labe W rare 0 50 ' M M 892 e94 ? YhCN K04 SCOTT OPOD+t14 $16 _ HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Cantur Hand 7 E CHAR E TI KET 880 882 884 95 Spnhld LIFE OMNI Hrshy Date 885 886 .888 891 Willi eel care Therapist Numb r 892 894 004?fl ? sxirs?os kSL AM. MuKAMM#d 1/06/1447 ORO i 0 ss K CGS I - .....,.... ol*cm M0, itb T. -- A v. a 1 a x?r> r ..rK CX N/S ? R/S Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable 0-4o new complaints ? Increased/Decreased pain after last visfi ? Patient pain level ® 11U Patient Reports: ([J " a 1 CL n Area Treated: ROM: Strength: Function; Comments: svccd Description SvcCd Description 50119 PT Eval - 11/4 Hr 50167 Isokinetic Test -112 Hr 50029 Wheelchair Eval -1/4 Hr 50165 Isokinetic Training -114 Hr 50077 CS Traction: Static , Int _ Ibs on , Ills off -_ min _ 50130 LS Traction: Prone _ Supine _ Ibs on _ Ibs off - min _ 50036 Ultrasound Single conNpulse,W/cm _min 50163 Ultrasound Comb conf/pulse _W/cm ^min 50035 lontophoresis -15 Min @ ^MA/Mln S M L 50037 Phonophoresis 50013 Jobst Compression 50128 Moist Heat X Min 50010 Cold Pack / Ice Massage X. Min 50014 WP 0 _ FX lmin 50005 startle WP @ _ FX _ min 50028 PT -114 Hr 50017 _ PT Individ -1 Hr (Aqua) 50126 PT Group Ther -114 Hr 50172 PT Group -1 Hr (Aqua) Edchymosls: DURES: A 47 vcCd Description vcCd Description f ?? 50118 OT Eval -114 Hr 50119 OT Re-Evel -114 Hr 50168 Home Evai -114 Hr 50029 Wheelchair Eval - 114 Hr 50169 Job Site Eval -114 Hr 50170 Seating Eval - iA Hr 50016 AOL - 114 Hr 50015 Community Mob Assml - 114 Hr 50030 Sensorimolar - 114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgrNFamily Ed -114 Hr 50167 Commun Re-irdeg -114 Hr 50165 Patient Ed - 114 Hr 50125 Group (2-3) - 114 Hr 50024 Neuromuso Re-Ed -114 Hr 50164 Neuromuso Stim- 114 Hr 50012 Fluldotherapy -114 Hr 50163 Adjustment 50028 _? OT Indivld -1/4 Hr 50050 Splint - Simple 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50023 Massage - 114 Hr 50112 PT Wrk Rsadl Eval • 1/2 Hr 50111 OT Wrk Readl Evel -1/2 Hr 50164 Progressive Ex -114 Hr 50127 Elec slim 50113 PT Wrk Readi - 1/4 Hr 50112 OT Wrk Readl - 1/4 Hr 50166 Home Pgm/Family Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromuso Re-Ed - 14 Hr 50012 Fluldotherapy 50174 PT Wrk hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath A99ESSMENT: X? /J / STG Current: / t Met: Yes I No LTG Current : / ? Met: Yes/No Roset in: Weeks R t' { k te r ese n: Wee s ient tolerated tre?ant well ? Hom Exarclse Pro am reviewed ? The Exercise Prog ram advanced as per sow sheet PLAN: pgmde acilvllla_ as tolerate 7 er pro ocol ? Disc rge rpm The spy Comment: THERAPIST SIGNATUREr? C L. THERAPY MINUTES: TOTAL UNITS. eWc HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP censor CHAR E TICKET 880 Hand 882 Nwcmb 895 884 : O t SprUrd LIFE mM Hrahy Date 885 886 888 891 4?t!'i llY?? 0001 01158 Llr Labn 8 Cam A S`f A.X, MU144MMAD V W Therapist Number 892 8 894 94 CX N/S R!S w/ ?/06/1947 4 A Y Rx Expires; - 105111 K W A DAILY NOTE 04c" Moll Scott SUBJECTIVE: CYNn new complaints ? Increased/Docream n d pain afteAD43?s?L `v A j 91 ? Patient pain lava[ 6,1-W110 ? Unremarkable Patient Reports: Area Treated: ROM: Strength: Function: Comments: Swelling: Ecchymosis: vcC Description SvcCd esc o vcCd Description 5vood Descr[oilon 50119 PT Eval -114 Hr 50167 Isokinetlc Test - 112 Hr 50118 OT Eval - 114 Hr 50119 or Re-Evel -114 Hr 50029 Wheelchair Eval - 114 Hr 50165 Isokinetic Training - 114 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval -114 Hr 5D077 CS Traction: Static In( _ 1bs on _ Ibs off _ min - 50169 Job She Eval -1/4 Hr 50170 Seating Evai • 1/4 Hr 50130 LS Traction: Prone Supine _ lbs on - Iba off _, min - 50016 ADL - 114 Hr 50015 Community Mob Aasmt • 1/4 Hr 50035 Ultrasound Single cont/pulse _ W/cm -min 50030 Sensorimotor -114 Hr 50163 Ultrasound Comb conVpulse ^ W/an min 50020 Cog Retraining - 114 Hr 50166 Home Pgm/Famlly Ed -114 Hr 50035 lonlophoresls -15 Min ® _MA/M)n S M L 50167 Commun Re-Integ -114 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3) -114 Hr 50024 Neummusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuranwac Slim - 114 Hr 50010 Cold Pack 1 Ice Massage X Min 50012 Fluldotharapy -1/4' Hr 50163 Ad)uslment 50028! OT Individ -114 Hr 50050 S lint - Simple 50014 WP a _ FX lnrln p 50005 Startle WP ® _ FX _ Min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT -1/4 Hr 50017 PT Indtvld - 1 Hr (Aqua) 50011 Paraffin Bath - 50126 PT Gawp Thor - 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wit; Readl Eva) -112 Hr 50111 OT Wrk Readl Eval - 112 Hr 50164 Progressive Ex -114 Hr 50127 Else Slim 50113 PT Wrk Readi - 114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home PgrrJFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE .2 Mrs 50024 Nourcmusc Re-Ed - 114 Hr 50012 Muldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - i Hr 50011 Paraffin Bath ASSESSMENT: STG Current: C Mot: Yes/No L TG Current: - I C - Met: Yes / No Reset Weeks Ire Reset: 7 In: Weeks ? ? / anent tolerated treatment well me Exercise Program r ? 416 eviewed f3LA% Exorcise Pro gram advance d ea per flow sheet PLAN: t rods activities as saluted per protocol ? Discharge from /he/rJapy Comment: THERAPIST SIGNATURE: 7C?Je??/ ( 1? r r flTY) /( THERAPY MINUTES: ` TOTAL UNITS: j be 10"% OUTPATIENT WORKERS' COMP CHAR E ]KET 1 __ lP Dare _ Therapist Number CX N/S R/S Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkat? ? J.1 ? o new Patient Reports: Ihff// CentOr Hand n1ryM NwCmb , 880 882 895 884 ? r 1 ? ? Q SPHAM LIFE ChmHt Hrshy 000 885 886 888 891 AS-LAM, M UN A "M A D C Labn Gal Cara 892 894 ?/06MO47 0ft0 058 N MA 1.?IIIICH 140, SCOTT ?UOxb?lt?"1 30? mpla/ints / ? Increased/Decreased pain after last visit aUent pain level lm 110 Area Treated: Swelling: ROM: Strength: Function: Comments: Ecchymosls: vcCd Description SvcCd Description vc ? tin vcCd Description 50119 PT Eval -1/4 Hr 50167 Isoklnstic Test -112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Evol - 1/4 Hr 50029 Wheelchair Eval -1/4 Hr 50155 Isokinetic Training -1/4 Hr 50168 Home Eval -1/4 Hr 50029 Wheelchair Eval -1/4 Hr 50077 CS Traction: Static _ Int _ his on _ Ibs off _ min _ 50169 Job She Eval -114 Hr 50170 Seating Eval -114 Hr 50130 LS Traction: Prone _ Supine _ Ibs on _ Ibs off _ min _ 50016 AOL -1/4 Hr 50015 Community Mob Assml -114 Hr 50036 Ultrasound Single contipulse_ W/cm _min 50030 Sensortmotor- 1/4 Hr 50163 Ultrasound Comb conupulse _ W1cm ---min 50020 Cog Retraining - 114 Hr 50166 Home PgnVFamky Ed -114 Hr 50035 lontophoresis -15 Min a _MA1MIn S M L 50187 Commun Re-Integ - 114 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophoresis 50013 Jabal Compression 50125 Group (2-3) -1/4 Hr 50024 Neuromusc Re-Ed - 114 Hr 50128 Moist Heat X Min 50164 Neuromusc Stim -114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluldotherapy -114 Hr 50163 Adjustment 50014 WP Q _ FX _min 50028 OT Individ -114 Hr 50050 Splint - Simple 50005 Sterile WP al _ FX _ min 50125 OT Group -1/4 Hr 50050 Splint - Complex 50028 PT - 1/4 Hr 50017 PT Individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar - 1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Readi Eval -112 Hr 50164 Progressive Ex - 114 Hr 50127 Elec Sllm 50113 PT Wrk Readl -1/4 Hr 50112 OT Wrk Read( - 114 Hr 50166 Home Pgm/Family Ed 50040 Tana Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath ASSESSMENT: l j STG Current: Y Met. Yes / No LTG Current: Reset; "7 j- In: Weeks Reset: '04 '1 In. ? Patient tolerated i and well ? Home Exercise Program reviewed ? The Exercise Program advanced as per now sheet PLAN: "'grade acttvilles astolerated ?/per protocol ? Discharge ".o lm Therapy Comment Met: Yes / No Weeks THERAPIST SIGNATURE- THERAPY MINUTES: TDTAL UNITS evlaa OUTPATIENT WORKERS' COMP CHARGE TICKET I to v Date Therapist Number CX NIS WS Rx Expires: Cent& Hand 7Cn1rYMdNwCMb 880 882 Spow LIFE A$ L A M, 01U#4 A 4111 A D 885 886 DAILY NOTE 'SUBJECT(VE1 ? UnremarkalAe 71 ? No ney complaints Lob, 1961 Care 1/06/1947 ORO 692 894 ti 5 e M MA Y4CH Mot KOTT _ 10420404 sib „ ., ,?a? ncreasad/Dec sect pain her lost visit ? Patient pain level 110 Area Treated: ROM: Strength: Function: Comments: Ecchyrnosls: PROC Description SvcCd D s r ton SvcCd j?cdotton SveCd Description PT Eval -114 Hr 50167 lackineft Test -1112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Eval - t/4 Hr 50029 r Wheelchair Eval - 1/4 Hr 50165 IsokineUc Training - 114 Hr 50168 Horne Eva$ • 114 Hr 50029 Wheelchair Evel • 114 Hr (3 CS Tracson: Static - in[ _ Ibs on, Ibs off _ min _ 50169 Job Site Eval -114 Hr 50170 Seating Eval • 114 Hr 50130 15 Traction: Prone _ Supine, Ibs on _ Ibs oft, min 50016 AOL - 114 Hr 50015 Community Mob Assmt -1/4 Hr 50036 Ulrasound Stngle contfpulse __•_ W/cm _min 50030 Senaorimotor -114 Hr 50163 Ultrasound Comb contipulae ` Wkm _min 50020 Cog Retraining -1/4 Hr 50166 Home PgmiFamliy Ed -114 Hr 50035 lontephoreals -15 Min a ,MA/Min 5 M L 50167 Common Re-Intag -1/4 Hr 50165 Patient Ed • 1/4 Hr 50037 Phonophoresls 50013 Jobst Compression 50125 Group (2-3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Stim- 114 Hr 50010 Cold Pack i Ice Massage X Min 50012 Ruldotherapy -114 Hr 50163 Adjustment ?f 50014 WP a ` FX _min 50028 cX oT individ -114 Hr 50050 Splint - Simple 50005 Startle WP Q ____ FX _ min 50125 OT Group -114 Hr 50050 Splint -.Complex 50028 PT -114 Hr 50017 PT Individ - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar - 1/4 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 1/4 Hr 50112 PT Wrk Readl Eval -1/2 Hr 50111 OT Wrk Readi Eval -112 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Stim 50113 PT Wrk Readl -114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home PgrrVFamlly Ed 50040 Tans Appllcatton 50173 PT FCE .2 Hm 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluidotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - t Hr 50011 Paraffin Bath ASSESSMENT: ? STG Current: 1 d " Mat: Yes I No LTG Current: Met: Yes I No Reset: Im Weeks Reset: In: Weeks ? Patient tolerated treatment wa1 ? Home Eymise Program reviewed ? The Exercise Program advanced as per flow sheet t/ c: Ann eA4 ha.4-tay-w.X._ PLAN: ? Upgrade activ s as tolerated Iper protocol r ? Discharge trom Therapy Comment: THERAPIST SIGNATURE: [?i{ ?f• / THERAPY MINUTES: TOTAL UNITS: Kwised W24/0U HEALTHSOUTH Rehab of Mechanicshurg V Ise 12.11 s/'os OUTPATIENT WORKERS' COMP Lento/ Hand CnhyMd N*Cmb A SLAM 0 NUM A ImA D C CHA GE ICKET 880 882 895 884 I?, I(M Sprii id LIFE ChmHf Hrshy 1/06/1q47 v R Der 885 886 868 891 0S$ M VA Law Bar Cam l rNC44 M0, SCOTT Therapist Number 892 894 p 0 AftVy 4 i f „ ... CX IS R1S V is I' + Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable a--N. new complaints ? Increasedloacreased pain after last visit ? Patient pain level (M HO Patient Reports: Area Treated: aweam , - 10 ROM: / Strength: Function: Comments: I TREATMENT CONSISTED OF THE FOL OWING MODALITIES AND PROCEDURES: SS-Cd Description SvcCd Description SvcCd Description Svoco Description 50119 PT Eval -1/4 Hr 50167 lsokinellc Test - 112 Hr 50118 OT Eve] -114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval -1/4 Hr 50165 Isoktnetic Training -1/4 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Evat • 114 Hr 50077 CS Traction: Static- Int _ Ibs on _ Ibs off _ min, 50169 Job She Evai • 1/4 Hr 50170 Seating Eval - 114 Hr 50130 LS Traction: Prone _ Supine _ Ibs on _ Ibs off _ min _ 50016 ADL -1/4 Hr 50015 Community Mob Assort -114 Hr 50036 Ultrasound Single =Vpulse_W/cm -min 50030 Sensortmotor- 1/4 Hr 50163 Ultrasound Comb conepulse _W/em , _min 50020 Cog Retraining -1/4 Hr 50166 Home PgMFemily Ed -114 Hr 50035 lontophoreais -15 Min Q _MA/Min S M L 50167 Commun Ro-Integ - 114 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresls 50013 Jobst Compression 50125 Group (2.3) -1/4 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc 3tim - 114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluldolherapy -114 Hr 50163 Adluslment 50014 WP a ____ FX -Min 50028 OT Individ • 114 Hr 50050 Splint - Simple 50005 Sterile WP 0 _ FX _min 50125 OT Group -1/4 Hr 50050 Splint - Complex 50028 PT - 114 Hr ,50017 PT IndlvW - 1 Hr (Aqua) 50011 Paraffin Bath _ s?;atxr.-. „ 50126 PT Group They -114 Hr 50172 PT Group - i Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Read] Eval -112 Hr 50164 Progressive Ex -1/4 Hr 50127 Elec Stlm 50113 PT WrK Readl -114 Ht 50112 OT Wrk Readi -114 Hr 50166 Horne Pgm/Famlly Ed 50040 Tans Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 We 50024 Neuromusc Re-Ed -114 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hand -I Hr 50011 Paraffin Bath ASSESSMENT: STG Currant: t Met: Yes/ No LTG Current: ??j Mat: Yes I No Reset: In: Weeks Reset: U In: Weeks O Patient taler aled treatment well ? Home Exercise Program reviewed ? The Exercise Program advanced as per flow sheet ? / PLAN; ?'Uppr a adtvHles as tcAeraled rper pretocol ? Discharge tram Therapy Comment: C- SIG THERAPIST SIGNATURE: THERAPY MINUTES: TOTAL UNITS: aNaa HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP CardDr Hand CrryMd CMb - -- CHARG TICK T 880 882 895 684 3 SpdMd LIFE ChmHl HrshY 000101158 Date 885 886 888 891 A S L A M r M IJ N A M M A Q C Labn gal Care I? ig Therapist Mum-her 892 894 2/0611947 g4 R 4 CX NIS R/S 05$ M 1 WAS A Rx Expires: LYNCH IVO 1 $ tr .O 1 T DAILY NOTE Q D t1 O t 4 9 S 31 SUBJECTIVE: y ,Cl Unremarkable W'<0 new complaints ? IncreasediDscreased pain aller last visit E3 Patient pain leval'0 ?/1,D/?i Patient Reports: /t?' ; r , Area Treated: Sweltin Ecchymoals: ROM: Strength: ` ?j pC' Function: Comments: vcCd 50119 50029 50077 50130 50036 50183 50035 50037 50128 50010 50014 50005 50028 50126 50023 50164 50166 50024 50011 Descriotion SvcCd Description v Cd D on vc d Description PT Eval - 114 Hr 50167 laokinellc Test -112 Hr 50118 OT Eval - 114 Hr 50119 OT Re-Eval -114 Hr Wheelchair Eval - 1/4 Hr 50165 Isokinellc Training -114 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Eve) - 114 Hr CS Traction: Static _ Int - Ibs on _ Ibs ofl_ min 50169 Job Site Eval -1/4 Hr 50170 Seating Eval -1/4 Hr LS Traction: Prone _ Supine _- Ibs an _ lbs off_ min 50016 AOL - 1/4 Hr 50015 Communtty Mob Alarm - U4 Hr Ultrasound Single conllpulse _ W/cm _min 50030 Sensodmotor -1/4 Hr Ultrasound Comb cantipulse _ __W/cm _min 50020 Cog Retraining -1/4 Hr 50166 Home PgmtFamtly Ed -114 Hr Iontophoresfs -15 Min ® =MA/Min S M L 50167 Commun Re-Intag - 114 Hr 50165 Patient Ed -1/4 Hr Phonophoresis 50013 Jobst Compression 50125 Group (2-9) -114 Hr 50024 Neuromuac Re-Ed -1/4 Hr Malst Heal X Min 50164 Neuranxisc Slim - 1/4 Hr Cald Pack! Ice Massage X Min 50012 Flyl?dja7t'n is • 1/4ij 50163 Adjustment ZP5 P _ FX ,min 50028 OT ndll vld - 1 V VP 50050 Splint -Simple Sterile WP a _ FX _min 50125 OT Group - 114 Hr 50050 Splint - Complex PT - 1/4 Hr 50017 PT Individ - 1 Hr (Aqua)-" 50011 Paraffin Bath PT Group Ther -1/4 Hr 50172 PT Group - 1 Hr (Aqua) Massage - 1/4 Hr Progressive Ex -114 Hr 50127 Elec SUM Home PgmlFomlly Ed 50040 Tens Application Neummusc Ra-Ed - 1/4 Hr 50012 Fluldolherapy Paraffin Bath ASSESSMENT: Af) 50112 PT Wrk Reedl Eval - 112 Hr 50111 OT Wrk React Eval -112 Hr 50113 PT Wrk Readi -114 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 His 50179 OT FOE - 2 His 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard - 1 Hr STG Current: Met: Yes / No LTG Current: Met: Yes /No Resat: In: Weeks Reset;_ in: Weeks ? Patient taieralad "taeatmen [ell // / ? an orcise Program reviewed ? The Exercise Program advanced as per flow sheaf PLAN: 011 pgracie waiv as ((S(af?djet i [ ezl? ? Discharge tram Therapy Comment: THERAPIST SIGNATUR C_ THERAPY MINUTES: TOTAL UNITS. Is I e e W24100 OUTPATIENT WORKERS' COMP CHARGE TICKET /)-hq I0 bete Therapist Number CX WS Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Reports: _ osburg cantor Hand CnfryM Nwcmb 880 882 895 884 + SpHkfd LIFE ChmHl Hrshy 000101158 885 886 888 891 A SLAM r M I)N N 11414Aqq Y Leon Bel Care 892 894 1/06/19147 ORO 4 11.6 14 WA R/6 l 4cm "01 SCOTT OHO 04199 ?4+? :A{4f vA.Q .1 t44v ? :.. W navt complaints ? IncreasediDecreased pain after last visit El Patient pain level ® I10 . Area Treated: ° O.Wo"u• ROM: .1-1.1,4 7_7 W _,Zek CA Strength: 'L s w Function: ? 'rn 12 ",f 19 L Comments: Ecchymosla: -. A-E- /`•7l vc Da ril n 5vcCd Description Amu scriotion SvcCd Description 50119 PT Eval -114 Hr 50167 leokinaUc Test -112 Hr 50118 OT Eval - 1f4 Hr 50119 DT Re-Eval -1/4 Hr 50029 Wheelchair Eval - 114 Hr 50155 laoldnetic Training • 114 Hr 50168 Home Eval . 114 Hr 50029 Wheelchair Eval - 1/4 Hr 50077 CS Tractlow Static - Ink _ Ras on _ be off _ min - 50169 Job Site Eval -114 Hr 50170 Seating Eve] -114 Hr 50130 LS Traction: Prone _ Supine _ lbs on Ibs off _ min V 50016 ADL - 114 Hr 50015 Community Mob Assmt - 114 Hr j 50036 Ultrasound Single wnupulse ___ Wlcm _-min 50030 Sensortmotor - 114 Hr 50163 Ultrasound Comh conl/puise _ W/cm ^mtn 50020 Cog Retraining -114 Hr 50166 Horne PgrrJFamNy Ed -114 Hr 50036 lontophoresis -15 Min 0 _MA1Min 5 M L 50167 Commun Re-Integ -114 H r 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2-3). 1/4 Hr 50024 Neuromusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neuromusc Stim -114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluidotherapy - 1/4 Hr 50153 Adjustment 0- 50014 WP Q _ FX lmin 50028 OT Indlvld -114 Hr 60050 Splint - Simple 50005 Sterile WP 6 ! FX ,min 50125 OT Group -1/4 Hr 50050 Splint - Complex 50028 PT - 114 Hr 50017 PT Individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar - IA Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage -114 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Readl Eval -1/2 Hr 50164 Progressive Ex - IA Hr 50127 Elec Stim 50113 PT Wrk Readi - 114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home Pgm/Famlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hn 50024 Neuromusc RB-Ed - 1/4 Ht 50012 Fluldolherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraiftn Bath ASSESSMENT: STG Current: ?C Met: Yes / No LTG Current: ?T { rn 6 Met: Yes / No Reset: In: Weeks React: In: Weeks ? Patient tolerated treatment well ? Home Exercise Program reviewed - ? The Exercise Program advanced as per pow sheet PLAN 0vupgrada activities as tolerated /per protocol 0 Discharge from Therapy Comment. ^7 THERAPIST SIGNATURE: C??'<C? " fit. (?G ?? _. THERAPY MINUTES: TOTAL UNITS: oC ??? aVI6 ? _0 HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Carver CHARGE TICKET 880 ?a-a?-'OS - spdW Date 885 Therapist Number CX N/S IRIS Rx Expires: DAILY NOTE SUBJECTIVE: ?? ? Unremarkable B"NO new complaints Patient Reports: 1) "vW CMry NwCmh 882 895 884 ?r ^ r LIFE Chm" Hrshy } 1 / / ?O S 886 888 891 A SL Am a %U4A144AD 7 L.bn eel Care 892 894 1/06/1947 ORO $9 14 WA LYNCH 00, SCOTT 000a04M 31 ?w. ? Increased/Decreased pain after last visit ? Patient pal" level ® 110 QBJECTIYE: Swelling: Echymosls: Area Treated: ROM: r a l e r1 0 l , v+ c? y?mt-r is jjX.9 = 4y -' J CA:e? Strength: t1ClF x l v, Function: r Comments: rA r 11 S m S tix 1 vc Description v C Description 50119 PT Evai -114 Hr 50167 isotdnelic Test -112 Hr 50029 Wheelchair Eval - 114 Hr 50165 Isokkletic Training -114 Hr 50077 CS Traction: Static ^ Int _ Ibs an _ Ibs off _ min _ 50130 LS Traction! Prone _ Supine _ Ibs on _ Ibs off _ min 50036 Ultrasound Single cont/pulse _ W/cm _min 50163 Ultrasound Comb conlipulse _ ,W/cm _min 50035 lontophoreals -15 Min a _MA/Mln S M L 50037 Phonophoreals 50013 Jebel Compression 50128 Moist Heat X Min 50010 Cold Peck I Ica Massage X Min 50014 WP C , FX _min 50005 Sterlie WP C _ FX _ min 50025 PT -114 Hr 50017 PT Indivld -1 Hr (Aqua) 50126 PT Group Thar -114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex -1/4 Hr 50127 Elec Stim 50186 Horne PgmlFamlly Ed 50040 Tens Application 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldotherapy 50011 Paralfin Bath Svrod Description vcCd Description 5011 B OT Eval -114 Hr 50119 OT Re-Evai - 14 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50169 Job She Evai -114 Hr 50170 Seating Eval -1/4 Hr 50016 ADL - 114 Hr 50015 Community Mob Asamt -114 Hr 50030 Sensorimotor -114 Hr 50020 Cog Retraining - 114 Hr 50166 Home PgmlFam4y Ed -114 Hr 50167 Commun Re-Integ -1/4 Hr 50165 Patient Ed -114 Hr 50125 Group (23) .114 Hr 50024 Neuromusc Re-Ed -1/4 Hr 50164 Neuromusc Stim -114 Hr 50012 Fluldotherapy - IA Hr 50163 Ad)ustment 50028 OT Indivld - 1/4 Hr 50050 Splint - Simple 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50112 PT Wrk Readl Evel -1/2 Hr 50111 OT Wrk Read( Eval -112 Hr 50113 PT Wrk Readi - 1/4 Hr 50112 OT Wrk Readl -1/4 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard - 1 Hr 5018D OT Wrk Herd -1 Hr ASSESSMENT: STG Current: I-c3sv •y Mel: Yes I No LTG Currant: Met: Yes I No Reset: In: Weeks Reset In: Weeks ? Patient tolerated treatment well ? Home Exercise Program reviewed Q The Exercise Program advanced as per flow sheet PLAN; 6M Hpgradeactlvfties as tolerated /per protocol ? Discharge tram Therapy Comment: THERAPY MINUTES: SIGNATURE: ?] TOTAL UNITS: / evise OUTPATIENT WORKERS' COMP Cenlpr CHARGE TICKET 880 ,) a") ob sprtma Da a 8a5 Therapist Number CX Nis Pis Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable 1 / No new c Patient Reports: P1?? +_ ?1x! 00010 1.158 12/131/011 ASLAM, MUHAMMAD C 1/06/1447 000 U Ss M WX L yucm 00. SCOT 000204195 ? IncreasedlDecreased pain after last visii ? Patient pain level @ liC OBJECTNE: " - Area Treated: ROM: Strength: SveCd Description SveCd Description 50119 PT Evel -1/4 Hr 50167 Isoklnetic Test - 112 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isokine(Ic Training -1/4 H 50077 CS Traction: Static _ Int _ _,, Ibs on _ Ibs off _ min _ 50130 LS Traction: Prone _ Supine _ Ibs on _ Ibs off _ min ,_ 50036 Ultrasound Single conl/pulse _ W/cm _min 50163 Ultrasound Comb conupulso _ W/an _min 50035 lontophoresis -15 Min C _ __MAIMIn S M L 50037 Phonophomals 50013 Jabal Compression 50128 Moist Heat X Min 50010 Cold Pack 1 tee Message X Min 50014 WP 0 _ FX ymin 50005 Sterile WP ®_ FX _ min 50028 PT -1/4 Hr 50017 PT tncitvld -1 Hr (Aqua) 50126 PT Group Ther -114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50164 Progressive Ex - 1/4 Hr 50127 Else Stim 50166 Home Pgm(Famlly Ed 50040 Tens Application 50024 Nouromusc Re-Ed - 114 Hr 50012 Fluidotherapy 50011 Paraffin Bath 6vcCd Description SvCd Description 50118 OT Eval - 114 Hr 50119 OT Re-Eval - 114 Hr 50168 Home Eval -1/4 Hr 50029 Wheelchair Eval -114 Hr 50169 Job Site Eval - 114 Hr 50170 Seating Eval -1/4 Hr 50016 ADL - 1/4 Hr 50015 Community Mob Asamt - 114 Hr 50030 Sensorimotor-1/4 Hr 50020 Cog Retraining - 1/4 Hr 50166 Home PgnJFamlly Ed -114 Hr 50167 Commun Re-Integ - 1/4 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) -114 Hr 50024 Neuromusc Re-Ed -1/4 Hr 50164 Neuromusc Stlm - 114 Hr 50012 Fluldotherapy -114 Hr 50163 Ad)ustment 50028 = OT Indivld - 114 Hr 50050 Splint - Simple 50125 OT Group -114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50112 PT Wrk Readl Eval -1/2 Hr 50111 OT Wrk Readi Eva) -112 Hr 50113 PT W rk Readl - 114 Hr 50112 OT W rk Readl -114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 HIS 50174 PT Wrk Hard -1 Hr 50180 OT VVrk Hard -1 Hr ASSESSMENT: STG Current: ( ?! ?/ -?1[ ti . Met: Yes/No LTG Current: Reset: In: Weeks Reset: ? Patierd toiorated treatment well ? Home Exercise Program reviewed PLAN: ??lpgtade activities as tolerate or protocol ? Discharge from Therapy Comment: THERAPIST SIGNATURE: fn?.tli.?ti C Hand CnfryM NwCmb 882 895 884 UPE ChmH1 Hrahy 886 888 891 Lebn Sol Caro 892 894 Met: Yes I No -?' - 7- In: Weeks ? The Exercise Program advanced as per flow sheet THERAPY MINUTES: 0 nI TOTAL UNITS: ev V24100 TRF4TMrMT CONSISTED OF THE FOLLOWING MODALITIES AND PROCEDURES: HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP cantor 880 Hand GnbyMd NwCmb 882 895 B84 ^ M ii?7 11W1 ?j ! i ! .r 'i r CHARGE TTIIC /ES T, { a -A S L A N o M UM A 014A D C + 7 ? J SprtVd 0 ?. LIFE ChmH! Hrahy 885 Date 886 888 891 C{/ ^ 1 a f V v `! ? • Ono ; V Leon OW Cara 892 894 058 VA Therapist Number 0`11i W ! f 0 S C O T T CX N/S R/S / U0010419$ y L Rx Expires: DAILY NOTE All. P? SUBJECTIVE: ? Unremarkabl No new com alms ? incressed/Dacrpasad pain after last visit ? Patient pain level ® to Patten[ Reports: 411-4- / If MECTIVE: ?.. I Area Treated: r - Swelling: Ecchymosla: ROM: C C ?? Strength: Function: ?n Comments: L t _ TREATMENT C SISTED Tidt FOLLOWING MODALITIES AND PROCEDURES: SSvcCd Description vcCd Description SvcCd Description SvcCd De ton 50119 PT Eval -114 Hr 50167 Isokinetic Test -112 Hr 50118 OT Eval -114 Hr 50119 OT Re-Evil -1/4 Hr 50029 Wheelchair Eval -1/4 Hr 50165 isokinetic Training -114 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Evel - 114 Hr 50077 CS Traction: Static _ Int -_- his on _ ibs off _ min - 50169 Job She Evai -114 Hr 50170 Seating Eval -114 Hr 50130 1.9 Traction: Prone _ Supine -_ his on _ Ibs off _ min - 50016 ___-?__ ADL - v4 Hr 50015 Community Mob Asamt -114 Hr 50036 Ultrasound Single cantlpulse _W/cm _min 50030 Sensorimotor -114 Hr 50163 Ultrasound Comb conl/pulsa _W/cm _min 50020 Cog Retraining - 114 Hr 50166 Home PgnVFamliy Ed -1/4 Hr 50035 lontophoresis -18 Min C _ MA/Min S M L 50167 Commun Re-Integ -114 Hr 50165 Patient Ed -114 Hr 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2.3) -1/4 Hr 50024 Naummusc Re-Ed -114 Hr 50128 Moist Heat X Min 50164 Neutomusc Stim - 114 Hr 50010 Cold Pack / Ice Message X Min 50012 Fluidotherapy -114 Hr 50163 Adjustment 50014 WP g ^ FX _min t 50028 OT Indlvid -114 Hr 50050 Splint - Simple 50005 Sterlie WP Q ,_ FX _min 50125 OT Group -114 Hr 50060 Splint - Complex 50028 PT - V4 Hr 50017. PT Indivld - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther -114 Hr 50172 PT Group - 1 Hr (Aqua) 60023 Massage -114 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Readl Eval - 112 Hr « 50164 Progressive Ex -114 Hr 50127 Elec Slim 50113 PT Wrk Readl - 1/4 Hr 50112 OT Wrk Readl - 114 Hr 50166 Home PgnVFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neummusc Re-Ed - 114 Hr 50012 Fluidotherapy 50174 PT W rk Hard - 1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath A,95ESSMENT STG Current Met: Yes/ No LTG Current: Mel: Yes / No Reset: In: Weeks React: In: Weeks ? Patient tolerated treatment well Q PLAN, `0 U r d tl li mo E erclse P gram reviewed ho Exercise Program advanced " l?' -?J?n e ?V Z as per flow sheet pg a e ac es as tolerated / pe protocol ? Dis charpa fron Therapy Comm er8 THERAPISTSIGNATUR THERAPY MINUTES: (Po TOTAL UNITS: J - ' KW3cd31£4106 ,ON HEALTHSOUTH Rehab of Mac OUTPf2?L ENT WORKERS' COMP CHAR TICKS ?. 16 L) tea,- ? ? , Therapist Number CentDr Hand CnrryMd NWCmb 880 882 895 884 spnMd UFE ChmH1 H-hy 885 886 888 891 Labn Sal care 892 894 oS a1o158 ?n AM, r?Cb?IVli7 ONO 05 WA 1t»11ql$ Rx Expires: WS R/5 ?L 111tH . e r e S C O T T DAILY NOTE SUBJECTIVE: 17 Unremarkable SJ,No naw complaints ? increased/Decreased pain after last visit ? Patient pain level a /10 Patient Reports: sue///t OBJECTIVE: Area Treated: Swelling: Ecchymosis: ROM: /I J? Q/ QQ?? r Q I7l/1??I C C?' ?f Gi r n Strength: Funcllon: Comments: /11 ..eZ4-ci- -- ? vcCd esc tion SvaCd Description SvcCd Description vcC Description 50119 PT Eval - 1/4 Hr 50167 taokinetic Test -112 Hr 50118 OT Eval - 114 Hr 5D119 OT Re-Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50165 Isokinetic Training -114 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Eval - 114 Hr 50077 CS Traction; Stella- Inl ` Ibs on _ ibs off _ min _ 50169 Job Site Eval - 1/4 Hr 50170 Seating Eva] -114 Hr 50130 LS Traction: Prone - Supine _ his on _ Ibs all _ min _ 50016 ADL - 114 Hr 50015 Community Mob Assmt -114 Fir 50036 Ultrasound Single conVpuise-W/rm - _min 50030 Sensorimator- 1/4 Hr 50163 Ultrasound Comb conitpulse _ Wlcm . -min 50020 Cog Retraining - 1/4 Hr 50166 Home PgmlFamAy Ed -114 Hr 50035 lontophoresis -15 Mtn Q _MA/Min S M L 50167 Commun RB-Integ -114 Hr 50155 Patient Ed -114 Hr 50037 Phonophoresls 50013 Jobst Compression 50125 Group (2.9) -1/4 Hr 50024 Neummusc Re-Ed - 114 Hr 50128 Moist Heat X Min 50164 Neummusc Sum - 114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluidotherapy - 114 Hr 50163 Adjustment 50014 WP Q _ FX lmin 2 50028 OT IndIvId - 114 Hr 50050 Splint - Simple 50005 Startle WP a ^ FY, _ min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT - 1/4 Hr 50017 PT Individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Writ Readl Eval - 112 Hr 50111 OT Wrk Readl Eval -1/2 Hr 50164 Progressive Ex - 1/4 Hr 50127 Faac sum 50113 PT Wrk Readl - 114 Hr 501 12 OT Wrk Readl -1/4 Hr 50166 Home PgmlFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neummusc Re-Ed - 114 Hr 50012 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard . 1 Hr 50011 Paraffin Bath AS5E$SMENT; 57G Current: L Met: Yes ! No LTG Current: Met: Ves 1 No Reset: In: Weeks Reset: In: Weeks 63-'Vattant tolerated treatment well ?. Homo Exercise Program reviewed ? The Exercise Program advanced as per how shoat ?? Cam' fi L / C/?--- PL_ AN pgrade activities as tolerated /per protocol ? Discharge from Therapy Comment: THERAPIST SIGNATURE} ( ? 11 _ ?(/rYj /L? THERAPY MINUTES: ? ? ?? TOTAL UNITS: B . HEALTHSOUTH Rehab of Moo OUTPATIENT WORKERS' COMP CHA TE TICKET Defs Therapist Number CX Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremao Patient Repotts. N/S CsnlDr Hand ntryMd NwCmO 880 882 895 884 Spdmd LIFE ChmHl Hrshy 885 886 888 891 Lebn Bat Care 892 894 ws Anse Treatad. ROM: Strength: Function: Comments: ? No new complaints ? Ecchymosls: / SvcCd Qescrinitort vc d De ton SvoCd Description vcCd 50119 PT Eva] - 1/4 Hr 50167 Isokinatic Teal -112 Hr 50118 OT Eve) - 114 Hr 50119 50029 Wheelchair Eval -114 Hr 50165 lsakinetic Training -114 Hr 50168 Home Eval - V4 Hr 50029 50077 CS Traction: Static- Int _ Ibs on _ Ibs oft _ min 50169 Job Site Evei • 114 Hr 50170 50130 LS Traction: Prone _ Supine _ Ibs on Ibs off _ min _ 50016 AOL -114 Hr 50015 50036 Ultrasound Single conl/putse _ Wlcm _min 50030 Sensorimator -114 Hr 50163 Ultrasound Comb contlpulse _ W/cm _min 50020 Cog Retraining -114 Hr 50166 50035 lontophoresls -15 Min 0 _-MAIMIn S M L 50167 Commun Re-integ • 114 Hr 50165 50037 Phonophoresis 50013 Jobst Compression 50125 Group (2.3) -1/4 Hr 50024 50128 Moist Heat X Min 50164 Neuromusc Stim -114 Hr $0010 Cold Pack / Ice Massage X Mi n 50012 Fluldotherapy - 1/4 Hr 50163 50014 WP _ FX lmin 50028 OT Indivld -114 Hr 50050 50005 Sterile WP 6 FX _ min 50125 OT Group -114 Hr 50050 50028 PT -114 Hr 50017 PT Individ -1 W (Aqua) 50011 Paraffin Bath 50126 PT Group Ther - 114 Hr 50172 PT Group -1 Hr (Aqua) "Zt- tin OT Re-Eval -114 Hr Wheelchair Eval -1/4 Hr SeaBng Eval-1/4 Hr Community Mob Asemt - 114 Hr Home Pgm]Famliy Ed -114 Hr Patient Ed -114 Hr Neuromusc Re-Ed -114 Hr Adjustment Splint - Simple Splint-complex 50023 Massage - 114 Hr 50112 PT Wrk Readl Eval -112 Hr 50111 OT Wrk Readl Eval -112 Hr 50164 Progressive Ex - 114 Hr 50127 Elec Slim 50113 PT Wrk Readl -114 Hr 50112 OT Wrk Readl -114 Hr 50166 Home PgrrYFamily Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wyk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT: STG Current: Met: Yes / No LTG Currant: Reset: In: Weeks Reset: P-10".1lent toiaratud treatment well ? Home Exercise Program reviewed PLAN: tis^tlpgrade activities as tole /per p t 6 n4 _ ? Ischarge from Therapy Comment: THERAPIST SIGNATUR //? ?- ?ON DQQ?O?,???8 tar«ros A 5i AM aUwA*14AC G ?/06/m l 5I M kA '1. pain after last vises atlsnl pain level ® ?/to - ? Met: Yes I No In: Weeks ? The Exerclso Program advanced as per flaw sheet THERAPY MINUTES: (j TOTAL UNITS: p? eNS / HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Cenror Hand cnlryMd Nwcmb CHARGE TICK PT 880 882 895 884 /( Spr(Md LIFE ChmHl Hrstry Oete ' / 885 886 888 891 x a U Leon Bat Care Therapist Number 892 894 CX N/S RIB Rx Expires; DAILY NOTE SUBJECTIVE: ? Unremarkable E3 No new Patient Reports: '/ X 1h / d j u) l AreaTreete : SweAing, ROM: Strength: Function: Comments: f/AI I //,A 0 Y Svecd Description SVcCd Description 50119 PT Eval - 114 Hr 50167 Isokinelic Test -112 Hr 50029 Wheelchair Eval -1/4 Hr 50165 Isoklnefic Training - 114 Hr 50077 CS Traction: Static _ Inl _ Ibs on _ Ibs off _ min _ 50130 LS Traction: Prone supine _ WE on _ We off _ min! 50036 Ultrasound Single cant/pulse ___W/cm _ _,-min •50163 Ultrasound Comb conUpulse _-_W/cm _min 50035 lootophoreais -15 Min 0 ,MAIMIn S M L 50037 Phanophoresis 50013 Jobst Compression 50128 Molat Heat X Min 50010 Cold Pack / Ice Massage X Min 50014 WP 0 _ FX _min 50005 Sterile WP @ _ FX min 50028 PT -114 Hr 50017 PT Indivki -1 Hr (Aqua) 50126 PT Group Ther -114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Slim 50186 Home PgnVFamily Ed 50040 Tens Application 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldotherapy 50011 Paraffin Beth 00010,1158 12,111"Wes ASL AN t KU-MAMMAQ C 2/abJt?lO? DRG DJ8 M MA L YNCO NO iC o t UQc?2d4195 sib Decreased pain after last visit ? P lent pain 194.,91® 10 Ecchymo Is. j JWING MODALITIES AN PROCEDURES: vcC Descdotbn SvcC Oes4r19tion 50118 OT Eval -1/4 Hr 50119 OT Re-Evel -114 HT 50168 Home Eval - 114 Hr 50029 Wheelchair Eval - 114 Hr 50169 Job Site Eval -114 Hr 50170 Sealing Evel -114 Hr 50016 AOL -114 Hr 50015 Community Mob Asantt -114 Hr 50030 Sensorimotor- 114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgmlFamliy Ed -1/4 Hr 50167 Commun Re-Integ - 114 Hr 50165 Patient Ed - 114 Hr 50125 Group (2.3) - 114 Hr 50024 NOUTOM raC Re-Ed - 114 Hr 50164 Neuromusc Slim -114 Hr 50012 50028 Fluldotherapyy- V4 Hr 50163 7WIT AdJrstment Ivid -1/4 Hr 50050 7 ? ' Splint - Simple 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paraffln Bath 50112 PT Wrk Readl Eval - 1/2 Hr 50111 OT Wrk Read) Eval - 112 Hr 50113 PT Wrk Read! -114 Hr 50112 OT Wrk Readi - 114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Writ Hard -1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT: i7G C C;44 / / j Me V r u!/ urrent; t: Yes/No LTG Current; Met: yes/ No Reset: In: Weeks Reset: In: Weeks ? Patient tolerated treatment well ? Home Exercise Program reviewed ? The Exercise Program advanced as per flow sheet PLAN: ? Upgrad e activities as tolerated /per protocol _ Q DI (us from Therapy Gommont: THERAPIST SIGNATURE : THERAPY MINUTES; TOTAL UNITS; N HEALTH50UTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP cenro Hand CHARGE TICKET 880 882 SpdMd LIFE Date 885 886 7-5 U Therapist Number CX Rx Expires: DAILY NOTE OUBJECTIVE: ? UnremaO Patient Reports: Area Treated: ROM: Strength: Function: Comments: _ r11(1a4 N/S R/S ? No now complaints ED U1 13 1r?W9t7 ORO 058 #4 WA LYNCO NO, $Cott pain after last visit ? Patient pain level ® tic Swelling: Ecchymosis: PROC vc Description SvcCd Descriptio n SvcCd D s rl i 50119 PT Eval - 114 Hr 50167 isokinetlc lest - 112 Hr 50118_ OT Eval - 114 Hr 50029 Wheelchair Eval - 114 Hr 50165 isokineticTraining - 114 Hr 50168 Home Eval - 114 Hr 50077 CS Traction: Stal int _- log on _ tbs off _ min _ 50169 Job Site Eval - 1,14 Hr 50130 LS Traction: Prone _ Supine _ (be on _ Ibs off _. min ^ 50016 AOL - 1 /4 Hr 50036 Ultrasound Single conVpuise ___ W1cm _min 50030 Sensodmotor - 114 Hr 50163 Ultrasound Comb conUpulse - Wlcm _min 50020 Cog Retraining -114 Hr 50035 lontophoresis - 15 Min ® _ MA/Min S M L 50167 Common Re-Integ -114 HT 50037 Phonophoresfs 50013 Jobst Compression 50125 Group (2-3) -1/4 Hr 50128 Moist Heat X Min 50164 Neuromusc Stim -114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluidotherapy -1/4 Hr 50014 WP a ` FX _min 50028 OT Indivld -1/4 Hr 50005 Sterile WP ® _ FX ` min 50125 OT Group - 114 Hr 50028 PT -114 Hr 50017 PT Individ - i Hr (Aqua) 50011 Paraffin Bath 50126 Group Thor -114 Hr 50172 PT Group -1 Hr (Aqua) vrC Description 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50170 Seating Eval - 1/4 Hr 50015 Community Mob Aasnrt -114 Hr 50166 Home PgrrVFamlly Ed -114 Hr 50165 Patient Ed -114 Hr 50024 Neuromusc Re-Ed -1/4 Hr 50163 Adjustment 50050 Splint - Simple 50050 Splint - Complex 50023 Massage - 114 Hr 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Readl Eval - 112 Hr 50164 Progressive Ex - 114 Hr 50127 Elec StIm 50113 PT Wyk Readi -114 Hr 50112 OT Wrk Readl - 1/4 Hr 50166 Homo PgaVFam#y Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath ASSESSMENT: STG Current: Met: Yes I No LTG C t urren : Met: Yes/No ea st: In: Weeks Resot I • n: Weeks Patlon l tolerated treatment well ? Home Exercise Progr am reviewed ? The Exercise Program advanced as per flow sheet PLAN: ? Upgrade ct ollerated /per protocol ? Discharge from herapy Comment: T C/ 7 THERAPIST SI GNATURE: K. 1? l/ u ?( THERAPY MfNUTES? TOTAL UNITS: av e 01 C NBCmb 895 Q t 1 i i j Mf• ,.a $?M ass sea A S L A M(, M V H A 1Itp A D C ChnrH1 Hahy 888 891 Labn Bat Care 892 894 Internal Document for.•QI Purposes-Onty Do'Not Cony or Release with Medical Record File in Correspondence Section D1GQ-ttQn-3?jC,-8 --- 12/13/05 AihiribftVMHAMMAn r DIC Date 2/06/1947 ORO 0UTPAT ENT DISCHARGED MEDICAL P4V4?RDp(VECICWT LYNCH M0. SCOTT Results ofTtnal chart review: 0 0 0 0 4 1 9 5 316 The chart is complete. ? The following items are incomplete: Circle discipline(s): PT OT SP Item. Present or Therapist Date(s) missing complete Signature! Co- (in box below note (please check box signature missing date in question) below if present) (in box below note date is question) 1. Addressograph area complete on all documentation (Name, LW, DOB 2. Patient Information Record 3. Initial MID Orders 4. Consent for Treatmmt S. Outpatient Clinical Assessment v, 6. Addendum(s): 7. Initial Plan of Care 8. ReceN[lpdated POC (mi-nir um 30 days) 9. Daily Dotes 10. Weekly Notes 11. Flow Sheets 12. Discharge Summary / Date: d3 0(p Reviewer's Signature: 4) -?11-1 IbL?2? Clinic Manager's Signature (if incompletc items): Date: The above items an unable to be completed because (enwloyee) Has moved out of the area Is no longer employed with HEALTHSOUTH Is other lnternal.Document far. 0TPurpuses:0nly, D.o-Not'Cypy or Release with Medical Record ?. File in EorresTwnd?irce Sectianr 000?01158 9tfw?fos A 5L AM a MUHAMMAD C 2/06/1947 ORO HF4L MSOUTH. 0 58 M WA LYNCH MD, SCOT! 516 occupational Thera FIW SWAB Patient Name:? Dx: Precautions: ?l 000?0?iS8 12/13/05 `v ASLAM , MUHAMMAD C HE &MSOUM. 210611947 ORO «? 0 58 M WA Occupational Therapy get C 0 T T 316 Patient Name: aGkm E rV1 Dx: CQ Y9,,,h Precautions: a Goals: 9 Gtc AJ6 I no Pain Level O 60 c? _ BP IJ)n ti?? AM IJ YI ?Sh!aC 5rA u3 R0..?1'It JL? I AAibmE ? l gm IMP>r= ee td R d ?'a y?`t ? t? j?hld CL-am ?r4?s dv?a r? IC 3rr?ln ?es ??i , r?r?? t'? 3m???c?? b I? 1? ?cC? ?Fa UNI vy`?? 5? tb ?en cL i? ? f U P?1 I (?> ?z,:;r „? a ? ? ,? I o I ? d e64I rn V. Q-YN L 6LtA I I S t, q d k X 3 r>1id wY t'`'P j Ett?r?d 1/???tj ?? r?? Iyuk P9??'' x 1' ?s p r? Ent n+t 9 . _ 6 r t,?, y,.i - G-a X0 {'r 0 mn u tst+? At won, ?QD M ? MU S?r?AO C a 5? k? ??Q?Jti9d? ORO ? psa Mw+o. Sco?? 51b H So?? Y NC: occu ational Thera Dx: ame? w' patient N G?? e ? ? precautions: `1 Gtp ?S r p Goats: pam?,evel BP ?r S?t ?? rvt J? a IV, 0. GYYI (hwl t ML C tl?y `,' ; z" ,?,?' kz Ifx?dil??!??±t5 L CA" ? -t? vae leg 7j L'If PON %k nu 000?07158 12/13/05 ASLAM, MUHAMMAD C HEA?.THSOUTN® 7/ 0 6/ 1 9 4 7 O R O 058 M WA Occupational Therapy f A d t 0 T T Patient Name: Dx: / Precautions: Goals: j j 3 1A, 0' Pain Level G .9 10 $P Wq 1I Lo Q ko m © sh 1,4 , i w(Vajd c ?v?i e ?u.l! ieat J x . ,q aaeom H`'? iva,vl ? N W ? ? a , E LI t SSt ny Lk i ""-4 Ol? 3 , - Qo CP ,1 1, CALL U,C p1fw? ??^? u.R I1?llh 1"LV.r`C G?.G<?:L. Y?t2.N 7 d,, C?s??d r (2 p Nn ? / ?J U...cfi a 07r a t 1,3 L) u.L- ( ! se Sri Cu Jnc6 x F*C ter Gtr` cJa?i. ful i G , UA; t .-7 Ica a+y,z 7Ra( W-I C rrl6 lW I1R ?? ?V ?..? L ?? 000101158 12/13/05 ASLAM, MUHAMMAD C HEUMSOWN® 2/06/1941 Oa0 058 M WA YN M , SCOTT Occupational Therapy Fl?,#?We?5 516 Patient Nam e: Dx: f? - Precautions: 1 4 5 Goals: y lp t v 0 Pain Level I)' P. A o D )e4 J3P N ra 1 DU tJ t?l 5 r.1 d c?.2U'^ -ry? 17 dl'- 51AL J I,, L'kl, 5+%??t ? f ?G c Caan?7 n R -L l he vic dw1 ?ryN L' r i -e 31Rt r 5)J- See ",,,e , a b c"'t a k a x,-? 5+-U 4 (D LLe IZc? Y 0) CL& cl\j V 6Lb6t - 0 ??.P,? 11eslwl P? 5 i v n I rn L r1lik 00010?158 12/13/05 ASL.AM1 MUHAMMAD C ® 2/Ob/1947 ORO 0 58 M WA Occupational Therapy F l a x K S h w S C O T T OU0204195 516 PatientName: thaYY)Ma8 14b)6?Yr? Dx: Sh c? Precautions: Goals: , 'L I 9 n5 l .7- ??d K- 11 D`) Ir I? ?Z 2$?aS Pain Leve] to )h b n 10 BP l ?! to yjw- to $,,I t LM } ad,4rr -w fbida u C ?? ? G ?Kq ?N? P S?(1YY16?! 1vt2 ? J a-r S hR Rt?crr l S Gt0.xLpm lt`U ?? F 5k Q C Y 1 *IJ ? ? ?•. ru.td.r... s?? f 1 C/?'/ S 1 n d 1 ?+ d , n? qn `s??l?t V, ? c R t : (, t' I L G 5G[ W? i 1/ L: cl.+. cat w? i t 2U I C utz Sl??? ? Ad ?1V {Ai1. ei C 6?..?eJc]?( a si = l k. 1 Y? ?k ?v jr} a G F i- Sh rr K t-5{ m X -ti- si":, x , t? m?1nCwS ?g? t U?S? ?. m5. DR ` a ??t aatt,n?l ;??d?(??` wltiti . A L . 1 n'?il X ??. CxGL? sa.J, sh A 10 r, a. A K 1 - N A." u.c1 Fm ? ? % e*44), HEAUHSOU7K Hi:ALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 DISCHARGE ASSESSMENT 000?0?IS8 t2l13/09 ASLAM, MUKAMMAD C 2/0b/19d7 ORO y 058 M WA LYNCH MD, SCOTT 000204195 516 AODFWMOGPAW Discharm DOW. 3 /1-7 h0to ? Funcoonel 0 Hand ? Wound ? Wheelchair Dagnosis: i. 17 LE Addendum 0 voice ? Lymphaderna 0 VestlWw Admission Data: O'llf'Addendum ? Cogn*m ? Pulmonary Referri ? Ankle/Foot 0 Communk:aWn ? Amputee Primery ? Cervical 0 D a he ia ? Uri ar Inccntl W Number Of?otel Vieltif . p y g y = n l Number Of No-Show/Caricalla tlone: C] ltmtnar ? Visua Perceptual [3 Other DURABLE MEDICAL E UIPMEWr Assistive Devices: ? Standard Webcer 0 Rolling Walter ? Harrill Walker ? Quad Cane, Large / Small Base ? straight Cane ? Other zl? m he Bathroom Acessaotrlos GlNone ? Grab Bars ? Shower Chair ? Tub Bench ? Raised Toilet-Seat ? BSC Ottrar Equipment None ? Hospital Bed ? Wheelchak O Cushion ? Other PAIN ASS M PAIN REUlf STATUS Pain ?No pies o00 0?0 K Yes, Location: ?- o f s t; e 7 e sit D-MedostlonlPmasclure DA- 0 Relmtatlort Techniques l AodaittylAotMty that decreases pain:. Pain Scala (D -10) Beat Worst D Pain Symptoms: Cktul Sharp ? BA*ig ? R ? Numbness ? Radlcular ? Throbbing ? Other o /Actlvlty Increases ZZZ= Pas comment sectlan for detailed deakxl Frequency ? No Path ? Lase Then Daly ? Deily ? Daly - Increases throughout day Muttlple Daily Episodes ? Constant ? Nlg n ? Disturbed Sig Com ants: a T Ing Dnascxl pbo1w TrS19199 P dad: U Wt Receiv Summary at rasa; - ON R iC: ? pools Met 0 Med?a(Condition olleached Maxim o ntle ? Deneff Udllzed Objective findings inconsist with patient's complaints and/or lagnasls. ? Non CompII her RECOMMENDATION; Co tinue with HEP as Issued ? Equipment needs Mwesu ne Therapy flow up with physldan 27j A' ? Other COMMEN IB: AT SIGNATUA frLB 11 DATE SIONATUREMTLE -L7 .TN7=_PM1SaP( INARY ASSt ;'MEN T 000?0?M?sg t2/13/05 ASLAM, A,,AMMAO C 1/06/i047 . 0RO 058 M WA LYNCH MD, SCOTT KEY: ROM is passive unless indicated otherwise with an "A", Use standard muscie test grades for strength, WFL = Within Functional Limit N = Not Tested k• LEFT ROM VRENGTH RIGHT ROM Siren Action I ROM S Shoulder Flexion ISO Shoulder Extension 60 - - Shoulder Abduction 180 d - Shoulder External Rotation 40 = Shoulder Intemal Rotation 70 -A j7/ 1 &4wlk-, -? - Elbow Flexion L50 -/57 - Elbow Extension 0 i Forearm 5u ination 80 S Forearm Pronatlon 80 Wrist Flexion 86 ?t4?e_ I .14P .457. Wrist Extension 70 t Pinner Flexion Full 1) _4?L_ Ft - 4 /41t Finger Extension Full Other. Other I Comments (Tone, Movement Patterns, Pain, Reflexes): Tone: ? W1L Motor Co I ? Pain. 77 4? Upper mtty cs(Prostttedc:s with pabenW V.-<d ? Yes -IF yes, describe (Including wearing instructions): Dons/Daft Independently- " A ? Na D Yes Joint Deformity: I1jo ? Yes-- If yes, describe: 5ubtuxatlon: No C7 Yes Left: Mont: Coordination Upper.E.•-rremlty Grip Strength H and Do nce f drde Left Right ?? ? WFL ? N i- Right N Y` Grp ? Functional Functional Grass Grasp G v,{?1 CrImpaired ? Impaired t 3 Point Pinch AJ _ , yt 4 Fine ; ndlonal "acdonal I 2 Point Pinch N /L 0 Im aired ? 1m aired Lateral Pinch SENSATION N = Nonnal N 17 = Not Tested I - Impaired A = Absent Shudder Amt Farearm Hand Shoulder Elbow wrist Fingers ? WFL /T L R L I R L I R L R ? W FL &KrT L R L- R I L R L R Light Tauch I i I Proonoceodon Sharp - Dull Stereoanosis Localization Of Touch i Is impaired sensation the result or a lesion to the spinal cord? 0 Yes o 0 N/A 0 DermAtnme Serrso Addendum: Meal Prefl 60 Ma aaes Finanr-< C° Driving 12'- Laundry ? Oeantno ? Siioooina ? /Other (DME at home, living arrangemenm, endurance, etc.):1 ? Slgna Rtlelpate ???? ? I r MAR-21-2006 TUE 12',57 PM J SPORTS MEDICINE MU OM9 r?utarwur?t cou??try ?M?aora ? 6aii T1111d1! ROa?d gyp, PA t7C?S =Oman uvrmr ? o Pile FAX NO, 7 i31 4640 P. 02 A?IAM? ?uWAMr?AD ? ? ?f0611047 ORO 055 M WA LYNCH $0, SCOTT ASSN G F4+nalkx,?+ 0 Hmd G Watw av?A?lelah C_! L?,,E?f+?dd?iditn t71k16u ! C l??F+l+rM?n1 C 1?nlhAar wcJU"oIoo.. Ar+oOhNbe, 0Pwrawy a aww o a o q llRr??kflarrlnlro? r R t?+?r? YuYAar d C?uw caw ?u?q? 1 e?+r?l i?a *1a PN a am obwq, aotrr- Totr>m o" 1t .p h iviz 'd wpr t Q E?ipntartl r?eedt WIGOW UP *m -7-4 HL' 11.THSOM Rehab Country Mmdow : 4' '" T Adlo Road Moc 4mbwl, P, , VDS5 PhUM 214-1 T75 Fax V4 W MAR-01-2006 RED 0131 PM ^ SPORTS MEDICINE FAX NO, 531 4640 83/01/2B06 98:43 717-214-2907 HS COUNTRY MEADMS /UL'1 Noms N"7WMnN h0ob Cmintty Maadoft 4905lmAT6%ft Rood Mobr*sW% PA 47055 Phdae 214.1776 Fax 2i&-Z tP1 tl1`WM KU OF &W (s 00 doW - OD011PX=KU VNE VY P. 02/02 PAGE 02/82 000 01 58 AD 12/1 Vol z/06/1447 ORq .: U)s M WA w LYNCm MD, SCOTT .?.r.wa ^"- atr^ PAW Netm, I"— ....?--?-... %R mvt Gi mr . ??OM1 Lip PIfiRy DIaQnOabe ihlar hOlpl4elltedarl ?c,r current M0f°Ci?s ? 1(?i{?? ED ?twtrtwt Rehab pd G A 6aaetlaSlt p Oood 94 CwrYN oom pow, pmm dWag lb. ft== of emmmolft" "WAd ftm ptrft,* trued 2*0 _ Cl hVA .- ?hJUe" E4Y¦1ms :m ? +r+1i t11? eA a*0 lq?.apetiMrK?v6?ne t?aliauld t+,Tih 1a bt10 Is++nOo?R wtw w, ow 4, 1 • b?iaw? PgMt 1ri to aFd+v for ' 11. Q hnP?Q? haMNfo?x+rtArvdlon 10f 1?otlaild lMpr WOh on .,..,.,.?,. L M Ararotr bet Ytnal w - - 21 R bw*W Itch 0 i3, WFWPWO%%UkfA,, ttlyW prrcip in m btpwe 0 PNktfn tta li hwtwitalA Abl,4t. Mtti101NtlAOLtweltaa t4 Cl In?gONt?tlnatllotorsiiMelarftp+oWNA"Umhae ;, ?. _ .."." >a PMMtR D7 drmonwlal PtOP?? P?1iAa Ind ? ? nnahr1pl wNlt AtN.t?attd pstg. 1d. q F wIh atn d pttgant h tri4ltr ataac ?„ . ? kKfIRM--M-NpANlarlN to - -.-mhos 1Q y Wllh p10pI?R? e if[_.. 10. hapl ?R 1tRarNd J 1 t. A Mnpta?. biro to dw?nww m ol taMe ?m.?la.rx?td t?._.__.. , at, a arrwr ? c L / ? ? 1J ;1 L k9rrvarttlan W Qalet?ftQr? Q t]gpr11lN9 tebelnMlR u Try" 0 VIl o tr>rC ttaking AO n tm*, ? tar Rv?dumtlon 0 Poehxe wow Body Mot wt ' Oa-Fdfww t Domlom"m C2 Fkl$ w a-mobetymboftv ? Egtiprne[tt- n gJam la Edema martpgtwwg by - - 0 a r prrtlo llan to ? spOngnwatho ttoa a? q tuner oaf oaf b r mg prat ? Cl Othw ywoRl"am Frwrpanavt ---- tKnaaMNM k o ww"mU .F Vvwm Olt. ? by rerlwtea nd Plan of aa4 wttlt nta, l??ltrr +umrt?arn, HfiALTHS0U7W RWtab Country tvla*dowa 4905 Emt7rloala Read Mnchantasbur9, PA 17088 phame 21 4.1T7b pxx214-2907 0^ Total Vlslts from SOC ?73 Total cancellations/no show 0 0 0 ? 0 ? 15 8 12113/05 HM HSOM, ASLAM, MUHAMMAQ C HEALTHSOUTH Rehab Country Meadows 2/06/ 1947 O R O 4905 East Trindle Road 0 5 8 M W A Mechanicsburg, PA 17055 t Y N H M p Phone 214-1775 Fax 214-2907 , S C O T T UPDATED PLAN OF CARE (z 60 days) - OCCUPATIONAL THERAPY 0 0 0 2 D 4 1 9 5 516 AMFESSOC4WH Patient Name: u aMmQOC Onset Date: )d) U any Begin Data: d ? Ob?• Primary Diagnosis: Prior hospitaltzatton (for current episode): Fro r os to JV_"_A1 '5 ? N/A Treatment Dia osis(es): &A be-41 fg_0 Physician; ill. Ali a Rehab potential: ? Excellent ? Good I12<air Certification period: From To M45ornpleted Medicatlon/Diagnosis Update Form 1. 2. 3. 4. 51 to long term goals. Lo ng Term Goals, 4 Weeks _ 1. Gr*6ecreaae pain to i j,, 0 to allow for A? Y i-I dr •9 Q t ry ? 11, ? Improve baiance/coordlnatlon for functtonal skills such as 2. [U Increase bed/mat blpty to ? 3, Z Increase transfer status to 12. Return to work at mods iedlnormal duties. h. ? Increase sensellaNpropriocepttoNvisual perception to Improve 13. ? Perform normal household ADL's. functional ADL's such as 14. ? Improve fine motor sidlts for functlonel ADL's such as 5, 0 Patient to demonstrate proper posture and sate body mechanics with ADL's and lilting, 15, ? Famllyicaregiver independent with care of patient In these areas: 6. ? Increase functional standing tolerance to minutes, i 7. 8. Q JDrProve skin inie9Y ar- increase ngth of - 16, Patient v+ith Home exercise program, J} eOther ? 17 et 9, 10 m to lprove functional mobliltylADUs e I . . 18. moth . ncrease FIRM of 4,4 18, G?Other from ?_ to l r? to fmprnva functitionai mobility/ADL's. 20, Vothsr 11. ? Improve balance to decrease risk of fells as evidenced by 21. ? Other P ationt Goals: ? ro u..- tr`-g - Skilled intervention may IL)elude the following: alftles lk'S trengthening Exercises ? Cognitive retraining - ? Transfer training ? Visual perceptual training ? ADL training ? Aquatic exercise Ne?uromuscular Re-education ? Posture and/or Body Mechanics L?ratlent/famlty training &,'AROM/PROM ? Fine motor/dexterity W JRexibility/Stretching GYtOlan I Therapy ? Equipment evaluation ? Edema management by caregiver participation in ? Splinting/orthotics ? Other ant of treatment plan. ? Other Treatment Frequency; 71mesMieek Duration: - Weeks I have reviews this an o are and have seen this patjenf and re-ceril a continuing ne ed for services, Physician Signature Date Therapist Signature (establishing POC) te My therapist has reviewed my Plan of Care with me. Patient/Caregiver Signature Short TArm Cilloeis• - - Weeks f 01 HEAUNSOUTH® ? >?-7 HEALTHSOUTH Rehab Country Meadows 4905 East Trlndle Road Mechanicsburg, PA 17055 UE ASSESS ENT ADDENDUM o Ir>Itlal e-eval ? D/C .I? 000101158 12113105 ASLAM, MUHAMMAD C 2/06/1947 0 58 M WA LYNCH MD, Sr 0 0 n /ADEFEASOGF ORO ICEY; ROM Is passive union Indicated otherwise with on °A". Use standard muscle tat grades for strength. . 10 WFL a Within Functional UmHS NIT ¦ Not Tinted N/A ¦ NOT APPLICABLE LE FT ROIWSTRENOTH R1CI W ROM MENOTH ACTION ROM STRBNdTH T' - SHOULDER FLOGON 180° F,- '3 4S - - SHOULDE R EXTENSION BO° SHOULDER EX. ROTATION 9M I AK 121- Is'e, SHOULDER IN. ROTATION 9M MY& SHOUI?ER ABDUCDON ISO, ELBOW FLEXON I-A 1 ELBOW EXTENSION (APL, I FOREARM SUPINATION am &t,f, q -A .1 W177 7, FOREARM PRONATION or WRIST FIBOON &A 4/17 '1 W7C, x WRIST EXTENSION 700 OTHER AJ #\J1 14 OTHER A/, Id OTHER 'g OTHER COORDINATION UPPER ®CrREMffV LEFT RIG Command cne pafttAr test ,sauna GROSS O WFL - RrWFL RTM 1palrod ? 1 Ired FINE L la Itn Trod O Im olred COMMENTS, GRIP STRISNQTH HAND DOMINANCE Circle One ?..,_ . __.._-,.._a .. LEFT RIGHT Comments Oro" are"-- 7- n 3 Point Pinch 1,t1?t. 1 Point Pinch Lateral Pinch EN8ATION N ¦ Normal HIT ¦ Not Tested 1 • Im mired A at Absent 'Sho ulder U r Ann Forearm Hand 017,16' Uk Shoulder Elbow wrw Fin era cf C, d) L R L R L R L R .Q?, Q4a L R L R L R L R Lt. Touch Pre ,low on Sna ull Stare nosis y Localization Corpmonntsi (Tons, Movement Patterns, Pal., R.fle:ea?: GAIT OBSERVATIONS: Q ormal ? Antal to O Ann Bwln L R JOINT DEFORMITY ? YES 11 • describes SUBLUXATIONt O ? YES Left: cm Right cm TRUCTURAL OBS}Ei ATION Ooalput Shouidera fLl 6oapuia Cleviiclas _ Cervical Lordosis Ttr"s o Kyphoals 11, 414 Wmbar L rdosts pt Let Posturs/Ob+lous mechanhel stress nts Date Signature / Title Date Signature / Title w t .?A- d S "-I' o."7b r-D - HEALTHS UT Rehab Countrv Meadows 4R(15 Fast 7rindlo Rnsd MRnhanicshurn PA 17nF,F, PhnnR 214-1775 Fax 214-2907 FEB-07-2006 TUE 03;29 ... Hm" SPORTS MEDICINE HEAM SOU HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanl PA 17055 csbUNCTIUNAL ASSESSMENT ADDENDUM 0 InItal &. -WW ? D/C FAX NO, 1. i31 4640 P 02/02 AA? 000?O?L58 ?a?13ios _ ASLAM, MUHAMMAD C 1/00/1947 ORO 058 M WA LYNCH MC, SCOTT ?- 0 0 0 2 0 4 19 5 KEY IND ¦ Independent MODI ¦ Medlded Inds andent sWSPV ¦ sat Up/ "Mu rPAsien MIN a mNM Mm NM MOD ¦ Mod. Aeslst ..MAX ..?.=?r, Mis, a /Assist TTbtal Da nd lot Tested PRIOR CURRENT BED MOBI IND MOD I SWVV MIN Maa MAX TO N/T COMMB Rom To Mght Side Rm Sft - To - Su ne S e-To-St poebmirm TRAM FERS EQUIPMENT TYPE: INITIALS Bed Toilet - Tub/Shower car rrY19 Other, AMBULATION INITIALS Sft - To - Stand Stand -To - SI Level Surface DWce/listance: Oelt Devlatlons: (describe) EgUHbrkrn Readons: Anide, Hip In describe Stairs # at Stairs Other, Dor0off aftWhowbod Type of Device: WHEELCHAIR MOBILITY Parts M enlent PROPULSION TYPE; INITIALS Level P Dlatance: Other. ACTIVITIES OF DAILY LIVING EQUIPMENT USED N[rIAL8 Groorrd ? UE Dressft LE Dreatift = Tollatim Does Y lnual Parse teal Abiil /Go nl tlon Appear To Limit Function ? o ? an ACTNITY Meal Pre EQUIPMENT USED 1 IT LS HousekeepIng /Laundry Telephone Use A l I DrMn [ l Chlid Care Flrw dal M ement Othar. Date Signature / Ti tle InftiaL Date Signature /Title als IW Total Matta from SOO / ?) Total ncsllabon no show HMUHSOUM. HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 Phone 214-1775 Fax 214-2907 UPDATED PLAN OF CARE (x BO days) - OCCUPATIONAL THERAPY Patient Name: Ll AMAr Primary Diagnosis: Prior ha Treatment Di gnosi as): Physician: Rehab potential: ? Excellent ood ? Fair 915ompleted Madication/Dlagnosis Update Form (Progress achieved from 000?U?IS8 12115105 ASLAM, MUHAMMAD C 2/06/1547 ORO 0 58 M WA LYNCH MD, SCOTT 000204195 516 ADDrEss0c4 AFH Onset Date: D Begin Date: (for current episode): From to Certification period: To •n ? N/A Zp 4, Lo ng ?rgrm als: 2 weeks 1. Decrease pain to !7 to allow for 11. ? Improve balence/coordlnatlon for functional skills such as 2. la Increase bedlmat mo Ulty to 3. .? Increase transfer status to 12. stum to work at mofte Vnarmal duties. F 6 -45- 4, ? increase.seneatfon/propdoceprdorVvisual perception to improve 13. ? Perform normal household ADL's. functional ADL's such as 14, ? Improvalne motor skis for functional ADL's such as 5. El Patient to demonstrate proper posture and safe body mechanics with AD1 s and lifting. 15, ? Family/caregiver independent with care of patient in these areas: 6. ? increase functional standing tolerance to minutes. 7, ? rove skin Integrity 16, atlent wfth 8. 1Wn strength 1 17. he 9, horn to to mprove functional mobNity/ADL's 18. er 10. l rncrease DM of 19, Oche 4Fw to to Improve functional mobllity/ADL's. 20. ? Other it. ? Improve balance to decrease risk of tells as evktenceci by 21, ? Other Itputment • Skilled intervention may ingglode the follavvinQ: dalitles m.Bfrengthening Exercises ? Cognitive retraining ? Transfer training ? Visual perceptual training ? ADL training ? Aquatic exercise ? omuscular Re-education 11 Posture and/or Body Mechanics CL Patient/famlly training - OM/PROM ? Fine motor/dexterity dbility/Stratching RHw( 01-- anual Therapy ? Equipment evaluation ? Edema management by caregiver participation in ? Splinting/orthotics ? Other development of treatment plan. ? Other I Treatment Frequency: - TimesMeek Duration: Weeks ave reviewed this Plan of Care and have seen this patient and re-certlA, a condnuina need for services. Physician Signature Therapist Signature (establlshtng POC) `?- Date - -11,//O[?oz My therapist has reviewed my Plan of Care with me, atlent/Caregiver Signature Short tarm',goa/s are written & address patient problems and should relate to long term goals. Short To-rrn Goals, I - 2- Weeks HEALMSOUTH® HEALTHSOUTH Rehab Country Meadows 4905 East THndle Road Mechanicsburg, PA 17055 UE ASSESSMENT ADDENDUM ? Inltlal I <sR vel ? o/c 000'10-1 L4. C ASLAM, 2106/1947 ORO 058 M WA O NAM Mp, SCOYt 00020AI95 12/13/05 isIIIYs ROM is psaslve unless indicated otherwise with an "A". Use standard muscle test grades for strength. WIFL ¦ Within Funotlanal UmItS NIT ¦ Not Tested N/A ¦ NOT APPLICABLE LE FT ROM/S'TRO40TH ma w ROM STRENGTH ACTION ROM STRENGTH SHOULDER FLDWN 1800 M . 4 SHOULDER EXTENSION 80° -A 4 1V 't SHOULDER EX. ROTATION 90° SHOULDER IN. ROTATION 97 SHOULDER ABDUCTION 180° ELBOW RZOON 150° ELBOW DXTENSION 00 FOREARM SUPINATION 80° WE &),.!r4 tQ414-1 FOREARM PRONAMON 80° -K JrF WRIST FLEXION 80° WRIST EXTENSION 700 OTHER OTHER &1 -14 A 1141 OTHER NIA 41/n -Ailm OTHER COOR DINATION UPPER MCTREMITY LEFT RIGHT Comments fast results GROSS ? WFL mpolmd ? Impaired (YM FIRE FL 1 ? lm red COMMENTS: 410 -All . RIP STRIEWbrrH HANG DQ*llU-W CE Circle O LEFT IU Comments Gross Grasp 11 F Z46 3 Point Pinch 2 Point Pinch JA& Lateral Pinch ENSATION N ¦ Normal NR ¦ Not Tested I ¦ Impaired A . Absent I') Z9 ? Shoulder Uppe r Ann Forearm Ha nd b Shoulder Elbow at Fingers L R L R L R L R L ai R L R L R L R Lt. Tsuoh i I Preorloce tion ) rr A I 1r k)l-.n 0v Zha -Dull m kr tip] Steve nosis sil.n.. W1 Rill UL ?ZE 41: 41n u mments: (T ne, Mo ma Patty s, Pain, Roll ash: GAIT OBSERVATTONts: ? Normal ? Antal to ? Ann Swing L R JOINT DEFORMITY: ? NO ? YES It es describe: J rj- SUBLUXATIONi O NO ? YES Lett; cm RI ht: cm STRUCTURAL OBSERVATION OWIPut Shoulders Scapula clavicles Ow&W Loniods U 1 TMreclc Kyphoals Nr/b Lumber Lordosis Posture/Ob vbus mechanical sttesa rile Date Signature / Title Date Signature / Title if 000lu X158 ASLAM, MUHAMMAD C HEALTN.SWTH HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road MechanlcslPdi4GTl0NAL ASSESSMENT ADDENDUM ? Inidal a -evel ? D!C T T .k mcp 1/06/1447 ORO 058 M WA LYNCH MD, SCOTT 000204195 12/13/09 916 ADDRESSOGRAPH KV IND ¦ Independent moms od10ed nde endent Su/aPV a tact UP/ Sa rion MIN a Man., male`! MOD a no-so/ Mod. Assist VA" . him. Asalat TD * Total Depend Wr e Not Tested PRIOR CURRENT BED mostury IND MOD I swarv MIN MoD MAX TD N!T COMME INITIA LS To R-ght Side Rolhnr RoMm To Loft Side Sit - To - Su ne Su e - To - Slk Poskkrdn-q TFIANSIVERS EQUIPMENT TYPE: INCMLS Bed dlat hyl-m Tub/shower Car Other. AMBULATION INn IAL.S Sit - To - Stand Stand - To - Sit Level Surface DWce/Distanca: Gait Deulatlons: (descif ) EgIAWum Readons: Anita, Filp Ste I describe Stairs # of Stairs Other. Domvoff oftftoPrmth T of Devloe: WHEELCHAIR M®BILITY PROPULSION TYPH: INiML9 Parts marmement Level Distance: Other. ACTIVITMES OF DAILY L rm ci IPMENT USED INITIA Grooming 11-1 1 A Bething _ 3 UE Dressing LE Dressing 1TOlleting Does sual Pen:e tual Ablli /Co n ltion A ppear Tb Limit Function? o ? Yea ACTIVITY EQUIPMENT USED et pre M / au ' M a Use ! Driving 71 d Cars Flnandd Men ement Other. Date Slgnatu / Tltl init ials Date Signature / Title In as L JAN-18-2006 WED 09:57 AM HK SPORTS MEDICINE FAX NO. 717 r31 4640 91/18/2806 09:13 717-214-2907 HS COUNTRY MEADOWb W VWtx km $QC _I- "low cen09pptbwno atoms ? P. 02 PAGE 02/03 0001011?A 12m/0 A$LAM, MUHAMMAD C ?/06/1447 ORD 616 M MA ?rsc% No, SGOCt ?DQ2??t95 „ S10 „,, onset Odr, D-9 - 0a Av Nmpib ksmn mr mmt 5000* prom ¢flos to f ? N!A Tramb lam OIE?11 r I1.? ' 171 f$AAfa m: PM11b potenttd: tj'tstadwm C10ood a PO cam moor, pmod: ftm To a6mpf m m A0ati0tll wr0ft Up wa Poem &m VA-4wG Fm9mm am4voed from pr"U* taw go") /_ - a mmmrwmm . w--- - - -e 116AL,TNiOUTN Rehab Country k4 adovre 4eo9 F.aaf Tfl Road Maclalnkabwo, PA 17M phone 2U.1775 Fan 244-2907 nonavi Pt jkw no CAIN aftf PAT10RAL THERAPY "14 S,141 1. gr6woft to / - 2 w allow tar ? .1!/, . Z.gdJ t 1. A Imp+ave nelenmlanadkmgon for><rbd0lMlt afdib euw+ ac Q. a k aemo hallhrwamo4lMy to a, a wx mu ow wo etiaa?e m 12, Fban to wmk m mxmm r4fff p dAft, - w 4, a IM"m peRnptim w im= 13 M m"W howehoa AMA. e Ptk1 ?o meahanlra 14. 6- trela or & d fiORpw+??AAI kA tr10tIRM{ A 7 hoe . 11 pmp pC u 6. PatiOhtlp wnanl r+m?a wa of podant kl exam _ wo ACLX and emo, 16.0 IL o 1?aeme AroAft wwrwnl9 bakrenaa sa rtd"Am. e: in - - 1i +• ?f .mtdeaprv5ram e e - ? fli+ .+0 d L. ? vlr?m ao rt moalhy/AOtx i s o o r r fa tt u,?,aam a ROIN d f ! .,. nmft lunOpOrlel nlobtllV/A Us. 2D. o Other m to e ira deClaea9 tpk or IWN v< wldanaod by 21, L1 (Ytw 11 bel t? . i was &,e Pmflmnt GGRA ! ,Y1 - ?f'lnnc ?latl?f Irtterverldan m C the ?a m?enin@?eee ? ©CtapnrtNa toarahhp - - 1 ,^- .J.O J s ? 'hanabrtridNna ? Vtsual "Maptual uelnkV ? ADLttokdnD 11 Aquatic aar h,! ? waummu cmw Raclaucattm ? Posture and/or Body Moahw*x "aUmt/fa Nt flaming WAROMMROM ? Fhte manor/o"ortty "030Bty/Sltrartahkl8 Thprmpy t7 SgUtpmw t Wiekmmn ? Edema mem4p nern by ^ hrer part>ejwton in Q SpdrMnWanhoooa 13 0tw - of 0 eatnlertt W. / deftOwpwft 319M 2021611 o Other z- Sk of mov --I+ 2. A " C ` 13. 4. 5. r vmft Tlmat/WeCk cwarNont 1V & PJOrslchn Stprlattrn+ 'TheragiaR atgnlllurw (oambROhtng Pt7C?T??.•W?•u /= ?.J? -- NY ttwrapitt has revl+wed nN vun At Cart whh mt. ? ?mnt+?a+v9lrrw ?lgnar?rx ,? )fEALTHSOUTH Rahab Country Maadowe 4905EW70ndle Road pA 17t]SS Aane 214-1778 F69214-2907 Total Visits from SOC 7 Total cancellations/no show -(Z HEUTHSOUTH® HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 Phone 214-1775 Fax 214-2907 UPDATED PLAN OF CARE OCCUPATIONAL THERAPY Patient Name:. e Primary Diagnosis: Treatment Diagnos Physician; Al ADDRESSOGRAPH ,S_ Bealn Date; Rehab potential; 91fxcellent ? Good ? Fair Certification period; From /&,2 1_4e To „2 116 P3 Completed Medication/Diagnosis Update Form (Progress achieved from previously stated goals) -AD L's - /V 4 fits Short term goals are written to address patient p, ,'$hort Term Qoals; -.2 Weeks 1. 2. 3. 4. 5. .?? Pie' i! r ?i woo -CLi ? .KS.? /J'I?? ' ? ?iu,1,.,.,?.?• •ic.Gt? and should relate to long term goals' ?a fi ? Cc ? c >? IYivl, f -fvv? Aluoy, ?? L.onn term Gools• 4/_ Weeks 1. Decrease pain to / - 2 to allow for 12 e v. ?c 4 l?6, 11. ? Improve balance/coordination for functional skills such as 2. ? Increase bed/mat mobitty to 3. ? Increase transfer status to 12. urn to work at modified/normal duties. P, J- 10/ 44a 4. d Increase sensatioMproprioceptionivisual perception to Improve 13. B'Emprove arm normal household ADC's. 94 Junctional ADC's such as 14, fine motor skills (or functional ADC'; quch as 5. Patient to demonstrate proper posture and safe body mechanics kjff gm., tic, -'-/'Z4 with ADts and lifting. 15. ? Family/caragivsf i d e dent Min care of patlent In these areas; 6. ? Increase functional standing tolerance to minutes. 7, CI improve skin Integrity 16, W-Patient - -MitrHome exercise program. 8. tiKhorea strength of k) ,7,f k 17. q?rOther - to r cti al oblit /ADCs 18 r t f ? Oth 9 f m ?> Civ o ov . rom u on , m y e 10, increase ROM of ?- G 1E _ X_ i a-? 19. ? Other from 1-- to to imipro? rove balance to decrease risk of tells 11 m functional mobility/ADLs. 20. ? Other as evidenced by 21 ? Other . r,p r -' m t . }patient Goois:., elr'__1PLA Z &11 ?t Ciri?c Treatment Plan; Skilled interventio n may ipdude the following: @Yfvlodalities 1 1'Strengthening Exercises ? Cognitive retraining ? Transfer training ? Visual perceptual training ? ADL training ? Aquatic exercise ? Neuromuscular Re-education ? Posture and/or Body Mechanics Z05atient/family training 0--AROM/PROM ? Fine motor/dexterity (Taxability/Stretching l:IUanu Therapy ? Equipment evaluation ? Edema management by ati aregiver participation in ? Splinting/orthotics ? Other development of treatment plan. ? Other Treatment Frequency: _ 3 Times/Week "Duration: _ Weeks I have reviewed this Plan of Care and re-certity a continuing need for services Physician Signature X Date Therapist Signature (establishing POC) I V- 0`Nr ate //3/orr' My therapist has reviewed my Plan of Care with me. Patient/Caregiver Signature D00?0`I1?8 1211,3105 ASLAM, MUHAMMAD C 2/06/1947 ORO 0 58 M WA LYNCH M0, SCOTT 000204195 516 P4 HEALTHSOU774® HEALTHSOUTH Rehab Country Meadows 4905 East Trindie Road Mechanicsburg, PA 17055 UE ASSESSMENT ADDENDUM ? Initial "B-eve! ? D/C / /z //,i_ 000 1158 12/131/05 ASLAM, MUHAMMAD C 2/06/1947 ORO 0 58 M WA LYNCH MD, SCOTT 000204195 gib KEY: ROM la passive uniaaa indicated otherwise with an "A", Use standard muscle teat grades for atrengft WFL a Within Punctional LimltS WT a Not Tested N/A a NOT APPLICABLE LE FT ROM/STRENGTH FAG W ROM /0 1 STRENGTH ACTION ROM STRENGTH 0 0 o SHOULDER FLEXION 180° SHOULDER EXTENSION air l L SHOULDER EK ROTATION 90° t t SHOULDER IN. ROTATION 90° kh- L 5P11' - t SHOULDER ABDUCTION 180° FL- 4010 1 - SBM RMOON 150° (-A A ELEM EXTEMION 0° / FOREARM SUPINAMON &r LAf, FOREARM PRONATION S? '?- -41T /6) WRIST FLEXION W WRIS71'WENSION Ar OTHER OTHER OTHER ,%j in OTHER I\jl OOORDINATION UPPER.®CTREMrrY LEPT RIGHT comments (ab tier tear teR^ GROSS ? WFL m Ind ? Impaired G FINE L D Im Ind 17 tm aired MCI, MENTi1: RIP STREN HAN DOMINANCE Circle One LEFT RIGHT Comments amen Gras 3 Point Pinch Aft LAAt- '11 2 Point Pinch Lateral Pinch SENSATION H ¦ Norm al NIT a Net Tasted I ¦ Impaired A a Absent Sho ulder Upper Amt Forearm Hand k T Zb 4 6 Shoulder Elbow Wrist Fing ers L R L A L R L R 4 , . L R L R L R L R t. Touch Proriooe tlon MI-r 1A V7- &0 1,' She Dull ILU) Al Stan noaia A.11 -1 I ,Adq Localization Common" rbne, Movement P its , Pain Reflexes): rvi, 4 GMT OommuTIONS: ? ormsl Arttai to D Arm Swing L R - - JOINT DEFORMITY: O ? YES R ea describes SUBLUXATION: D*b ? YES Left cm Right om STRUCTURAL 098EFIVATION Qcciput Stwulda:a rt 4 Scapula 7 7= Q.Vi is CeNlow Lardoala _ ft . Thoracic Kyphosie 4 f Lumhar Lordoala 142 - Posture/Obvious mechadcel stresa points Date Signature f Title ate Signature /Title iL3mb lm-6 14b 4e T-4-1 tl- HEALTHSOUM HE.4LTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsbu PA 17055 FU14CTIONAL ASSESSMENT / ADDENDUM Q Initlal Cl Re-evel Q D/C 000?U '!58 12/13/05 ASLAM, MMUHAMMAD C 2/06/1947 ORO 058 M WA LYNCH MV, SCOTT r 000204195 516 A KEY IND r independent A?DO I ¦ IMI indepandent SUISPV ¦ S t uR,b n MIN ¦ nahit MOD a MAX ¦ Mod.Aealet t TD a i Depend NR ¦ Tsiied PRIOR CURR ENT B MOBILM tNC HIOD I SWSFH HON MCI) WX TD NN COMME INITIALS To Side OM TO Left Slde Sit - To - Su ne Su a-To-St Podlord TRANS PER9 EQUIPMENT TYPEt INITIALS Bed Toilet Tub/Shower Car Other, AMBULATION INITIALS St -To - Steed Stand - To - SA Level Surface Devica/Dlatence: Batt Deviations: (desalbe) Equi&Wum Reaatlorts: Amide, Hip S n descdde Stairs p of Stara Other Doft/W oftt miff tlt of DEVICE: WHEELCHAIR MOBILITY PROPULSION TYPE- INITIALS Parts M ement Laval P Usfon Dstance: Other. ACTIVITIES OF DA ILY L IVING EQUIPMENT USED INITIALS Eating hlj? Grooming Hethl UE Dreasln .LE Dressin a? Tolle oeo V isual Perceptual A611f !Ca nitlan ear To Limit Function? LO No ? on ACTIVITY EQUIPMENT USED INITIALS Meal Prep OArl f?A Telephone Use Dr n Chid Care v 1ZL Rnandai M ement Other. Date SlAnaturffi ! Title Inl tiala Data Signature ! Tate Initials' LJG`A I TI1e??rrrrr r r-. - PENNSTATE 1 Milton S. Hershe?._ dical Center College of Medicine NAME: ASLAM MUHAMMAD C E7 MO: LYNCH SCOTT A MRR: 7002936 PY REF??pyjC IDNS: WORKER?S4coMp /F rjC'(V_T?. n n G / ?0 J ? LOOOS?t:084263475 F - MDN: 24835 SEX: M STANDARD VISIT DATE; 03116/2006 S8 M WA Admission Date: Pati@rdls9*iM4k , 5 C 0 T Age: Outpatient: Inpatient: I N POW Doc6q.0204195 TServiciqj. Phone: Dia nosis: 9 7' P/111 Ile, P, ,5 Rx Frequency: Di1e iX: L a EVALUATION AND TESTING PROCEDURES Consult Activities of Daily Living Evaluation Cardiac Rehabilitation Cybex - Gonlometry/ROM JOBST Measurement _ Manual Muscle Test - Splint Fabrication T Static - Dynamic Other MODALITIES _ Cold Pacs _ Contrast Baths Diathermy Electrical Stimulation "(TENS, HVGS, Low Volt, Etectrostim 1130) Hot Pacs Ice Massage - JOBST Compression Massage Moistaire Paraffin Traction ^ Cervical ...- Pelvic Ultrasound Ultraviolet/ Cold Quartz Whirlpool - Other "TENS: Transcutaneous Electrical Nerve Stimulation; HVGS. High Volt Galvanic Stimulation THERAP iLTIC EXERCISE - Coordination/ Balance _ Gait Training Full Weight Bearing -. Partial Weight Bearing Toe Touch Weight Bearing - Non Weight Bearing Home Exercise Program - Isokinetic Exercise _ Muscle Re-education Neuromuscular Facilitation - Posture Training Pre-prosthetic Training and Stump Conditioning Progressive Resistive. Exercise P?rostt is Training -!ROM ,Active -Active Assistive Passive - Tilt Table ___. Wheelchair Skills Other _ COMMENTS; Physician Signature Ito 0 O O M O M UH5 g A D' ??FTANS SSION VERIFICATION REPORT ASL 2/06/1947 ORO 0 59 M wA LYNCH MD, SCOTT 000204195 DATE DIME FAX N0,/NAME DURATION PAGE (S) RESULT MODE 516 03/21 12:01 5314640 00:00:39 02 OK STANDARD ECM TIME NAME FAX TEL SER. # 03/21/2006 12:01 HS COUNTRY MEADOWS 717-214-2907 BROL2JB47063 067-M (L1L) XYJALLT-pit (LTL) # 5SDLT Vd'2ingo7impon + pr.og ofpWj, pva 5060 -no?f ?1+???J. ?,?nssaut rnu,2uo ar(? down pate anagn ,raque?ra ?? ? f?'1I a?1 ?englno dq i?r'i r+r?t sfr ?tfOou seraajd norm fn ddoa jW styf paw anar? rod ?I a7A?s.o iol?j.a?fo rrrroprplor w;gnra.r iG?. a r rx p Wo,,geauurraaW n (rta pop pvgpou ?iq zray prro avd *nd puv pvm4?ttp0 V mopeuofiq stys fo R*doo ao uoM popwm no per' A? aRvxww no o -wpm1 RIPA wo po "m bra io ?VmlA.ptq avok m ait Ao{djao Pwamm upsouafiff TPA-?iroa ? pa,?alt?nrd ?,4?1 aq rfprk a?nssa?u ap?,ura?n.?'?r?,t'irt Pa'?W? ?p.??? o?LL ;GLOM ?.L .Zht?1?'dN ? SGGI-?I? (GIG} ;jje0 as>,ajd j??rrasu?.? s>? ?autaoal s?axojgo?d an a?a1?.? ,0moq,l jEaQuradmoo T TsoisAijd otgvua.j) . 9qR' I.181nq'POA SU0'q=T2Ag W'I xOAojVsrso!jl ztj8AH JMoj0ag11!y _. ¦ Azivgj, TmoRr-dnoop ?Y Fc)lshgd ar aN TemuoD AU-EJ0 1, jmopvdTtDop V lrozsAgd oipodoipQ jmauaD . =S?:.?IA?S rJ.hIltti1 'I'Tpd 5'tI'T:T.iCt A:4,C1Q?V?I A2I.LATIlf?? 3Q ,PIDZI',?'.LT'IIH;t?Iii3'2i F?LC1t,??.F?l'x PENNSTATE -Polk n S. H??rr?rdical Center O O O M M of Medicine 2/06 / 1PAYSlCAkT04ERAPY REFERRAL LYNCH MD. SCOTT 0002 ray .. PON NAME: ASLAM, MUHAMMAD C MD: LYNCH SCOTT A MAN: 7002936 008: 02/06/1947 INS; WORKER,s COMP LOC: ORT2 DOW 6213986 MON: 24836 SEX: M STANDARD VISIT DATE: 01/02/2006 Admission Date: Patient's Name: Age: Outpatient: Inpatient: I Number Doctor: Service: Phone: Diagnosis: Z. %1,1, -- , ti ?=,vL ,? h. ???? r T Rx Frequency: IO // R ? Z EVALUATION AND TESTING PRO EDURES /,-- --e THERAPEUTIC E C XERCISE! .- Consult Coordination/Balance Activities of Daily Living Evaluation _ Gait Training - Cardiac Rehabilitation - Full Weight Bearing -__- Cybex _ Partial Weight Bearing - Goniometry/ROM _Toe Touch Weight Bearing - JOBST Measurement - Non Weight Bearing - Manual Muscle Test Home Exercise Program - Splint Fabrication - Static - Dynamic _ Isokinetic Exercise - Other _ Muscle Re-education Neuromuscular Facilitation MODALITIES Posture Training Cold Pacs _ Pre-prosthetic Training and Stump Conditioning - Contrast Baths ressie Resistive Exercise _ Diathermy -Prosthetic Train, e"k _ Electrical Stimulation . AOM ____ Active T Active Aesistive y *(TENS, HVGS, Low Volt, Electrostim 180) ? Pa'?ssive _ Hot Pacs Tilt Table Ice Massage ^ Wheelchair Skills JOBST Compression `. Other - Massage - Moistaire - Paraffin Traction -Cervical _Pelvic - Ultrasound _.__ Ultraviolet/Cold Quartz Whirlpool Other *TENS: Transcutaneous Electrical Nerve Stimulation; HVGS: High Volt Galvanic Stimulation COMMENTS: Ph icia Signature HEAL 7'HSOU7H INTERDISCIPLINARY PROGRESS NOTE ok? NOTE; ALL ENTRIES MUST BE SIGNED AND DATED. -age of -. :::HRC 2001 nevisea 02101 308- tnt. pr-egress Nate Patient Name: HEALTHSOUTH 0OOAM0?158 12/19/05 COUNTRY MEADOWS AS LAM, MUHAMMAD C 2/06/1947 ORO 0 58 M wA LYNCH M0, SCOTT 0 0 0 2 0 4 1 9 5 PATrm r mPORMS'FIV Diagnosis: DATE PROGRESS NOTES THERAPIST Q ONTACT FORM ADDREtnAlb 1.? 7 Q 1 z/ 13 /D 3 LLAjj$??JJL((JJaM. MUHAMMAD C 110611947 ORO 0 58 M WA LYNCH MD, SCOTT 000204195 ? ste DATEMME DISCIPLINE COMMENTS (EACH E4TAY MUST BE iDUIT1FiED WITH SIGNATURE AND i PROFESSIONAL DESIGNATION) 1 Gtr G ° ?. ll::4 go Cal LAY fl I I .. I ? I HEALTHSOUTH COUNTRY MEADOWS 0 0 0 ? 0 ? 15 8 12/13/03 ABLAM, MUHAMMAD C 2/06/1941 ORO 058 M WA LYNCH mD, SCOTT 0 0 0 2 0 4 19AnENT WFORMAZ7001 6 AL .. Diagnosis• A DATE PROGRESS NOTE5 THERAPIST n, 17 7 41 G 42 41, vLy? c7^ Gti , D 119 2° FEB-23-2006 THU 10;53 AM HtASPORTS MEDICINE FAX K 717 531 4640 P, 02 000"1018 12i J/05 WAN M A 1, c ? / 6 / 10*2* f. Hms&y M? &t ?w?; rr+; e4ae6 0 58 M Q90* ?; ?Yxe+ of Ot???n ° eT reri 7WISU 04 000204195 441 1W R6l OF1AL M. ? 'a ?'"° vsatT nrtt ; ?„•,? Air, x?M: 48AOOeE Admission pan: PeNent's Nam: Ap9: Qutpgtierttz inplttMnr r?nr»r Doctor, Servtoe: Phone: per; ?' ,t.Fw ..Y...y,t,? f Rx Fre?gwncy: ? ?C t EVALUATION AND TWnNG FROOWURES _ ., Atrti4m of Daily Living " aW Cardiac Flehabllhatlen Oybax Gon{arnalry+'/itdM JQBST Measurement Manual Muscle Toot Splint FelbricMlcm -$Mo Dynemi OthW MODALMIS _ Om pw a Oontrast Raft _ .. _ - ^ Dl?ttternty ... _ Efectf4cAl Sumlation *(TENS, HVGS, Low Vol, Eivctroatim 1 -Hot Pem .?, iCp Maauge _.? JWST Campmasion .?..,, Massage Moistalre Paraffin Tn wOon Cervical Peivic ultraeound ultrRVloletlCold Quartz. - Whirlpaal Other 'Vft Tromm anevuo Etvatrlgui Nvnw S mWaNan WW no Van G&N*nto Sftmlamn G_?RAPEUTIC EXIERCISE - 0oardlnellon/BAletrtae daft Training Full Weight Bowing ,,,,_. Pertlat Welght Beerinp -'rot Touch Welght Seaft - Non Wsloht wring Home &AMI a Program c _ )soidnetia lIxerais e Muscle Reeduearlon Naumrnusctdetr Fbcllitwian _,. Posture Training .,,._ Pr"rosthettc Training end 8t mp Cmdltt wft rt'salve Reakettve Fxeraistw_ Pro* p er ?...- rr M ..? Act Acttve Aeftm Tih Table Whvvicheir Shills Other OOMMFNM, P*kmn avn6um PT 7 jIN" Oct Fo,i;ts,r,I THERAPY REFEWAL PENNSTATE Milton S.H??e//??rs??h'; ?7, edical Center C*M 1h "Cg_?`f4`?'e t p i t 3, n g r", fl- THAAAI ARAL 058 M WA ?? - s 138 1AME; A5LAM, MUHAMMAD C ' MDN; 24835 to LYNCH S60 GOTT A ARk: 7002936 SEX: M )OB: 0210611947 INS: WORKER'S COMP STANDARD a Or,: ORT2 VISIT DATE: 0211612006 ? )OSN: 6349058 0 M Admission Date:. it ; ;' .... Patient's Name: .:... je: Outpatient: Inpatient: Room Number Doctor: Service: Phone: Diagnosis: Rx Frequency: Dal R x: EVALUATION AND TESTING PROCEDURES - Consult -Activities of Daily Living Evaluation Cardiac Rehabilitation _ Cybex _ Goniometry/ROM JOBST Measurement _ Manual Muscle Test _ Splint Fabrication - Static - Dynami Other MODALITIES - Cold Pacs _ Contrast Baths Diathermy Y - Electrical Stimulation "(TENS, HVGS, Low Volt, Electrostim 180) Hot Pacs ice Massage JOBST Compression Massage Moistaire Paraffin Traction + Cervical _ Pelvic - Ultrasound Ultraviolet/ Cold Quartz - Whirlpool Other 'TENS: Transcutaneous Electrical Nerve Stimulation; HVGS; High Volt Galvanic Stimulation GHERAPEUTIC EXERCISE _ Coordination/ Balance - Gait Training Full Weight Bearing Partial Weight Bearing -Toe Touch Weight Bearing Non Weight Bearing r Home Exercise Program c -, isokinetic Exercise Muscle Re-education Neuromuscular F-acititation Posture Training Pre-prosthetic Training and Stump Conditioning _lPfogressive Resistive Exercise ____ Prosth i OM -'At tives-__ _ Active Assistive passive Tilt Table Wheelchair Skills Other - COMMENTS: w? Ph sicl n Signature DEC-07-2005 WED 02:40 PM Hl SPORTS MEDICINE ooo-?o?Is8 92/13/09 ASL AH, MUHAm MAD C 2/06/1947 ORO q 58 M WA LYNCH M0, SCOTS X16 000204195 FAX NO. 71A731 4640 P. 02 PENNSfA- Milton S. Hershey Medical Center M.C. 3089 i i College of Me&mt P.O. Boz 850, Senhey. 4A 17033-0850 (717) 531-5639 PCS Z2 7102 NAME mcaad ftSl aM DOB HT WT ADDRESS DATE ! PATMNTN•O. ALLERGIES DW10 TION n Yang All Preuciptiane ! Scott A. Lynch. M.D. ' NAMH(P)wcPrW) MD/DA, _MP 062970-. 3Ua9T I MONPBRMfMSMLB M.D-D.O. TN CMMLFOR&BRANDN'AW PstADUCT TO BE DISPENSED, THB ?MCRMER MUST HANDWRITE "BRAND NECESSARY" OR "BRAND MEDICALLY " D E A REQ NO NECESSARY IN THE SPACE BELOW. . . . . i PENNSTATE I fm- AP Milton & Hers Medical Center NAME : A? MUHAMMAD c tCollege-of Me?me MD: LYNG,;60TT A p MRN: 7002938 DOB: 02/06/1947 ?} ?p INS: WORKER'S COMP U O ( I Cifi .gHERAPY 6AL LOC: 0 OOSN: 61 613 37239 ASLAM. MUHAMMAD_ C_ Y1 C L C )/(1A/10A7 n0l) 58 M WA ;i Admission Date: M 'M m Age: Outpatient: _TI Inpatient: NNuumher Doctor: Serv Phone: Diagnosis: SrL?wf,T Rx Frequency: p B? Z' ?d EVALUATION AND TESTING PROCEDURES Consult _ Activities of Daily Living Evaluation Cardiac Rehabilitation Cybex _ Goniometry/ROM JOBST Measurement - Manual Muscle Test Splint Fabrication - Static - Dynamic - Other MODALITIES - Cold Pacs _ Contrast Baths Diathermy Electrical Stimulation *(TENS. HVGS, Low Volt, Electrostim 180) Hot Pacs Ice Massage _ JOBST Compression Massage Moistaire Paraffin Traction _ Cervical Pelvic Ultrasound _ Ultraviolet/ Cold Quartz _ Whirlpool Other Kr. THERAPEUTIC EXERCISE i Coordination/ Balance Gait Training Full Weight Bearing Partial Weight Bearing ____ Toe Touch Weight Bearing Non Weight Bearing Home Exercise Program Isakinetic Exercise Muscle Re-education Neuromuscular Facilitation _ Posture Training _ Pre-prosthetic Training and Stump Conditioning _ Progressive Resistive Exercise Prosthetic Training. ROM _? ive Active Assistive Passive ga Tilt Table Wheelchair Skills V Other COMMENTS: "TENS: Transcutaneous Electrical Nerve Stimulation; HVGS: High Volt Galvanic Stimulation MDN; 24836 SEX: M STANDARD VISIT DATE; 1210112006 7 6 Physlci signature DEC-15-2005 THU 02;33 PM WPORTS MEDICINE FAX NO, 71,i%-31 4640 P. 02/02 12114/209$ 08:98 717X21q 2997 HS COUNTRY MEADUM PAGE 02/82 000` 01SE 12/13/03 A Sl AM , MUHAMMAD C I f l U T W U M R . n W b -wonnley uro 21061194 7 O R O 810 Not1h pmnt Street wcmd.,phurq. F+A 1? 0 5 a M w a pgane 97$4337 FIX 975-NI3 L r C H HO, SCOTT It MAL PLU OF OME OCCtlN ATIONAL TA Y o 0 Pdam Nana C7t16E! 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Pa wtt WIC IL Pxdmr4 wk 4, Pon war waft t."?,ikr..+. w+n m 1 7?_ m claw kx 1 t, a bropwa bwar aalooardtralOrr ex Rum" m Sam r s. 47 trlne.e?e ts,tettnrrt rrae?ry m 41 $ ?a>rrmr,raw.m ta, tawartcee?euaea. w trtlptar. fa? rtotmol traleertolo Aotst tu,ctionr,nnpl,h,p,?, 1?; mterrtetarraeroetteteaanr+?aaue, s a mar, aw.rar bed a? attar m w a in V "am "W"1m st+r?dr mrrane?n ip? rriertei ,n, a M IP ? ? ? trd.pendene wMn eras priaR to tlrars a eas ., R hr?rena ftt>cmr?l mohANyJApt=a T b 9 dno M FlOM d " %wrap PgDtme vft . r iw 16, G mw fnam ? ?, to - Rpm iune m /A01.9 19, a oft ,q o?R d h:t + V , Aww P etc y tr a a t en x ? /y rnnd 21 Q dth?r F+aIrnlt t7o>tleq MIS t m ktrferVERptprt Q?9 s to toliewh CP + • QG ? tt?lkt4 TI ?t Sp Q AWWa m rd" a AML Meuwrwaoubr W-OWN "160 e " 13 Posh" /or Bally Madw*:u AP4M Reo f "M 0 Fka mpwft*ft 5*" J? ?•air?et pnalttalprNan in .0 spindt,# "ka Q Other r'slLL dt ?+?Iwt• p Caer?Ne ntralnNt9 IrNttimw p'" L7 c>tha r Womowr Tlrno q/NM*k bM om Webrs a 1 xrat Pei* aw naed Rvriwm mvkm dmahedwx rmpw tyhwtmnr ad whb anermycam. PbpaAaiensture Oefe Thee' sfid 9lgnnops Issiab i 3 My thwzPbt has rROWd my PIM of Cate wM ma >'rtian n /ps HEALPNdourMRohab-Wormt4Yabur4 340 North Front8lrgpt ihQrMleyeburP,IPA 17043 Phww 0763337 Fax 975.3973 HEALMSOWN. HEALTHSOUTH Rehab - Wormleysburg 840 North Front Street Wormleysburg, PA 17043 Phone 975-3337 Fax 975-3973 IRITIAL PLAN OF CARE OCCUPATIONAL THERAPY Patient Name: V if Physician: 1)l f ow? 00?07158 12/13/05 .. A SL AM , 'tUHAMMAD C ?/ 6/1947 ORD 058 M WA w L YN H mD, SCOTT 000 04195 516 AD0RE550114RAP.H Onset Date: L 05 Begin Date: j, (h Primary Diagnosis: uif r or hospitalization (for curt t episode): Fr Treatment Dlagnosis(es) ' QSSG Rehab potential: )ZExcellent ? Good ? Fair Gertffic on period: From 1 i • (Reason for referra) Pain in lr ? 1 cognition ? Joint hypennobtllty of ? 1 baWmat mobility status ? 1 nack/trtfnk ROM ? Joint hypomobllity of ? Difficulty ambulating ? 1 respiratory capacity ? Joint Instabllllty, of ? 1 w/c rtiblitty ? Skin breakdown ? Contracture of ? .1 transfer status 1 WUB UE strength ? Soft tissue dysfunction ? Abnormal tone 1 neckRn.rnk strength ? Postural dysfunction ? Abnarmat movement 1 endurance ? Improper body mechanics Atrophy Limited R/L/B UE ROMl ( Coordination Short Tenn noais: Weeks Short term goals are written to address patient problems and should relate to long term goals. 1, Patient will: ito 3'y K r 2. Patient will: °i?u 3. Patent will: 4. Patient will: 5. Patient will: Long Term Goats• Weeks to ? N/A To ? } balance 1 functional acWlty: ADUwork sldfis 1 fine motor/dexterity ? 1 sensatiorvproprioception ? 1 Visual perception ? Edema of ? Other ? Other i. Decrease pain to I -S to allow for i 6 1'1. ? Improve balanceicoordination for functional skills such as 2. Increase bed/mat mobtfiry to 3. ? Increase transfer status to 4, ? Increase sensation1propriocepttoriM ual perception to Improve functional ADC's such as 5, ? Improve balance to decrease risk of falls as evidenced by a' ? Increase functional standing tolerance to minutes. 7. ? Improve skin integrity a. )a incrsass strength of from to o improve functional mobility/ADC's 9. ,Increase ROM at from to U7W to Improve functional moblllty/ADC's. 10, "Writ to demo trate proper posters and safe body mechanics ( "Mth ADC's and 11 Patient Goats: )4 12 Return to work at modlffed/normal dales. 13, Perform normal household ADLs. 14, Improve fine motor skills for functional ADC's such as 15, ? Family/caregiver Independent with care of patient In these areas: T 16. ?9 Patient with Home exercise program. 17. ? Other 18. ? Other 19. ? Other 20. ? Other 21. ? Other Lt?'4a3p; Skilled intervention r ay inVads the foliowing: Mod?liti .t? Strengthening Exercises ? Visual perceptual training ? Transfer training ? Aquatic exercise ? ADL training Patient/famity training Neuromuscuiar Re-edu a n ? Posture and/or Body Mechanics ? Flexlbiity/Stretching AROM/PROM ? Fine motor/dexterity ? Edema management by Manual Therapy ? Equipment evaluation ? Other ?D Patientlcaregiver participation in ? Spllnting/onhatlcs ? Other development of treatment plan ? Cognitive retraining ? Other ?zf Treatment Frequency; Times/Week Duration: -Weeks ? 1 r, visit I certify the need for these services rumished under this plan or treatmentt and while under my care. Physician Signature ` 1, /i? Date Therapist Signature Date 17-1h 3 l o?- W therapist has reviewed my Plan of Care with me. HEAL LTHSOUTHTHSOUWormleysbur TH. 840 North Front Street Wormleysburg, PA 17043 HAND ASSESSMENT ADDENDUM \n. 00?0?1158 12113/05 SLAM, MUHAMMAD C f?nidal ? He-eval ? U/U DRESSOGRAPH Chief Complaints H nc Left I ht Vlaual Observations Inciuding wound/sear. ?' C.I?(,tt d TZ. Edema: Ali- aL#L j" l l b l Postura a m nc,'1 r RANGE O F MO TION ACTIVE PAS SIVE ACTIVE PAS SIV ELBOW L R L R WRIST L R L R COMMENTS: D7 to li EX T v FLEX o FLEX PRON In 4 1A) R, DEV SUP S ' U. OEV ACTIVE ROM THU MB I F LF R F S F L- R' L R L R L R L R COMMENTS: MP EX7/FLD( PIP EXT/R.EX DIP EXT/F EX PASSIVE ROM THU MB I F LF R F S F ' • L R L R L R L R L R CO ENTS: MP EXT/FLDC PIP EXT/FLEX DIP DCTIFLFX SENSATIO N THUMB IF LF RF SF L R L R L R L R L R COM ENTS: RAOtAL ULNAR STRENGT H LEFT RIQ T COMMENTS: Grio Stye Ava. Am Key Pinch Siren [Avg. Avg. 3 Pt. Pinch Strancrth v , Av . HEALTHSOUTH, OUTPATIENT CLINICAL ASSESSMENT ? Physical Therapy ? Speech Therapy ? Other ftaddant patlonal Th ? Neu syc o ogy/Psychology Name: AS 000`10?158 12/13/03 ASIAM, MUHAMMAD C 2/0b/1947 ORD 058 M WA I Y N Q }+ , S C O T T ? AMFESSOOFAPH 008 Age;? Date of Evaluation Referring Physician Precautions: Ea1aZ ? N0OIJtES W ? c?,d tx3# 7 0 1 2 9 7 a sic Pain Seale tp-itf): Now 8 4 e Wont I yea, location: Pain Symptarnu ? Dull ? Sharp_ ':Q HumUrg ? Referred 0 Throbbing ? Numbneea ? Redh4er ? Other ow comment saction du detailed deacribWN Pnquenaya ? No Pain ? Leaa then dally 11 Daily ? Daly-Increases throughout day ? Multiple dally eplaodea ? Constant 0 Night Pain ? DlaWrbed sleep 0 Other. QURR C3 Medknaflon/Pmcechr? 013d 1AA0 _ O Raiexatlan 7echnlquae.'-- 11 ModaWActlvity that decrmw pain, _ ? Modality/AcWity that Increases pale: COMMENTS; w ? Functional ? Hand Q Wound ? YUhodahdr ? LE Addendum ? Yolca O Lymphedeme ? Vestibular ? UE Addendum ? Cognitive ? Puimonwy ? Ankla/Foot ? Communication O Amputee ? cervical ? Dyaphagla ? Urinwy inmnlinerce ? Lumber ? Visual Pwceottlal O Other Current Living 9ltuatiorr, M Alone y/Reletive ? Caegvver twllone Situation prior .to iltnenr )%F-dn ty/RelaWe ? Caregiver ? Aaalsted Living ? Other ? Alone ? Assleted living ? Other am-Up Issues Don patlattt eurreMlly have akin braakdowT o YES 01Q0 Is Petlant =nabered to be at rialt for akin breakdown? M YES 13?1O DIET STATUS: __ _1-L MEN= Level of Fdueatinn- Patient: ? Caregiver, ? 0.7 0 8-12 CYCollace ? WA ? b-7 M 8-12 ? Cotade ? WA tisatlvatien to Leannm Patient: e ? Low C3 Mad Df1 P3t ian3 Ga malxac ? 7 None ? lgI - Language ? ?j Medical Condittan ? Cl Mental/Emotional ? M Vision ? ? Hearing ? ? Religious ? ? Illiterate' ? ? Other: ? 'It 111ltarate, all education material should be geared to non-reading popufaoon Caregiver. ? Low ? Mad ? Patient CaMaWer ? Reading' ? ? Video ? ? Healing ? ? Return Demo ? ? Other G 'M reeding Is checked, al education materiels should be in the patient/ canvkerla Primary language. AssioUve Devices: 11mone ? Standard Walker ? Ralling Walker ? Hemi Welker ? Quad Cane, Large / Smell Base ? Straight Cane ? Crutches ? Oxygen ? Sptnt/Brace ? Orthatics/Prosthetic ? Eyegiesses/Contacts L-YRIP- ll 4 , .. -1 . rAweAurs /;Tttte . _ , fit " Date 11 Signature / TMe I DlepnostlcTaetalAesyRaA HEALTHSOUM. PATIENT INFORMATION RECORD/HISTORY ASSESSMENT HEALT14SOUTH Rehab Country Meadows 4905 East Trindie Road nA 4'N%GC Alk McGfi:ii yn?uu, , Do you have pmWtraa wigs: Yes No Comments Do you heave problems wNh: Yes No Comments Bowel Control u Depression V Bladder Control Sling V Headaches U Fatigua Blurry Vlslan/0ouble Vlsian tr Weight loss or Cain ? Shortness of Breath '? Cheat Paln V Skin v Nausea or Vomiting v CoughlSneazing .I_ v... SweilingiEdema W- w~) tss x A It/, no you drink alcohol? ? No Yea How Much? 0 C. _at.; NO you ?nwrw? u ..? c+ anedhr anv reholoualcultural consideration: COMMENTS: la there anything we need to know that Is nat covered on this torn? Cl No If so, please explain: Patient's Goals For Treatrnant: only for those patients In pwadiatric program (Under age __J: i What childhood diseases has your child had? ? Measles ? Chicken Pox ? Mumps ? Rubella II Has your child been exposed to any of these In the past three weeks? ? No ? Yea Explain: Cherie Immunizations that are In the process of completion or have been completed tar your child: ? TDx 3 ? IPV ? Variaatis ? Hepatitia 8 Series ? MMR Please provide us with two people other than yourself who are suthortzed to pick up your child from therapy and a password for them to We will not release your child to any one alas but those you list here. Please update us with any changes Immediately. Name Home/Work Phone CeIVBeeper Phone Name HomeNVorkk Phone Ce1115eeper Phone in order to reach your optimum rehabilMOon, it Is essential that you follow your physician's prescribed treatment and the treatment plan established by your therapist. If you must cancel an appointment please no* in as soon as possible so that we can reschedule your missed appointment within the week. We appreciate notification of cancellasons 24 hours prior to scheduled appointments, this allows us to utilize your appointment time for othsr patients. We are obligated to record at/ carcallaffona and no shows In your medical record. If you are covered by worker's compensation, we are obligated to report cancelled and "no show" appointments to your Insurance carrier. ? Patlent/careghrer unable to complato farm; information reviewed and completed by themplaL Initials Date; `, \ o C Date T Date Clinical 5tgnaturaMilellnltlals Date Name of Person Completing Form: w?1a m?a M 'U m HEALMSOU7K HEALTHSou'm Rehab Country Meadows A905 East Trindie Road 00'?0-1 158 12/1%/05 SLAM, MUHAMMAD C Meohanic9burg, PA 17055 2 / 3 6/ I g 4 7 O R O Phone 214-1775 Fax 2142907 0 5 8 M W A MEDICATIONIDIAGNOSIS UPDATE LYNCH MO, SCOTT -j 'i j ^1 AcORE6SOC?FiAPH MEDICATION 1 DIAGNOSIS CHANGES Date: ? No Change a Signature of therapist: Date: ? No Change Signature of therapist: Date: C] No Change Signature of therapist: Date: 0 No Change Signature of therapist. CHANGE OF EMERGENCY CONTACT EMERUENCY CONTACP Name: Home Number; Cellular Phone: EFFECTIVE DATE: Relationship:.- Work Number Pager. -?- --» _ Revise with updated Plan of Care or at a minimum of Salo-, '2n -4- lv ~ ? ro5(D c ? m o s . W M in Q w x 3 a Z (0-0 cr tee, h ¢ O CD W h co 'r iT H CY ?-5 h c Al ;y a Oy a a a to rt owl NtD v 0 t? co En a CD O ?? c? cp Q O 1 3 Q n ? O ? -- l r? rr L.Ij d N O A- *00 000?0`I1 12/13/05 ASLAM, MUHAMMAD C HE LTMOU H'e 2/06/1947 ORQ PATIENT INFORMATION RECORD/HISTORY ASSESSMENT 0 5 8 M W A HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road LYNCH MD, S C 01 T Mechanicsburc, PA 17055 0 0 0 2 0 4 1 9 5 5 116 Ind d U -A -S I Lt. Name Name of ParenVOuardian Social Security Number 2 d I -6 2 Phone Address -qk Occupation Employer !t::Q -^ Primary Language Spoken III, Sax ? F Marital Status: ? Single -C Marrl 0 Widowed `E hnresd Relationship Home/Work Phone a ?z33 Primary Care Physlclan A - ? Q AV, L P.SSn eL A C 1+r L s a&u CA City "/\ f-C I- , State Z1p (mac ? Last Day Worked I b - ! 6 - o s Address G n o ?.. t s Q c Phone I/ ?} l 3 Emergency Contact 07? A - a a y a _Relationship , Hama Phone 2c S-o ,; 67 Work Phone 7- ? - 2 Ss 31 Cellular Phone/Bea or What Is the problem that brings you to therapy? _ Le-Lk is your condition due to ? Auto Accident ? Fell Work Injury ? Other Date of angst (n 116 lei S Prior therapy for this condition: ? Inpatient Rehabilitation ? Yes ®'No O HealthSouth Facility ? Yes o ? Outpatient Rehabilitation ? Yes 112'No O Other ? Yea [I?No If this Is a workman's comp Injury, where were your worldng when the Injury occurred? '`-I e-s If your primary Insurance Is Medicare and you have sustained an Injury, please describe In detail how and where this Injury o=urred Date of Birth: o !Age: -"N Primary Caregiver/Support System: Phone: Known Allergies: Adverse Reactions to Medications: DRUG DOSAGE/FREQUENCY DRU DOSAGE/FREQUENCY o (f OJtVLe Bx4 ur 1W Yes Tuberculosia (rB) No Comments Yas No Comments Diabetes Mellitus Respiratory (COPO) ? Cancer ASTHMA ? IQdneyNrinary High Blood Pressure U Eptiepey/Selmrse Low Blood Pressure ? Stornach/Oaatrolntestinal Ohmineaa ? Heart A4tock ?? Heart Disease ? Stroke ClroulationNescular .1 Skin Problems Arthritis ? Pacemaker Osteoporosis Intestinal Trauma Joint Replacement ? Psychletrio History Pregnancy i other ? Major surgical procedure with the last BO days (a,g„ craniotomy, laminectomy)? ? Yes ? No Ust Prior Surgerles/Hospital n Dpt@s -1 T r? Internal Doeument for.•Ql Purposes-Only Do Not Copy or Release with Medical Record File in- Correspondence Section ragcnctvacuc - 11 ? PatieatMRN ? -"@11-1! 0/06 ASIAM, MUHAMMAD OUTPATIENT DISCHARGED MEDICAL RECORD CHECKLIST 2/6/1947 PM Results ofjwat-chart review: 058 M 0 M ? e chart is complete. Y U C H A MD, T H O M A S J ? The following items are incomplete: 0 D C Z 0 4 5 6 8 516 Circle discipline(s): T SP Item Present or Therapist Date(s) missing ' ` ': complete Signature/ Co- (in box below note (please check box signature missing date in question) below if present) (in box below note date in question) 1. Addressograph area complete an jR documentation (Name, UR#, DOB 2. Patient TnibimAtIom Record V- 3. Initial UD Orders 4. Consent for Treato=t 5. Outpatient Clinical Assessment 6. Addendum(s): V 7. initial Plan of Care L' 8. Recert/Updated POC (r ini7m m 30 days) A-1111 9. Daily Notes V 10. Weekly Dotes l? 11. Plow Sheets 12. Discbwge Summary (r Y Reviewer's Signature: ? Clinic Manager's Signature (if incomplete items): The above items are unable to be completed because L Has moved out of the area is no longer employed with Is other Date:2 GCS Date: Internal.Documentfar.C_3FPurpn§'esnly D6;Wot,Copv or Release with Medical Record. F le,invCorrespondknce Section! rok. REHABILITATION PROGAVAII-Iq 1/10/06 FLOW SHEET AS`AMO MUHAMMAD C 2/06/1947 PM 0 58 M 0M Patient's Name: G= YUCHA MD. THOMAS J 060204568 316 Diagnosis:,J T) BATE EXERCISE Ma?n,A ? f gdf. )OD X 1h 4 V (D? 10? o V-1 i 02/15/2006 15:13 FAX 717 901 42.9 OIP POPLARCHURCH 0001/001 ORTHOPEDIC INSTITUTE OF PENNSYLVANIA 815 POPLAR CHURCH ROAD, CAME HILL, PA 17011 PHONE: (717) 761-5530 • FA7 -, (717) 737.7197 PAVIENT'e NAME DAI. ON, DI 836479 .w. 000?0'? ? 19 ASLAM, MUHAMMAD C 2/06/1441 PM 059 M OM YUCHA Mpr THOMAS 000204568 1/10/06 516 ORTHOPEDIC INSTITUTE OF PENNSYLVANIA 875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011 TELEPHONE: (717) 761-5530 - (800) 834-4020 • FAX: (717) 737-7197 www.olp.com PATIENT'S NAME 1..1..- u iA b lc?, rf1 DSe DIAGNOSIS 7 ? ?lL d>,j ro. /'SC o j tl -E ICE- SPINE STABILIZATION ACL-PROTOCOL E&T C-S SHOULDER PROTOCOL MOIST HEAT MCKENZIE BACK PROGRA ACROMIO PLASTY CUFF REPAIR EDEMA CONTROL RO CAPSULORRAPHY ACTIVE RETURN TO THROWING ELEC. STIM./TENS AA PROGRAM PHONOPHOREIS PASSIVE 10% CORTISONE CREAM PRE RETURN TO RUNNING ISOMETRICS PROGRAM ]ONTOPHORESIS 51,R DEC'ADRON CREAM ORTHOTICS TKE PARAFFIN CLOSED CHAIN SPLINT-STATIC & DYNAMIC DYNASPLINT FITTING P-F TAPING & REHAB ISKINETICS LUMBOSACRAL STRETCHING NON INVACTAEROBICS ORTHOTICS CTI FITTING 3 Y WIC X 30 DAYS AGILITY DRILLS ////jjj'' AQUA THEP,APY TESTING qa_) D.O. FEB-09-2006 THU 03:07 PM #ikSPORTS MEDICINE FAX NO, 71031 4640 P, 02 IEAL"AlOt"l e ?xuntaOM hymb C=" vo um mmmomw% PA lim 00 '101119 +rtaroe Z/ 6/1947 PK I il0a(fl' ' ?/ nHrM1 oww+nd ?? i C QP? Cw'?"rW m DA OM pq?p , QL%wv w*w mmoA +aao? c?or-r..?...».. ? /a d vco?ww PM po aTf•oa a c D ? n? d , at* uQj otr+er C1 '? nMd• PA 17os5 Pbom 214.1775 F"214-2907 MUL7HSOU H nSMjb CoW4ry MWdovro X906 gyp! Trtr?lo iWSa FAeattanir uG _ ,7., v,??nn c?, L06L-7GZ-LTL 8p 0T 9087160/70 HEWHSOUrH, HEALTHSOUTH Rehab Country Meadows 4805 East Trindie Road Mechanicsburg, PA 17055 DISCHARGE ASSESSMENT Date: Dets>' : Number Of Tatei VWW. Number of No-Show/Cencellatiom: CIURA13 Assistive Devices: ? Standard Welker ? ? Sh*ht Cana ? Other Bathroom Acomaries ? None ? 5r*rfi7w- i' 00??01719 1/10/06 A5L M, MUHAMMAD C 21 OUB 6/1947 PMm AMMO';'?5" n / 0 G G Aoo ? Functional ? Hand ? Wound rti Wheelchair ? LE Addendum ? Vdce ? Lymphedema ' IMVeellbuler ? UE Addendum nltlve ? Pulmonary ? AnWa/Fcot ? Communication ? Amputee 0 ? Dysphagla ? Urinary incontinence ? bar 0 Visual Perceptual ? Other ? Hem[ Welker ? Quad Cane, Large / Small Base ? None Other Equipment ? None Q ILKmItal Bed ? Wheelchair ? Cushion ? Other PAIN ASSESSMENT F%tbl E STATUS Pain ? No X?hs a Medcatlon/Procedure f no ?Sl 4° O od (?') q pelaimbon Techniques z s a s e 7 "` e a to ModelA.ylActlvtty that decreases pain; If Yes, Location: Pain Scale (0 -10) Now Best ME: Wam Pain Symptoms: ? Dui ? Sharp ? Buming ? Referred Modality/Activity that Increases pain: ? Numbness Aiadlcular ? Throbbing ? other Pas canment section for detailed description Frequency ? No Pain ? Less Than Daffy ? Daily Daly - Increases throughout day ? Multiple Dally Episodes Q Constant ? Night Pain ? Disturbed Sleep Patient/Caregiver Training Description of Training Provided: Treatment Received; Summary ress: ¢ /l N i u ? Rr-A ON FOR DIC: ? CMectlve Andings Inco ? Goals Met ? Medical Condition Alisachad Maximal Potential ? Benefits Utilized I ent with patleaft complaints and/or dlagnosts. ? Non Complence ? Other RECOMMENDATION: ? Equipment needs Continue with HEP as Issued ? esume Therapy Follow up with physician CT Other COMMENTS: DATE SIONATURE/TITLE DATE $IQNATURE/TITILE ??na<•d•i?.te b13?5?OjFAX 7117-21 97 OIP HSPCOLNTRY MEADpWfiq 11001/001 PAGE 02/02 MOUMe, ffEALTHSOM Rehab Country Meadows 4008 S"tTAndla Road Mechanicsburg, PA 17085 pheme: 214.1775 Fax 214.2107 INITIAL PLAN OF CARE PHYSICAL THEWY 000?0.? 9 ASLAM, MUHAMMAD C 1/10/0.6 2/06/ IPA7 PM 056 M OM YUCHA MD, THOMAS J ?misr,t Norrw .? a ?-?+- pnsat Dees; Sagkt Data FMM21y dlamosl0; 1 a Prior hoepbftdW (for ameM t p F= to __RrWA Trogplleftt 00gtto*88)t c7 D F hub polm1da1: Cl F=xt;efent food Cl Fsir C tlbtt pt3liod; Frrtn ? L a ? 1D 'L 6 U oL man t0r tt1(ertep % Pde In Lit G 1 AAim UK Flom q Ity+arntaaletlns C1.4ktt Ittsiabll?l at _ C2 1 bdhnoq m"ky trm ? vNnml peroaptlon O Abnattal Bak O OorybactTe of ? 4 RAJA Lfi PIOM ?. G tlaen? 01 ttmpkstory 4' Ct Sdam co ? sun ae 000,11 ? ,md ? 1 bte m 0 Dow A ,gttoNtyr ? frrtrxnpor etodytttgc?twft o pyesquft trn o otllar re o f Wk mom n 1 " n cromw 1 a ftm qu c J An rLa ri t- flue tt+aloddstderKy Cthcr ? Abn mod mite ©1 1wy*M sWAY, AAI U ak afa ,,, ,,, 0 Amami mo4meM ? icint by Mcb ty of Q to 1 Wmeft* occePtian ? Jotd t bk of sham Mem acmim 1 V "p G Wamm Q, allet nmbigam rnd 2hugW rulaf:a to !n addrm t b itte Sh t p rm gui n p or o am wr j?tl % . ;_ g .1 p -' Y/rte C' c dot-s'I`' l'v r 55, 8M®11t Wl" ?.. T x o a M? 1, o .. . tieflglit W61; -S 4. Patient w0: ' 5. Patent wk 7 LnsIre= QDUL-n G ' vvm l Y 1. n DeC"= peen lb -to Wk,, for t3, Cl itnaeaes ROM d 2 ? lnmm o bedhrfet mobAlty to tram -to to knpmue As>rtlartel mnblhylA17L9 3. ? Imam Rellnotar OtBete to 14, p Patlal:r:to demaratmtte Paper PMMre end sede body mcxmsl whh 4. Cl k= mm Astodartd walkng tolen, to ADLh and Nki;. y1- mlrttnee with d0Wt&a ddmca 1S. ? ImPPM lmlerr;droordTvftn luriurrcttmtal sidle m.Rh ae .5. ? In xnw arltce rd waldtl0 an mm m mxhmab bafth trs 16, U ROM 14 W* d medtOdlt>aettnd *Akm 6 O In1r 0e Mr/o 11t00M1g1 m ( t1CV) wRh 17, Cl POM n= W hmah ld ADUO nnaslOtBfrm 18. ? Impreme *10 =tar AMR tt r*rCtbttel ADt? vice m ?......J?// 7. ? trxrsaeesenseAJa tYR bpmvB t avtlamel ADLS nsmh es 18. ? Fon11Nf htdWmdent with rare of pmbrt M these ut0e0; a• ? Impious gall mmuhm* a by _ to decWm risk d Wa. 20. ? Ptttlsrnt Vdh Flo" oxmias program, 9. ? Ineraoes aaa gtli of £1. Ct Omer eon _ __ m t4 priptme Wi domrl atohtmy/A17t b. 22. ? Other 10. ? lnrsoaae t kOknd Mart k talenMq t4 _..-„ W MUt . M. ? Other 11. ? "p o" Wn h wgft 24, 0 Other 12. ? Irlgaws t to deaaerto Mk of tale, m sAdenced try P?tRi9r? Qi1Rl?A - 0e r•r r x.dl to i , 44- ka? 'if ?e hg? ?18r?t Skied 1111nrO r R19ft 11XQ1 in44B dllhe fO?OWlf1 m bs o a ? PotRrre ard/a DAecttsrico L) PtatietNFamf?y 1i np 0 s m Kxm ? m>omrnaeone v EAWM trakft q F?ripmstR arokstion ? edrrrrw by q slutrnnmr He ed, tSon ? FuncAmal mobft 4u}nkg 10 Qn1111g1a'dwfl,4 ? Outer M q ? •? ?? enal7 11 ADL TrOft rePY ? E?dulWM Ac00m: ? cmW tlA ca<au ? In r 'il'etlRtt+arnt F?at"a?1FZI W l'AyteeMleak nursn!lnn; '' ? 1Neskn ? 1 x wall 1 cw* Me need for these spvMm trrrcfer !VV760? errd whf9 =l r• rry care, Physician 5(gneturae TlwraPlat $lunatum (ostabLLs C) Date l y r a ra a my therapist tas maiewed mY Ptaz1 Cara w11t1 miL Ppunntlt aragh- -%miawre HEAL7HSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanlcsburg, PA 17055 Phone 214-1775 Fax 214-2907 JAN-18-2006 WED 10;48 AM HMC SPORTS MEDICINE VIB/2986 99:13 717 -?K`-2987 ff. WH" L ffix Ro . wo"o c mau?"VWW W 111" 4W ftW?* dls Road A omoolo rp, P4 IT= FAX NO. 717 531 4640 P, 01 Ps COUNTRY WAM - RAGE 03/03 000?O?Tlq 1/10/06 ASLAN, MUHAMMAD C 2/Cib/1947 PM 058 M OM YUCHA MD, IHQMA5 J 000204568 516 "rr1y01ivlodb DID ? Qar anrlt epleodlk F'pQfq -- tp TWA Tmdff nt C7 wwA 1 MIS O' bo dlk n C?IaelMfr Ml?'Aoed G PrE pM 15am 2 Uri • 14 0 .10 n ' wrl b L i s e A nnrs m =z*mbjAv * m .wlnt of .__ , 12 wwm rdit qq Mrd ArsR. O Abro" W 13 ? 0 Cenkaaras d - - d N m i } ? r a 1 IIIm "mm G C 1 DOW D Ariapfy 0 MIpISNI bvl?r AhaCtMnWO Dclaw . a 1 wuous>npn a y wbnloap+ D o m 0 1 MJB tsamp a rrR/A lox Q ? flna rt?lolrtl?Irrl4r I a AbW WON ON. E 0 krdOW@**ADAM II 1 d ` `I` af D prbeep8or 0 errrNaNpo tt •? -- " goal Iodo 'k blotftm#of. owMtwna?AMr?aae W+Wy +ahnoillnAl?sRO it It NMI #am a L- 1I -j :3 sit.) CaL. v& - II A. S I_ o IA v be Y 1. R moan P& Az _.?._ _ at abwtar L OlluoroshadhlrRrygb?rla s D wweao rrNAlr wrlua Ao p 1 arm rf? triM?pid?srosto IL ? blvasw Aaeilolpiwipdrg an ralaMn oNlfoanVbuct o to 1? q A'IglNple NOrI of .1 rN?1M?1 1?. a r? letoaanenaa»ti.v?op.?p?.aar?a?'..a?n?y ? 1d. O ?'FnsN t?IN ?oordYislan 1?r aateslkrsl alal4..h ? ' Q Q Mretssw?wln nK w in - " O wire 14 Q FWWloworkrtx=dWidMOpflY duWL 17, 0 P~ mmmi hous* , A131* T, >? blolalas UWdb lew plo pMaIP I 1L 13 lWVW *0ffW arsl4lhar$AW* rn A71.b WA N _ 1a 0 tdeAaldel?t w?h ase GI PAR rl MNM uaex ._ 4 Q WPM "t nl lq a >? frw1111Ma p?h of ?- AMI of IhAIr n t,, a CAher ,dh tlam..araw pr>Bnrn 22t 1?afll..-_? 1e to pI 1 W MdAPODU4, . 9L A Clhr 1G. 4 Ir91Mw ra?ararlM IMndrO ldnNM7r Oo rPYarra, ? o t7In11 l1. f0 lnp "MAMI W.13 Qw l? o Inprow brmpu to dAelsol Aw VI Nft l* %ft* sd ty , pollis"I 00" - _-cam _rr Par.,- i " +-1-- bow ad Y1ac paled ? ++o ?4"?Foora. ? AR'a '1F ? c ?+I M hM 01 t4..i U dr. lrrmtwn ? nl y e ar n ? >FWU q !NM r?OgfAf?aIR9 d p sown" M aft Q 0spM2 . by O O ? 0 AM %W . . 0 4a40lmh010yoe 0 C" o Aatl*a m*w ? oft q Rtid.M= AAIAAI - Q M w 'Tlwtrawrl fiwWsllgr; nsd_7blealWeek WXNVA lq.q_ WeBlta cl l xtaar IIIt need lbr ? sarvA? Iltrlklflod uno4r lhb piln o/ A'IgOnenf and y? under?rA' wa Dow tri '91 IF bq Mtraw No ooloorsd my Fm of am wo rw p4"w 'IWe1ti?Msr Zia mvm UPALTHBOUTH Reh*b 000*y Meadowa OM 6261 TWle Road M6chanfcs Kn, PA 170M Phone 216.177E Fm 214,2907 .,, 00A09 9 1/10/06 ASLr.., MUHAhIMAD C HFA 7MOUTHm 2 /Q b„ 4 7 Q 0 58 M OM HEALTHSOUTH Rehab Country Meadows Y U C HA MD, T H O M A S . 4905 East Tdndle Road Mechanicsburg, PA 17055 0 0 0 2 0 4 5 6 8 516 Phone 214-1775 Fax 214-2907 INITIAL PLAN OF CARE PHYSICAL THERAPY AcoRessooR PH t I t ? c? >r, Patient Name: C- n: i i Ph Onset Date: Begin Date: c a ys Primary Diagnosis D D Prior hoepttailzatlon (tor currant episode): From to A nosis(es): 00> D ent Dla t T g m rea L 8 u t Rehab potential: ? Excellent;9ood Q Fair Ceriftation period: From ° to (Reason for mierral) X Pain H US ?p -'- O 1 RUB UE ROM ? DIINcuky ambula8ng ? Joint Instabi9ty of ? 1 hedlmat mobility atatua ? 1 visual perception ? Abnormal gait ? Contracture of ? 1 i AJB LE ROM ? Soft tiasue dysfunction ? 1 respirstoty capacity ? Edema of ? skin braRkdovm ? Postural dysfunction ? 1 balance ? Other ? Atrophy ? Improper body mectvudca ? crtbriurn ? other ? 1 MA UE strength ? 1 w1o mobility ? 1 Coordination ? Other ? 1 WUS LE strength ? 1 "War status ? 1 one motcr/daxtarlty ? Other k strength ? Abnormal tone ? 1 futtc*Xvd activity. ADLArrork sWis scWbtnk ? Abnormal movement d Joint hyporrobllity of n ? ? 1 senedoni'propileception 0 Joint hypermoblltty of Short Term Goals; o L Weeks 01, Summary cif Evaluation Short term goals are written to address patiant probiams .and shouid relate to nnd ill r - L 0 k d long term goals, tt •- ? /? - c . 4- / . ?! !? CJ e.l atrT 4- ('e^ ?,, r - 1 Pa ant Wig: W r e G.Patent Wit; , . s x t Patent Vdi; - 4. Patient will: wzk r r E*c '- 5. Patient will: L a Term Goals- 2 a? weep y 1. ? Decrease pain to to show far 13. ? Increase ROM of from to to Improve funationai nabl9ty/ADUa 2. Q Increase bed/mat mobility to 3, ? Increase monster status to 14. ? Patient to demonstrate proper posture and safe body mechanics with 4, ? Increase functional walking tolerance to (dIstence A Us and MU. In rrYrnrtes with devic-a/asslatance. 15. Q Improve beiencelcoordinatlon for functional sfdis such as 5. ? Increase iuncional walling on uneven aurtnoaelatrbs/stsin to 1e. ? Return to work at modified/normal duties. B. ? increase w/o mablllty to (distance) with 17. Q Perform normal household ADL's asalstanes, i8, ? improve Line motor sWha for functional ADL's such as 7. ? Increase sensaboWproprfoceptlon/visuel perception to Improve tunctonal AOL's such as 19. ? Femlly/caregiver Independent with care of patient In these areas: 8, Q Improve gait mechanics by program. to decrease risk ot Jalls. ? 20. ? Patient with Home exerdse 9. 16 Inctsese strength of " ' ''1, a ¢ • ? P a c `? 21. ? Other ' ?4 from to to Improve functional mobpty/ADLt, • °? `' ??* 4 22,,e Other /a ?J 1 a. ? Inetease tunetional standing tolerance to minutes. 23. ? Othsr 11. ? improve skin integrity 24. ? Other 12. ? Improve balance to decrease risk of falls, as evidenced by Patient Goals; V. r-r 6 a?co? 1Z o 6? 1 t Plan: Skilled intervention may Indude the following: Mo alfdes ? Strengthening Exerciae ? Posture and/or Body Mechanlca ? Petient/Famlly Training , ? Home Exercise Program r 1 ? Fine motor/dwdsrk y ? F)axIbIItY&V3tc>Hg , ? Bois ice training ? Equipment evaluation ? t dsma Management by ? aurorrursctdar Re education ? Functional mobility training ? 8plnting/orthotica ? Other ? AROM/PROM ? Galt training ? Aquatic mwrelss ? Other I? Ianual Therapy 11 ADL Training ? Endurance Activities; C3 Other ( PA lent/caregiver participation in development of treatment plan. Treatment Frequency 1 w T1mes/Week Duration; __q__ Weeks ? 1 x visit 1 certify the need for these services furnished under this plan o/ treatment and while under my care. Physician Therapist Signature (estabitshhg P00) Date Date f to hkv thmmnitM hove mutnwnrl mu 131un of ('- u,Hh mn pnirwnt/C`aran{ver Clwn?r,ro ?h HFrAL.THSOUTH, HEALTHSOUTH Rehab Country Meadows 4905 East Trindie Road Mechanicsburg, PA 17055 LU AR ASSESSMENT nQ Re-evel .00X_ Oalt Obaervedon: ? Normal ? Antaigie A SHADE AREAS OR PAIN Ilhvetural Observatlon: Oodput alders Ci Scep?ila iliac Crest g, ASS IS - ltochantere Gluteal Folds Samel Subs Interior Angle of Sacrurn _ Cervical L xdosia ? Normal ? Increased ? Decreased Tharadc ? Normal ? Increased ? Decreased Lumbar ? Normal ? Increased ? Decreased , Lateral Shift R / L ? Nomral 00 7[ Poft"Ohvlous mechanical stress points 1- 1 ol t ? . -- f-• Lag Letrplh UscrawM ? No ? Yee ?,? ?a ,u rq Ran KXIES RANGE OF M OTION rMUN 0 a Absent 3 - Bdak P B A T' 1- Dknk*hed 4 a Ckxe,s G r ,? 2 - Norrnst 9BL -- SBR - Reflexes Ultt Rght ? Pewter 1_ _Z,- ? 7 Achilles j r _ NZ RL RR l Bebinsld - _1e o n R L L R DERMATOMES SENSATION ROOT TENSION TEST STRENGTH 7ype7bst 0 - Absent NT LEFT RICiHI mapper 1 5 UpperAbdomlrrels b SLR RCM _ Q dornlnda Lower A 1 - Decreesad SLR LEFT RIGHT 2 - ?as 3 - Not 4 - Not tasted Kemig LaSegue L" HeeVfoe (+l-) Hip Flexion (1-2-3) _,3_ Hip Extension ", S1-2) Femoral '-? Hip ER (1.3-4-5, S1) 1-1 L R Brachial Hip IR (1-4-15, S1) L2 Contra SLR H)p Aloof (1-4-6, S1) c LS Slump Test Knee Flexion (l.5-S1) ' LA L5 Pkitonnle Knee Extension (t-2, 3, Dorsiflerdan (1-4-6) 4) ur S1 - (31-2) PlantarflaxIon S2 (1-5- Eversion (L5?1) ? Lo ll E H 5 ' 6 „ x. a . ngue k ) JOINT MOBIUTtl Grade II - Hypomablle Palpation: nlr[ s r? S rimed . ?-? Grade III - Natural Grade N - Hrpemrobll ? cH _ fB SBL SBR RL BB COMMENTS OTHER TESTS Date Signature /- Tftla Date Signature / TltMa ? ?0 06 Lq//0 /zo0,5, ADDENDUM A5LAM, MUHAMMAD C 1/10/06 OM F+?-?'ior D THOMAS J GC0204568 516 HEWHSi UM4 OUTPATIENT CLINICAL ASSESSMENT Padem Name; ? - L ° ^ -C- J •A< 10-1 1!10/06 Litlysical Therapy ? Speech Therapy ? Other hology ? Occupational Therapy ? Neuropsychology/P7;-- 000 ASLAM, MUHAMMAD C 2/06/1947 PM 0 58 M OM iUCHA MD, THOMAS 0002C4568 S16 MR * Acct #; AODAESSOORAPH GENERAL IN FORMATION DOB; ^. Age; s SVALLIATIONIADDENDUM Data of Evaluation Referring Physician P1ec2utfons: 0 Functional ? Hand ? Wound a Whae6chair ? LE Addendum ? Voice ? Lymphedema ? Vestibular ? UE Addendum ? Cognttiva IJ Putmanmry a AnkkF-uct ? Communication ? Amputee H L oFunctional Staus ej? a„?t ,tea -/, 1 -4-,- ? CWk;W 13 Dyaphagta (2 Lttery t=*Oncs Visual Percepbiel ? Other )9?) J- I IF 11e, HOUSING Current Living Sfluatloot C1 Alone ? Assisted LMng C ?lJi a ../ ? Family/Relative ? CaregNer r/ o L Living Situation prior to Ilfneta: 0 e ? Assisted LMng ? Family/Relative ? CaregNer ? Other. Horne Set-Lip issues stem. g1ilON INr!lEGR17Y Diagnostic TwitaMesub Does pubent aurmrdty have elfin hreaWawnT ? YES ? NO Is ROW considered to be at risk for ekh breakdow ? ? YES ? No DIET 3TJnUSt PAIN ASSESSMENT He Weight FainT 13 NO YES EDUCATIO NAL NEEDS u O ' WOO 0 -10): Now 1 2 s a a 9 7 e v tq Pain Scale (0 Best Sdueatlon: Level of Patient; ? 0-7 12 ? CoY e? N/A Caregiver. ? 0-7 CW.12 ? Coq e? WA It yes, location; Pain Symptomsu DWI ? She ? B ? Referred i Petlenc Ivey. rp urn ng ? Ttrobbing ? Nurritmew ? Rtacflwlar ? Other (use comment section for dkwkd descriplbn) Frequency: a No Pah ? Less then dally ? Daly ? Dally-Increases Motivation to amt pWWrrt &_/1,A-- 0 taw a Mod ? High Caregiver ? Low ? High th h A d Potential Harriers to Lemming, Preferred Method of Lornlnot -V t ay ? Multiple dally episodes ? Constant ? Night Pain ? Dlehubed sleep ? Other. CURRENT PAIN gigu lm mgAsuRE4 ? Medkatlon/Pmcadtna; ? Rdsxatinn Techniques _ ...._,.., - - C3 McdaRY/Pointy that decreeaw pain; ? Modagh'/Ac1Wthat Increaaee p COMMENTS None ? Language ? ? lvfadical Cnrtdftior ? Mental/Emationel ? Vtalan a Hearing ? ? Religious ? ? Ilgtarate' ? Pidlent ? Reading- ? Video q ? Heating ? 11 Return q ? er Q V reedfn checked, of education ma should be in the patlend primary langueg®, ? Other; ? T UCterate, ap educe n material should be geared to non-reading po Watfon p . DURABLE MEDICAL EOUIPfV %WT Asala ve Devices; one ? Standard Welker ? Rolling Walker ? Herni Walker ? Clued Cane, Large / Smell Base ? Straight Cane ? Crutches 0 Oxygen ? Splint/Brace ? OrthoticslProsthetic ? Eyeglawes/Contacts Other E ufoment ? None 0 Nos fta1 Bed ? Wheelchair ? Cushion ? Other Date Signature / Title pate Signature / Title HEALTHSOUM, PATIENT INFORMATION RECORD/HISTORY ASSESSMENT HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road L.larhonlach,m PO 170RF 00070 9 1/10/06 ASLAM, MUW0xkMMAD C 2/06/1947 PM 0 58 M 0M , YUCHA MD, THOMAS J NG204568 516 ?.. e:4VT :u. Name sex ? F Marital Status: ? Single -E-Married ? Widowed ? Dhrorced 1-4 S 4 4 Name of ParenUOuardlan Relationship Homrark Phone a Social Security Number I -C 2 - v 3Prtnu Care Physician P: Vv N ?F1 VL l ASSo c ?C s Phone Address 49 ? A C. City W\ c. C 1,. , State -R_L ZIP i?o 5 Occupation "u_r U_ Last Day Worked --I b _ 16 _ u s' Employer c Q c . Address 6 " o C_, l S ' u Phone :?41 ! ?} 1 3 ?r ?d « n Primary Language Spoken Emergency Contact ^n 011'k . - a o v s? Work Phone ?z 3:? - 2 js 3 l What Is the problem that brings you to therapy? Relationship e- Home Phone 2_-0;_ a `? 6 q Cellular Phone/See or '?-r" m Q ? ?, gg ra,v +r wl f 4: f 11 Zile IS your condition due to ? Auto Accident ? Fall dT'Work Injury ? Other Date of onset I ° 6 S Prior therapy for this condition: • ? Inpatient Rehabilitation ? Yee 0'Nc ? HealthSouth Fe lity ? Yea CYNo ? Outpatient RehabliNatlon ? Yes WNo ? Other ? Yea CYNo It this Is a workman's comp Injury, where were your working when the injury occurred? ?I e s It your primary Insurance Is Medicare and you have sustalned an Injury, pleeae describe In detail how and where this Injury occurred Data of Birth; o e: Primary Caregiver/Support System: Phone: Known Allergies: Adverse Reactions to Medications: RUG DOSAGE/FREQUENCY DRU DOSAGE/FREQUENCY D C)C' eoeIkvk.C ?L c1 GU @'KCe ur -w \\ Yea Tuberculosis (TB) No Comments Yes No Comments Diabetes Meilttua Respiratory (COPD) ? Cancer ? ASTHMA ? Kidney/Urinary ? High Blood Preawre Epilepsy/Seizures Low Blood Pressure ? Stomeoh/Oastrointestinal Dizziness ? Heart Attack ? Heart Disease ? Straka Clmutetton/VescWsr / Skin Problems Arthritis ? Pacemaker Osteoporosis Intestinal Trauma Joint Replacement ? Psychiatric History Pregnancy Other ? Major surgical procedure w ith the last 60 days (e.g., cranlotomy, leminectomy)? ? Yea ? No List Prior Surgedea/Hoaphallz n D s l? r HEAL'tHSC,UTHe PATIENT INFORMATION RECORDIHISTORY ASSESSMENT HE4L7HSOUTH Rehab Country Meadows 4905 East Trindie Road na a??te 000-A01-; 9 tltar06 A S L A M VHAMMA D C 2!06/1947 PM 0 58 ri 0M Y+:CHA MD, THOMAS J 000204568 316 nrn 11 Ww M Do with ?Joh?itlwsms Yee No Comments Do you hWs problems wide Yea No Comments 6owsi Control ?? Depression I,/ Bladder Contrd Sleeping / Headaches Fatigue Blurry Vlslon/Double Vlsian Weight Lose or Gain Shortness of Breath ? Cheat Pain Skin ? Nausea or Vomiting t ?oughf8neezing Do you amoks? ? No Yes How Muth? SwellingfEdema csc GK ate . Do you drink alcohol? .? No Yea How Much? C Specify any raliglouefcultural considerstiarts: aWMENTS: le there anything we need to know that Is not covered on this form? Na If so, please explain- Patents Goals For Treatment: Only for those patients in pediatric program (Under age What childhood diseases has your child had? Cl Measles ? Chicken Pox ? Mumps O Rubella Has your child been exposed to any of these In the past three weeks? ? No ? Yes Explain: Check Immunizations that are in the process of completion or have been completed for your child: ? TDx 3 ? IPV ? Varicalia O Hepatitis 8 Swiss ? MMR Pious provide us with two people other than yourself who are authorized to pick up your child from therapy and a password tar them to use. We vAll not release your child to arty one also but Chose you list here. Please update ua with arty changes Immediately. Name HornaMfork Phone Call/Beeper Phone Name Home/Work Phone CollifBeeper Phone Password M order to reach your optimum rehabilitation, it Is essential that you lollaw your physician's prescribed treatment and the treatment plan eatsbNst?eti by your therapist. If you must cancel an appointment, please notify us as now as possible so that we can ruscheduL your missed appointment within the week. We appreciate nodflcatlon of cancellations 24 hours prior to scheduled eppolntmenta; this allows us to utilize your appointment Nme for other patients. We are obligated to record all cancellations and no Shows in your medical record, if you are covered by worker's compensation, we are obligated to report cancelled and'Sno show- appointments to your insurance carrier. ? Patlent/caregIvor unable to complete form; information reviewed and completed by therapist. InMals Name of Person Completing Font: Date: Clinical SignaturaMtWinitlaig Data r:nnlrsd Sln.,ar„rs,mtlarhniNain Date Clinical SignaturefTlUellnltals Date HEALTHSOUTH. Rehabilitation of Mechanicsburg Cent or ww Comm ew Pvl Chemb MR LIFE Wrmlysburg Hershey I CUy M,d A"Argle,whoeP feed OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES _.? m, r -2 , T ly'l rx ws ws ASLAM 0wv AMMAD C )/0611947 '„ 6 m ON rUC+?A Kq, t14014AA J 9 / 181016 (w HFALeTHSOUT Ne ?N%k. Rehabilitation of Mechanicsburg Cent or Now Grob East Pad Chsmb Hill LIFE Wrmlysburg Hershey Labygn E4) AA/SInale evolgep oared OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF SERVICE r /?1 Cx_ w5; R/S_ RX expires Visit# C?_o Authorized 10? 000 101liq MGM ASLAMr MVMA"114AO C Z/06/1047 p" M M 0114 t ?µQ.M? ! 'k MAMA li .?.? . t .. IeICeCMA : r OTHER 50001 97001 P hyalcol Thor, Evahgeon P d urpose of each Modality, Ac&Ny, Exereisovoistad W Problem llsftrKiMnal efktt and gosis: 50002 97002 P hysical Thor. Re-Evaktsllon 0 Decrease Pain 0 Increase Functional Ab018es 0 Increase Strength Increase ROM l 0 soils 97001 P h Ical Thor. Evaluation -114 hr. 50120 97002 P cal Ther. Re-evaluetion • 114 hr. 50008 ? 90BD1 gang B lofeadbetdl WW7 90911 B iofeedback - Panneal sme 50078 97150 97597 Grasp (2 or more Debddeme nt, SelaeOve a20 s cm 8 A selflc modal , actly , exwe a ertormed rameentin the cod a billed: REA TREATED: 113 lp(?% 0 Ther. Ex. Per Flow Sheet 50079 97598 Debridement, selective -20 cm K '. Q X '.r ?itlivuas 60004 97802 newde m nt, Non Sehetlve ? J 3D038 MWA 00261 MI Elec. Stim (Unattended) Chronic Wound Prone v r,DS >< M n l X ASSESSM2NT-Patients responas tl> trelan chat progreea Cs0282 Else. 8tim (Unahanded) other wound 7 GMB3 Elite. 8tim (Unattended) Non-Wound 64350 of TENS 500110 97010 1 old Paefrs Met t Crt 9* [ C- VI pft f? SM77 97012 TncOan, Mechartleal Pain level prior to that ? !0 Pain heal attartrat: ?0 W013 97016 sO c Device 50011 97018 Pandilm 50005 97022 DebrldemenUWnd Clesnln -N4ad I 50012 9702 Fiuldom 0 1 2 3 4 5 6 7 B 9 10 50014 97022 Nod t PROGRESS NOTE: WEEKLY 9UBJ8CTIVE Plndln slmeasursment: . 50028 97110 'I Thar. Prot (slrength, endur.. 11m) 114 tv 1 cI n CLeyl %0L) ` r 50024 97112 Neuromuscular Re-Ed 114 hr ' ^t MIA 50017 97113 Aquatic Thera 1/4 hr OBJECTIVE Ind! almeasumment: 50021 97116 Gott Training 1/4 hr 50023 97124 Massa a 114 hr W022 97140 'IC) i Manual Th era 114 hr 50025 97504 Orlholic FSdn ralnin 114 hr W025 97520 Prosthetic Training 114 hr rase AWW5MENT.Patl.nV. response to trsstmenf/functlonal pirog 50027 97530 Thar. ALtylty ove tuna. art. 114 hr 0 Patient lderaled treatment well 0 Home Ex. Program Reviewed 50016 97535 ADL Self/Horne M mt 114 hr 0 Ex. Program advanced w.tow sheet 50015 97537 ADL Comm;V* M ml. 114 hr 50029 97542 Wheelchair M mt 114 hr 1-irl Hy in pr r-? e- c 60032 97545 Wont Hardening Initial 2 hours o -'l r, 50033 97546 Work Hardening Addl Hour SHORT TERM GOALS 50018 97703 Chk OnWroalh. Use 114 hr 50031 97750 Physical Pelf. Teel or Measurement FCE 50081 97755 AnS130YO Technology am am 50034 97032 Elea Slim Attend Non-wound 1 /4 hr PLAN: Continue Current Treatment Plan Or Revise To: 50035 97033 ionto horssls 114 hr m e. 50019 97034 Contrast Bath 114 hr 50036 97035 Ultrasound 114 hr 50037 97035 Phono horesls 114 hr ? THERAPIST SIGN: Total Minutes 95 1 Total Treatment - Timed Total Units THERAPIST SIGN: Total Minute 1 Total Treatment - Unumed Total Units 1 unit > a minutes to <23 minutes 3 units > 33 minutes to <63 minutes Tonal Unlb la 2 units > 23 minutes to < 3e minutes 4 untie > 53 minutes to <ee minutes I UP PT Charge Ticket Revised 619105 Fvrmp OPFT05 ? .HEALTHSOUTMa a "N Rahabifitation of Mechanicsburg Cant Dr mevCamb nwePaM Chsmb Hill LIFE Wrmlysbur0 Hershey Leeando (Ctty r^e° ) ANSUGM svaholp bared OUTPATIENT PHYSICAL THERAPY CHARGE SHEET ?/1 DAILY NOT(,E,S DATE OF SERVICE of ! . ! CX_ NIS- R/S^ RXexpires elate a VISIMI of Autharizad 000101119 1t?0?b A St A * , MUMAMMA 0 .0 2/061 f 947 rH 058 M OM ,w Y UC %A &9r: M ONAl? ti 5001 97001 60002 97002 6D11e 97DOt P P P hyakyI Thor. Evaluation hyslwt TMr. Re-Evsluallon h fcat Thor. Evalualon - 1/4 hr. P d 0 urpors a1 each Modality, Activity, Ex-lae related to problem lia itch and goals: Dacresse Pain O Increase Functional Abilities 0 Increase Strength, Inueese ROM 0 W120 9702 P h alral nw. Re-eveWetlon -1/4 hr. 6009 96901 B wleedbeck MIX17 90911 50008 97150 S G loleadback - Perinea( roup (2 or mare) S ectne modal , ac , exerciaa etlormad 22raventing the codes billed: 60076 97697 50079 9'!599 D D ebrldement, Selective <=20 cm ebddemenl. Selective >20 cm AREA TREATED: 0 Thar. Ex. Per Fkyw Sheet 1 Q x 15 r r t 50004 97602 D abrldemenl, Non Selective 0.l 1 I !O rtt ors NJd '11o k t .rr,'n txF)L/G) ASSESSMENT-Patlant's rea s to tmsaftrictlorial progress 60281 T Elec. Sam (Umatknded) Chronic Wound x0282 Elea SBm (Unattended) other wound 00283 3 5W09 Elan SBm (Unhanded) Non-Wound W040 61756 App at TENS 60010 97010 ;Gxow Packs pfw,! , IOat; c 2 80077 97012 Tracuon, math-nicai Pain taval o w to frost Pain Isval atler treat: 013 97018 Vaeopnsuma6c Devk a W 80011 97018 Panamn U 60005 97022 Dehrldement/Wnd Geertn WhirlI 50012 S70221 I riuldotharapy 0 1 2 3 4 5 8 7 8 9 10 56014 97022 Whirlpool PROGRESS NOTE: WEEKLY 50028 97110 Thor. Proc (strength, endur., Oar-) 114 hr I 1?T- sUBJECTNE Flndln alnreasursment T'£ r GLi n hi '? r-,- pnr 5024 97112 Naummu"ar Re-Ed 114 hr I n\ 1 50017 OT113 Aquatic Thera 114 hr osiecTIYE Ftndtn UmessuremaM: 502i 97118 Galt Tralnln 114 hr I F: is 5" 6023 97124 Message 114 hr ' W022 97140 (0 Merwel Th 114 hr / 60025 97604 Ortholic Fittin ralnln 1/4 hr 500211 97520 Pro391e0c Training 1/4 hr pg 60027 97530 Ther, Adlvlt t lunct. rl. 1/4 hr Patent tolerated treatment weft 0 Hams Ex. P am Reviand 50018 97535 ADL Sag/Horne M t IM hr 0 Ex. Program advanced per flow sheet 50015" " 97537 1A-DI- Comm1Wk M ml. 114 hr c c LLIO t uc' 5029 97642 Wheelchair M mt 1/4 hr O 60032 97545 Work Hardening Inleel 2 hours 5033 9T54e Work Hardening Add'I Hour SHORT TERM GOALS 50018 97703 Chk Orth/Prneth. Use 1/4 hr W031 97750 Ph cat Pert. Teat or Measurement FCE 50001 97755 AssIsfiveTachridogy 50034 97032 Elec. B6m Amend Non-wound 114 hr PLAN: Continue Current Treatment Plan Dr Ravin To: 60035 97033 lontc horeels 114 hr 5019 97034 Contrast Bally 114 hr 50036 97035 Ultrasound 114 hr 50037 97035 Phano orris 114 hr THERAPIST SIGN: Total Minutes Total Treatment • Timed Total Unite THERAPIST SIGN: Total Minutes 10 Total Treatment • Unlimed Total Untta 1 unit > a minutes to < 23 minutes 3 units > Sa minutes to <52 minutes Total Units 12 2 units > 23 minutes to < 35 minutes 4 units > 53 minutes to Ae minutes OP PT Charge 1)&at Revised 819105 Form# OPPT05 ? .eALeTHSOWN. Rehabilitation of Mechanicsburg Cent Dr New C,•,b art Chamb HIII LIFE Wnnlysbur9 Hershey C" Mod AMingla ovotosp buod OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF 5 1 A/ D cx Ws/R/S- RX mOms Vlslk7 d _Authorized e1N ASIAMt NUHA">> kko C 2/06/1441 ?K 058 N ¢ 60001 60002 r Physical Thor. Ro-Evskutlon P d 0 urpose of each Moddlty, Activity, Ex•rol related to problem IIYtlfun :, enclt and goals: Decrease Pain el Abllitles 0 Increase Strringtli tnaaase ROM 0 0 o119 - Ev91uatkm -114 hr. 60120 970M F P IWI Thar. Re-evaluation -114 hr. 50008 90901 &dsedbedc 50007 50000 50078 90911 97150 97597 &deedbadr • Podr al Group 12 er more Debrldemall A.1-41- «20 cm S A amc modal , a , oz • wi mpmauntin the coda a billed: REA 7REA 0 That. Ex. Per Flow Street 50079 50004 97598 971702 DeWidemenl SatacOve >20 am Debridernenl Non selective 60033 00291 Elec. 9Um (Unattarded) Chronic Wound IBSMENT-Pstlent's mponss to traatmm0funcUonet progress, 50039 BOOM 00232 GM83 Elec. 9tlm (Unattended) other wound Elec. Stlm (Unattended) Non•Waund 60040 44550 dTENB 50010 50077 97010 97012 HotlCdd Peeks Troctlan, MeehenkmI prior to treat: Path level attar treat: Pain level maUe Device 50013 97018 P 30 005 9702 2 anUWnd Clean Whl I 60012 tiD014 97022 97022 0 1 2 3 4 6 6 7 8 PROGRESS NOTE: WEEKLY 9U E Findln slmasuremant 50023 97110 Thar. I>roc (strs h, mdur, az.) Whr 50024 97112 Neurornuscuier Re-Ed 11 r 50017 97113 A uall Thera 1/4 hr OEdECT1VE Findln dmessumnan . 60021 87116 Gal( Thm V4ty 50023 97124 Message 114 hr " 50022 97140 Manuel Then 14 hr 50025 97504 Odhotic Fittat Inln 114 hr 50028 W520 Prosthetic rein 1/4 hr ASSESSMENT-Patlant's response to treatmentlfuncllonal programs 50027 97590 Ther. ASA- Im rove tuna, rt. V4 hr O Patient tolerated treatment wag O Home Ear. Program Reviewed W D16 97535 ADL S I1FIcme M mt 114 hr O Ex, P ram advaru ad per lbw sheet 60015 97537 ADl onu vM Marini, 114 hr 50029 97542 IWAaicheir M m1114 hr 5W32 97b46 4ork Hardening Initial 2 hours 1 50033 97548 - Wcrk Hardening Add1 Hour SHORT TERM GOALS 50018 97703 Ch QMVProeth. Use V4 hr 5W31 97750 lphpical Pad. Test or Mee5uremenl FCE 50081 97766 W513tive Technology 60034 97032 Elec. Stim Attend Non-wound 114 hr PLAN: Continua Current Treatment Plan Or Rwiss Tot 5W35 97033 lonl horeais 114 hr 501719 91034 Contrast Bath J14-hr 5036 97035 Ultrasound 114 hr 50037 970 Phonoohorasis 1/4 hr THERAPIST SIGN: •? Total Minutes Total Treatment -Tined Total Units THERAPIST SIGN: Total Minutes Total Treatment • Untlmed Total Units ?_ ? l unit > 3 minutes W 23 nutes 3 units > 38 minutes to U3 minutes T.W lino. 2 unit. > 23 minutes 38 minutes 4 untta > 51 minutes to t98 minutes OF PT Charge Tlckat Revised 69105 Forma OPPT05 (v NVAL"N UTH. el"l Rehabilitation of Mechanicsburg cent Or New curb Ew Chemb HIII LIFE Wrmlysburp Hershey lebawn e "SkVW &v hasp cued OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE._ r Lbw CX, WS_ R/S Al"I 000101119 MCA& A SL AM I MVNA4"AD C 1/06/1947 ?M 0.58 N ON YUCMA 440, 1HOMAS d nrRAL"A&a ttA Rehabilitation of Mechanicsburg Cant Dr Nex Cumb Eon Pan Chemb Hill LIFE Wnnlysbur0 Hershey L CYY Mee ANSkv$. svc-haaa based OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF 9 V /o J OX ' NS_ R/S_ RXexpires M.Ito of Authodzed 000101119 1/10/44 ASLAM4 0*11JINAMl"i 2/06/1947 s?w 0 S D ? G'M , ti U C r•.ala9Pq t N 0 04 A S n f 4 , weaveew - oTN tt .. 5 P 12 h I Thor. Evaluation =1 Thar. R.E.Wallon P d 0 0 urpose of each Modality, Activity, E!7 related to problem Ilitlhln owt and goals: Decrease Paln 0 In Funclanot Abilities 0 Increase Strength blcreaee ROM 0 O 501,19 97001 P h Thar. Evaluation - 1/4 hr. W120 97002 I Thor. Re-evaA?a9on -1/4 hr. 50006 90901 B ldeedback 50007 5000e 90811 97150 B G lofeedback - Pennell roup (2 or more) 9 eetRc c eae lee Momted representing the coolie) billed: 5007e 97597 D ebrtdemen6 Selective <a20 so cm AREA TED: 0 Thar. Ex. Per Flow Sheet 5007B 97598 D abddemen6 Selective >20 cm 50004 97802 D etaidemenl, Non Selective 800311 G0281 Elec. Sum (Unattended) Chronic Wound ASSPSSMENT-PagenCs response to "afinentffunctional progress 60039 60282 Elec. Bien (Unattended) other wound 60009 G0263 Elec. Stlm (Unattended) Nan-Wound 60040 64550 Am of TENS 50010 97010 Hd/Cdd Pocks 50077 97012 Traction, Mechanical Pain level prior to treat: Peln level after trest: 50013 97018 Va opneumetlcOevlce 5001 1 87018 n PuaMn _6??. 50005 97022 Debrldeme"'Mrid Cbanln r 50012 97022 FWMWhere D 1 2 3 4 5 8 7 8 9 10 W014 97022 Whidpool PROGRESS NOTE: WEEKLY SUBJ VE Flnd urentent: W020 97110 Ther. Prot st mn , endur., flax. 1/4 hr KM - 60024 97112 Neuromuscular Ed 114 hr 50017 87113 Aquatic TheWpy hr OBJECTIVE Find Ingstmeasurement: 50021 97116 Gait Tral 1/4 hr 90023 97124 Masao_gd 1A hr 60022 97140 Me I Thera 1/4 hr 50025 97504 0 otlc Fittl Inin 114 hr 50026 97520 thelicTraining 1/4 hr ASSESSMENT-Pall rtfs F" pons* to treatntanNlunctlonal real 50027 97530 Thar. Acevll (improve Wnct. ad. 114 hr 0 Patient tolerated treatment well 0 Home Ex. Pnugram Reviewed 50016 97535 ADL Salt/Home M t 114 hr 0 Ex. PrE)gram advanced .lour sheet 50015 97537 ADL Comnl/Wk Mgmt. 1/4 hr 50029 97542 Wheelchair M ml 114 hr 60032 97546 Work Hardening Initial 2 hours 60033 97546 Work Hardening Add1 Hour SHORT TERM GOALS 60018 97703 Chk OftPromlh. Use 1/4 hr 56031 97750 Physical Pert. Test or Measurement FCE 50081' 97755 A3S130Ve Technology i .w , 60034 9 032 Elec. Slim Alend Non-wound 1/4 hr PLAN: Continue Current Treatment Plan Or Revive To: 50035 97033 lont 1loreals 1/4 hr 50019 97034 Contrast Bath 114 hr -- 50036 97035 tAtrasound 1/4 hr 50037 97036 Phon oresis 1/4 hr THERAPIST SIG . 11.q n- Total Minutes Total Trestmanl -Tired Total unlta THERAPIST SIGN: Total Minutes Totsl Treatment - Untlmed Total Un 1 unlt> 6 minulea l0 3 minuess 3 units > 31 minutes to X53 minutes Tahl Unite 2 uNts > 23 minutes to < 3e minutes 4 units > 53 minutes to 105 minutes OP PT Charge Tlckal Revised 619105 ?/ Farm# OPPT05 I.V HEWHSOUTH. Rehabilitation of Mechanicsburg Cent Dr NawCUmb Eur Chamb Hill LIFE Wrmlysburg Hershey L:: Cry Med AA/Skgie wahorp hued OUTPATIENT PHYSICAL THERAPY CHARGE SHEET/ DAILY NOTES DATE OF S E al j CX_ N/S_ R/S^ RX expires Vlaltf/ of AulhanzW aQ0?0?`"l1g AK? AMa Mu.."A"MAD M 2/04Jt947 PM 058 M QM U fMA Mott Nolus M TA Jl66 nruan 1 it 50001 97001 Physical They. Evaluation Purpose of each Modality, Activity, Exercise related to problem IleNlunctional d and goals: 50002 97002 Physlal They. Ra-Evaluaton Decrease Pain 0 Increase Functional Abilities 0 Increase Strength crease ROM 0 O 5011s 970ot Physical Ther. Evaluation - 114 hr. 50120 97002 Physical Thar. Re-evalua0gn -1/4 hr. 008 50 90901 aloleadback 50007 90911 Moleedbeck - Penneal 500 08 97160 Group R or meta) Spscmc rrtodell N role erfarmed representing the cadets) bl9ed: 50078 97597 Debrldement. selective <=20 cm AREA TREATER: O Thor. Ex, Per Flow Sheet 50079 97698 Debridement, selective >20 all cm 50004 97602 Debrldemenl, Nor selective 5N3e 60281 Elec. Slim (Unahended) Chronic Wound ASSESSMENT-PationPa reaponao to breatmentnunctional progress 50039 60262 Elec. Stlm (Unattended) other wound 50009 60283 Elec. Slim (Unattended) Non-Wound 5"0 64550 MOWTENS 50010 97010 fi) d Packs 50077 97012 chon, Mach kal Pain level prior to treat: Pain level after that: 50013 970116 aumatlcD evice 50011 97018 Palamn 50005 97022 DetatdemarlVWnd Cleaning-Whirlpool 50012 97022 Fklidothere 0 1 2 3 4 5 6 7 6 9 10 50014 97022 whirlpool PROGRESS NOTE: WEEKLY ME ME SUBJECTIVE Flndin s/meaauramsM: .50028 97110 Thor. Proc (strength, endur., Rex,) 114 tv 50024, 97112 Neummuswlar Re-Ed 114 hr 50017 97113 Aquatic There 114 hr OBJECTIVE Findin simeasurement: 50021 97116 Gall Training 114 hr 50023 97124 Message 1/4 hr 50022 97140 Manuel Thera 1/4 hr I V3 (z 50025 97504 Orlholk:Flttln ralnln 1/4 hr 50026 97520 Prosthetic Tralnln 114 hr SSMENT-Pationt's response to tmatmanittunctional programs 50027 97530 Ther. Activity Pan o ve funct. n. 1 /4 hr Patient tolerated treatment well 0 Home Ex. Program Reviewed 50016 97535 ADL Self/Home ml 114 hr O Ex. P ram advanced Per flow sheet 50015 B7537 ADL Comm/Wk M ml. 1/4 hr 50029 97542 Wheelchair MgnA( 114 hr _.._ _. .. _._._.._ _.__; .... ?........ .. 50032 97545 Work Hardening Initial 2 hours 60033 07546 Work Hardening Add'i Hour SHORT TERM GOALS 50016 97703 Chk OntVProsth, Use 114 hr 50031 97750 Physical Perf. Tesl or Measurement FCE - - - 50081 97755 Asslative Technology " " 50034'" 97032" " _ Sec. Slim Attend Non-wound 114 hr PLAN: Continue Current Treatment Plan Or Ravlse To: 50095 97033 Ionl horesis 1/4 hr . , 50019 97034 Contrast Bath 1/4 hr _ -- ?? 50036 97035 Ultrasound 1/4 hr - 50037 97035 Phono oresls 114 hr THERAPIST SI Tobl Minutes Total Treatment -Timed Total Units THERAPIST SIGN: Total Minutes Total Treatment - Untimed Total Units g" 1 unit > 8 minutes to < 03m tes 3 units > Js minutes to <53 minutes Twat Umts 2 units > 23 minuGa to 8 `}jllnutes 4 units >53 minutes to<ee minuto J Form# OPPTOS mmmsoww. Rehabilitation of Mechanicsburg Cent Dr Now Curb Ent Pad Chamb Hill LIFE Wnnlysburg Hershey OtrY Mad AMSkple svo-h 4p based OUTPATIENT PHYSICAL THERAPY CHARGE SHEET f DAILY NOTES DATE OF SERVICE 1 / V 1F CX_ N/S_ R/S„ RX expires 9, I q IT Ysllq__q_al AWhodvsd 000101119 A'SLAMII MUHAMMAD C 1/10/06 7/06/9417 PM 058 4 0.M Y U UN*aoo* N QMA,? ?1 ^A n. MBOfOAf! A OTHER 50001 97001 P hysical Thar. Evaluation P d urpose of each Modsllty, Acthrity, Exercles related to problem llatdunctlonst;5 eficit and goals: WW2 97002 P hysical Thar. Re-Evaluation Decro we Pain O Increase Functional Abilities 0 Increase Stranglh Increase ROM \L) - 0 50119 97001 P seal Thar. Evah atlon -1/4 hr. 50120 97002 P hysical Thor. R"veluallon -114 hr. 50008 90901 B lafeedback 60007 50008 90911 97150 Bloleedback - Perineal Group (2 or more Speo9k modal , activity, exerGss pertomwd repreeenting the eadsls billed: 50078 97597 Deibddemenl, Selective -20 act an AREA TREATED: 0 Thar, Ex. Per Flow Bheal 50079 97598 Debddemenl Selective -120 cm 50004 97602 Debrldemenl Non selective X 1()rvI;'1 P/ r 5 Floc. Slim (UMtiended) ChroMc Wound ASSESSMENT-Paflant's response to treabmntMunctlonal progress 50099 G0262 Sec. 8Um (Unattended) other wound 50009 G0263 Elec. Stim (Unattended) Non-Wound 60D40 64750 of TENS 50010 97010 ? EY' d Pecks 50077 97012 reton, Machanical Pain level after treat: Pain Wvoi prior to treat: (v '17i 5 97016 pneumatic De vfce /'^? 1 500 97 1)18 Paraffin ` J `` \ 60005 97022 DebddemenWlnd Cleaning-Whidpod 50012 97022 Fiuldothere 0 1 2 3 4 5 6 7 8 9 10 50D14 97022 Whirlpool PROGRESS NOTE: WEEKLY 50028 97110 J C Thor. Ptoc J*vingth, andur., Rex.) 114 hr 1 SUBJECTIVE Flndln9slmeawAr enwnt: ?- 01-F I r rvr ?r 50024 97112 _ =-." =- -: NsunxmscLdefTia-Ed1/4 hr 50017 97113 Aquatic Therapy 1/4tv OBJECTIVEFInd10 slmeasurement: 50021 97116 Gall Tretmn N4 hr 501723 97124 Massa a 1/4 hr 5OD22 97140 Manual Thoro 1/4 hr t 60025 97504 Ortholic FOU mining 114 hr 50026 97520 Proslhatic Training 114 hr ASSESSMENT-Patlanrs response to trestrivenUfunctiunal progress SD027 97530 Ther. Activity Im rove funct, rt. 1/4 hr Petlent tolerated treatment well O Home Ex. Program Reviewed 50016 97535 ADL Sell/Home M t 1/4 hr 0 Ex. P m aovanced r now sheet 50015 97537 ADL ComMWk M 1. 114 hr 64-, OL c. - '?Y, 50029 97542 Wheelchair M ml 1/4 hr 60032 97545 Work Hardening Initial 2 hours ,50031 97546 Work Hardening Add'I Hour SHORT TERM GOALS 50016 97703 Chk OrthlProsth. Use 114 hr 50031 97750 Physical Pert. Test or Measurement FCE 50081 97755 Assislive Technology 50034 97032 Elac. Slim Attend Non-wound 114 hr PLAN; Continue Current Treatment Plan Or Revise To: 50035 97033 lonlo horesis 114 hr 50019 97034 Contrast Beth 114 hr 50036 97035 Ultrasound 1/4 hr 50037 97035 Phono horesis 114 hr THERAPIST SIGN Toul Minutes Toul Treatment • Timed Total Units THERAPIST SIGN. T-I Minutes Total Treatment - Urdlmed Total Unlta 1 unit > e minutes to [ 23 minutes 3 units > 36 minutes to <53 minut" Total Units ?. 2 units > 23 minutes to < 3a minutes 4 units > 53 minutes to <aa minutes J OP PT Charge Ticket Revised 619105 FGM1# OPPT05 (v HEAcrHSOUTH. o•., Rehabilitation of Mechanicsburg Cent Dr New c mb East Park Chamb Hot LIFE Wvnlysburg Hershey Lsbaw C17idM AMSinpie W-hest) based OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF L f! ? / CX! N/S R/S_ RX expires VistNt of Aulhorfzed 000101119 1/10/04 1I SL AA r MUHAMMAD C x/06/1947 aM ass M 014 r U4 H4.= 1140I4AL4. YEN .•i1E 50001 50002 97001 97002 P P hysical or. Evaluation hysical Thar. Re-Evaluation P d urpose of each Modality, Activity, Enerelse related to problem 11aWundll 01- • a, encit and oala Decease Pain 0 Incr Functional Abilities 0 increase Strarso nuesse ROM 0 50119 97001 ] Physical Thor. Evalu6Non - 1/4 hr. 50120 97002 Physical That, Re-evalustlon - 1/4 hr. 60006 90901 Mcfeedback 50007 00911 Bloleadbeck - Pennant 50909 97150 Group (2 Or more) Specino modal , activity, exercise podo Natln the code(a b91ad: 50078 97597 Debrldemant, Selective ?=20 cm AREA TREATED: Ther. Ex. Per Flow Sheet 50079 97598 Debndemem, selective >20 cm C 1. 50004 97602 Debridement, Non Selective 50038 60281 per. Sam (Unattended) Chronic Wound ASSESSMENT•Patlent'a response to treatimintltunctlonal progress 50039 002112 Elec. Sbm (Unattended) other vround 50009 G0283 Elec. Slim tUnshended) Non-Wound 50040 64550 of TENS 50010 97010 old Packs 50077 97012 rac0al, Medtenk it Pain level prior to treat: Pain level attar that: 4fl) L7 50013 97016 Vasopnelrniatic Device r 50011 97018 Pere/8n ?`- CeO SOWS 97022 Dabrldemanl/Wnd Cleaning.Whnlpod ) 50012 97022 Fluldolhanspy 0 1 2 3 4 5 9 7 e 9 10 50014 97022 Whirlpool PROGRESS NOTE: WEEKLY 9 zmwE Plndingsl arsment: 50028 97110 Thor. Proc tatrength, endur., flex. )1A hr 50024 97112 Neuromusadar Re-Ed 1/4 hr ., :..: : 50017 97113 Aquatic Thera 114 hr OBJECTIVE Flndin afmsasurament: 50021 97116 Galt Trainin 114 hr 50023 97124 Massa a 114 hr 50022 97`140 Manual Thera 1/4 hr 50025 97604 Orthotic FittWminling '114 hr 50026 97520 Prosthetic Training 114 hr ASSESSMENT-Pathmrs response to tromicnewfunctional programs 50027 97530 Thar. AclMt (improve fund. rf. 114 hr 0 Patient tolerated treatment well 0 Home Ex. P mm Reviewed 50016 97535 AOL Self/Horns MgM! 114 tv 0 Ex. P mm advance r Govt apis 60015 97537 ADL Comm;Wk-M t. 114 hr T 50026 67642 Wheelchair M ml 114 hr cr 5032 97545 Work Hardertin Initial 2 hours 67- 50033 97546 Work Hardening Add1 Hour SHORT TERM GOALS 60018 97703 Chk0rlhlPmelh. Use 1/4 hr 50031 97750 Physical Pert. Test or Measurement FCE SW31 97755 - Assislive Technology 5W34 97032 Elec. Stier Attend Non-wound 114 hr PLAN: Continue Currant Treatment Plan Or Revise To: 50035 97033 tonto esis 114 hr 5W19 97034 Contrast Beth 1/4 hr 50036 97035 Ultrasound 1/4 hr 50037 97035 Phono horests 114 hr THERAPIST St Total Minutee, Tatar Treatment • Timed Total Un9a HERAPIST SIGN: Total Minutes ?. Total Treatment • Untimed Total Units ? unit > a minutest minute 3 units > 38 minutes to Cf3 minutes 4 Tarsal Units unite > 23 minutes to c 78 minutes 4 unlta > 53 minutes to 011 minutes 2 S ur v i unarge ncxet Kensed e,ame \_? Form# OPPT05 HEALTHSOVIK ?, Rehabilitation of Mechanicsburg Cent Dr NwCwobEsatPark Chamb Hit LIFE Wtmlysburg Hershey Lsmno dry Mee A4/Stnp19 avolnao bases OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF SERVIC J 1 17 / 0L0 CX, N/S_ R/S„ R.C expires Vtslt# _ot Aulhodzed 000101119 1/10104 ASIA#4 , MUHAPKAD C ?/Jb/i447 PM 0 5 6 ?+nM . Y UCC]p"?rA pp4D , T rs,GM?. ri 0 1r LPrflC' 6 07HER ?7 50001 50002 97001 971702 P P N re 1 Ther. Evaluallon hyslut Thar. Re-Evaluallon P d urpose of sash Modality, AcWRy. Exerehe related to problem llstltunetlonal eBOlt and goals: Dertsase Pain 0 Increase Functional Abilities 0 Increase Strength Increase ROM O O 50119 87001 sfcal Thar. Evahtabon - 1J4 hr. 5012D 97002 P R"vWwflon - 1/4 hr. sicai Thar, 50006 90901 Islas S lotaedbadc 50007 90911 B wineal eetlback - P bf 50008 W078 97160 97597 G O (2 or more roup ve <=20 tm ehMemeM, Selecti B A paoMt modality, activity, exercise performed representing the codes blood: REA TREATED; 0 L 0 Thar. Ex. Per Flow Sheet 60079 97598 aledive>20 cm lrrMtnnenl S De M t r+ : " r?11 e 1 . 50008 97602 Debndemenl Non Selective C Y S ASSESSMENT-Patient's rs pons to treaunso Hunctional progress 50035 G02B1 (Unattended) Chronic Wound Elec. 811m BW39 G0282 (Unattended) other wound see. 39m 50009 60283 (Unshi nded) Non-Wound . 39m rte 60040 64550 oITEN6 App WD'ID 97010 0 old Pa DO 50077 97012 it; fm-c n, Medtenkel Paten level prior la that: ? Pain Isvel after treaC W013 87016 Ve umeve Device AAA ??? ??? CCC """ u O O \ 60006 97022 Debrltlement/Wnd Cleenino-Whi W012 97022 FWWolham 0 1 2 3 4 5 6 7 S 9 10 W014 91022 whMt I PROGRESS NOTE: WEEKLY SUBJECTJVE Findingatmeasurerntent: ?- mm 6=0 ME 97110 0 Thor. Proc (strength, andur., flex.) 1114 hr 1 rvq c WW4 97112 Neuromuscular Re-Ed 1/4 hr 50017 97113 Aqualt Thera 114 hr OBJECTIVE Findings/measurement: 50021 97116 Gel) TralMn 114 hr 50023 97124 Mersa a 1/4 hr 50022 97140 Tharwy hr 50025 97504 Otthotlc FIIOn n 1141x W026 97520 ProsthelicTrainin 1/4 hr f?SSMENT-PallenCs resonse to lroatmentnunctlonal progress W027 97530 Thar. Adk4 rove fund. n. 1/4 hr Palienl tolerated treetmenlawe9- ' r 0 Home E:. P ram Reviewed 50016 97535 ADL Self/Hame M ml 114 hr 0 Ex. P ram advanced er now sheet 50015 97537 ADL CmvwWk M t. 114 hr 50029 97542 Wheelchair M 11/4 hr 50032 97545 Work Hardenin Initial 2 hours 50039 97646 Work Hardening Add'I Hour SHORT TERM GOALS 50015 97703 Chk OnhfProsth. Use 1/4 hr 60031 97750 Ph ical Pmt. Test or Measurement FCE 560131 97755 Awlaeve Technology 50034 97032 Elec. SUM Attend Non-wound 1/4 hr PLAN: Continue Cumnt Treatment Plan Or Reviss To; 50035 97033 )onto orests 114 hr 1-7 50019 97034 Contrast Bath 1/4 hr 50036 97035 Ultrasound 1/4 hr 50037 97035 Phono horesis 114 hr THERAPIST SIGN: Totat Minutes Total Treatment - Timed Total Units THERAPIST SIGN: Total Minutes 30 'total Treatment - Untlmed Total Unit 1 unit > 8 minutes to < 23 minutes 3 units > 38 minutes to <63 minutes Total Units 2 units > 23 minutes to < 38 minutes 4 units > 63 minutes to <58 minutes OP PT Charge Ticket RsAaad 6!9/05 Form# OPPT05 elr? RL.j HEALTH-SOUTH. pok, Rehabilitation of Mechanicsburg Cent or New Guns, 9-1 :ILL, Chamb HI6 LIFE Wnnlysburg Hershey Lab"n Clry Med A4/Slrele sv hdsp lased OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF SERI /? CX_ Z R/S, RX expires %E? Visit N of Authorized a0010'111q +?tofo? ASIAN, MUNAxmAC 21061t947 PH 058 M pM YUCCA MO, THOMAS , J C '" 4.6 $18 YEOICIRE OTME P50 1 97001 P hystcst Thor. Evaluation P d urpose of saeh Modality, Actlvlty, Exere plated to problem llatMunctlonsl onolt and goals. 6=2 97002 p hysical Thar. tie-Evakrellon 0 Decraess Pain 0 Increa Functional Abilities O Increase Strength O Increase ROM 0 0 Sells 0 ] Physical Thar, Evaluation - 114 hr. 50120 ;.70 02 Ph slcal Ther. Re-evalustlan - 1/4 hr. 50008 &oleedback 60007 Biofeedback - Perin" 500M 97150 Group (2 or more) spacinc modality, a WI , exercise performed representing the coda s) billed: W078 97597 Dabndement, Selective -20 $cm AREA TED: O Thar. Ex. Per Flow Sheet 50079 975911 Debridemenl Selective> 20 cm 50004 97802 babndement, Non Selective 50038 Guel Elec. Slim (Unattended) Chronic Wound ASSESSMENT-Patlent's response to trousimenthunctionai progress 5W39 60282 Elec. Slim (Unattended) other wound 50009 G02a3 Elec. Slim (Unattended) Non-Wound 50040 64550 AppofTENS 50010 97010 HoWdd Packs 50077 97012 Traction, Mechanical Palo level prior to treat: Pain level after treat: 50013 97016 Vasopneumeltc Device 50011 97018 Paretfln ` C90\\ ?` '? 50005 97022 Debddemenl/Wnd Gaanin pool ? 50012 97022 Fluidothem 0 1 2 3 4 6 6 7 8 9 10 50014 97022 Whklpaal PROGRESS NOTE: WEEKLY SUBJE E Findln afmsssu ent: Om 50028 an 97110 M ME Ther. Proc (atrat endur., flex.) 114 hr -Z i/ 50024 97112 Neuromuscular -Ed 114 hr 50017 97113 Aquatic The 1M hr OBJECTIVE Find Ingalmessurameft 50021 97116 Galt TmInl 1/4 hr SW23 97124 Masse 1/4 hr 50022 97140 Ma There 114 hr 60025 97504 O Ic Filtin ninin 114 hr 50026 97520 sthetic Training 114 hr ASSESSMENT•Patlent'a response to VsetmenbTunctlonal programs 50027 97530 Thar. ActM (improve tunct, rt. 114 hr 0 Patient tolerated treatment well 0 Home Ex. Program Reviewed SW16 97535 ADL Self/Home ml 114 hr O Ex. Program advanced per now sheet 50015 97537 ADL ComrNWk M gm(. 1/4 hr 50029 97542 Wheelchair Mgmt 114 hr 50032 97545 Work Hardening Initial 2 hours 50033 97646 Work Hardening Add'I Hour SHORT TERM GOALS 50010 - 97703 Chk Orth/Prosth. Use 114 hr 501131 97750 Physical Ped. Test or Measurement FCE 50081 9775S- AsMs0ve Technology 97032 Elec. Slim Attend Non-wound 1/4 hr PLAN: Continue Current Treatment Plan Or Revise To: 97033 lonto oresis 1/4 hr 7 97034 Contrast Baih 114 hr 97035 Ultrasound 1/4 hr 50037 97035 . Phon oresls 1/4 hr THERAPIST MZW- IT- Total Minotes Total Treatment - Timed Total Uni THERAPIST SIGN: Total Minutaa Total Treatment • Unllmed Total Unftk 1 unit > 6 minutes to 2 minutn ] units > 30 minutes to <53 minutes Tae{ Units 2 units > 23 minutes to < 38 minutes 4 units > 53 minutes to <1111 minutes OF PT Charge lickel Revised 6/9/05 Forma OPPT05 OL) . Rehabilitation of Mechanicsburg Gent Dr New Cumb East Puk Hershey laesron Cby Med Chemb Hill LIFE Wrmlysbur0 AAIShab evo-huep bored OUTPATIENT PHYSICAL THERAPY CHARGE SHEET t DAIIL'7Y NOTES DATE OF :W41 2j CX_ N/S_ R/S,_ RX expires Vis11111 of Authorized 000 0-' '?19 110/06 ASLAM, MU8AMMAD C 2/06/19A7 PM wlk4min ;W AS r5l ' 000? 01568 516 addremoaraph MEDICARE OTHER 50001 97001 Physical Thar. Evaluation Purpoae of each Modality, Activity, Exercise related to problem I15t/tuncllonal it and goals: 50002 50119 97002 97001 Physical Thar. PA-Evaluation Physical Titer. Evaluation - 114 hr. ease Pain D Increase Fundomt Abilities O Increase Strength Increase ROM O O 50120 97002 Physical Thor. Re-evalwgon - 1/4 hr. 500(16 90901 I Bloleedbedt ME 50007 90911 BidoWback • Perinsal 50008 97150 Group (2 or more) SpeclBc modal , a NI axsrelse part rusng the cods s billed: 50078 97597 Debridemenl. Selective 4=20 act cm AREA TREATED: ' Thar. Ex. Per Flow Sheet 50079 97598 Debridement Selective >20 s art SM04 97602 Debrtdernenl, Non Selective 50038 G0291 Elec. Slim (Unattended) Chronic Wound ASSESSMENT-Patient's response to trealmanidunctlonai progress 50099 60282 Eisc. Stim (Unattended) other wound 611009 60293 Elec. Stun (Una tended) Non-Wound 50040 64550 TENS 50010 97010 d Packs 50077 97012 raction, Mechanical Pain level prior to treat: Pain level after treat: 60013 97016 Vasomneumalic OeNCe ?? 50011 97018 PareMn ?` O J •, cam, ,., \ U O 50005 97022 Debrldement/Wnd Cleanlrtp•Whfrlpool ?s 80012 97022 FILMotherep 0 1 2 3 A 5 6 7 8 9 10 60014 97022 WNrlpool PROGRESS NOTE: WEEKLY IM 9 ECTiV F"I almaasurs"Writ: 1 1 50028 97110 !T Thar, Prdc (atren th, endur., Ilex.) U4 hr 1411, '( 1r -1 50024 97112 Neurnmusculer Re-Ed 1/4 hr 'X 50017 97113 Aquatic There 1M hr OBJECTIVE Flndin sJmaasurament: 50021 97116 Gall Training 114 hr 60023 50022 97124 97140 Masco 114 hr Bust Thera /4 hr 50025 97504 Orlholic Filln ralMn 114 hr 50026 97520 Prosthetic Trainin 114 hr AIMSSMENT-PationVe response to Itmatrnentillunctional progress 50027 97530 Thee AettMl 1 rove fund. art. 1/4 hr Patient tolerated treatment well O Home Ex. Program Reviewed 50016 97535 ADL Sall/Hone M mt 1/4 hr O EX. P ram advanced er how shoat 50015 50029 97537 97542 ADL Cornrrt/Wk M mt. 114 hr Wheelchair rrd 114 hr 50032 50033 97645 97540 Work hardening Initial 2 hours Work Hardening Add't Hour SHORT TERM GOALS 60018 97703 Chk Or9VProalh. Use 1l4 hr 50031 97750 Physical Pori. Test or Measurement FCE 50091 97765 _ _ AssistivaTechnology 50034 97032 Elec. Slim Allend Non-wound 1/4 hr P1A : Continue Current Treatm nt Plan Dr R a To; 50035 97033 lonlo horesis 1/4 hr 50019 50036 97034 97035 Contrast Both 114 hr Ultrasound 1/4 hr 50037 97035 Phono horesis 1/4 hr THERAPIST SIGN: Total Minutes Total Trptmant -Timed Total Unit THERAPIST SIGN: Total Min too Total Treatment - Unllnwd Total Units 1 unit > a minutes to < 3 utes 3 unit > 39 mi <53 t i Total Lnih nutas o m nute. 2 unit > 23 minutas to 36 minutes 4 unit > 53 minutes to <ee minutes Forms OPPT05 Rehabilitation Mn burV`9 , He ?? Cent Or Now Cu a all Champ Hill LIFE Wrmlysburg Hershey l n Cvy Mod AA 801" "'hasp based OUTPATIENT PHYSICAL THERAPY CHARGE SHEET / DAILY NOTES DATE OF SERVICE % ! /L_/ O G? C% NIS____ R/S! FIX expires vislt# o! Authorized 000?d ,'hq 1/10/06 ,h J' . MUHA,t MAD S ` 11 ,' r?l a .w., a 11,,)) a t!,yq 2/06/1947 PM 058 M 0M YUCHA MD, THOMAS lJ .e 000204568 516 f aadnawsraph MEDICARE OTHER - - 50001 50002 97001 07002 P cal Then. Evaluation hyakal Ther. Re-Evatua9Dn I P d jf? Emu urpose of oath Modality, Activity, Exercise related to problem 11111111111110001121 efic hand goals: se Pain 0 Increase Funollonst Ablllites 0 Increase 9trenum Increase ROM O O 50119 97001 P h sisal or. Evaluation - 114 hr, C;L 1.7 5D120 97002 rw P hysical Thor, Re•ev"Iton -114 hr. M UM 60006 90901 S lofeedback 60007 50008 90911 97150 B G loleelOteck - Perinsai roup (2 or more) S peeHle modality, activity, exerclae ertonned resentin the codols) blood: 50078 97597 Debndemenl 3eledive <e20 red A REA TREATED: 0 er. Ex. Per Flow Sheet 50079 97bt16 Dabridemenl, Selective >20 em 60004 97802 I Dstindoment, Non Selective SOM AMMSMENT-Pationes response to trestma nctional progress F6003111- I G0281 EIeC. Stan (UnatimMsd) Chronic Wound 50039 =62 Eltx. Sohn (Unattended) other wound 50008 G02e3 Elec. Slim (UrAtIonded) Non-Wound 50040 64530 App of TENS 50010 50017 97010 97012 HoOCold Packs Traction, Machonlcal .4- 107- Pain teal prior to treat: Pal level after treat: 50013 97018 Vaaopneumetic Device o ,CGS o 50011 07018 Perefik 7 7 ` J O, (?W) 50005 97922 Oebridement/Wnd Cieanin -Whidpool 50012 97022 Fluldolherap 0 1 2 3 4 5 7 8 9 10 50014 97022 ~0001 PROGRESS OTEi WEEKLY SUBJECTIVE Find slmMou emeM: 511028 97110 Thor. PrDc (sfrengDl, endur., flex.) IIA hr W024 97112 Neuromuscular R&-Ed 1/4 hr 50017 97113 Aquatic Thera 1/4 hr OBJECTIVE Findings/measurement: 50021 9711@ lTninln 1/4 hr 60023 97124 Messy 114 hr 50022 97140 Manual Then 1/4 hr 60025 97504 Orthotic FItO minim 1/4 hr 50026 97520 Prosthetic Training 114 hr ASSE53MENT•Patlent's response to W nt/tunctioMl PMRMSII 50027 97530 Then. ActrAl tm ove luncl, r1. 1/4 hr 0 Patient tolerated treatment well O Horne Ex. Program Reviewed 50016 97535 AOL SaIIMome M ml 1/4 hr O Ex. Program advanced per low sheet 50015 97537 AOL CommlWk M ml. 1/4 hr 601129 97542 Wheelchair M mt 114 hr 60032 97645 Work Hardening Initial 2 hours 50033 97546 Work Hardening Add'I Hour SNORT TERM GOALS 50010 97703 Chit Okh/Pro3th. Use 1114 hr 50031 97750 Physical Pert. Test or Measurement FCE 50081 97755 ASS1311ye Technology ru l III,- IN IN No 50034 97032 Elec. Stlm Attend Non wound 1/4 hr PLAN: Continue Current Treatmarit Plan Or Revive To: 50035 97033 lonlo oresis 1/4 hr O v r... 50019 97034 Gonlnsl Bath 114 hr 50036 97035 Ultrasound 114 hr 50037 97035 Phon oresis 1/4 hr THERAPIST SIGN: 11" -e2 Total Minutes Total Trestmanl -Timed Total Units THERAPIST SIGN'. Tatel Minutes 7otr11 Tnetmenl • Untlmed Tote{ Unto 1 unit > 8 minutes to < 23 minutes 3 units > 35 minutes to <53 minutes, Tolai Units 2 units > 23 minutes to 1.38 minutes 4 units > 53 minutes to 1811 minutes OP PT Charge Ticker Ravlsed 6/9105 Forme 0PPT05 Internal Documentfor.QI Purposes-Only Do Not Conv or Release with Medical Record Frye hr Correspondence Section DOB: DR; ARMSTRONG AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712W ``M`R``N:2`0ff 45``68 IIIIII?IIIII?IIIIIIIII lll?lllll?lll?llll 0 UT PATIENT DISCHARGED MEDICAL Results of Tmal chart review: ? The chart is complete. ? The following items are incomplete: Circle discipline(s): PT O SP Item Present or complete (please check box below if present) Therapist Date(s) missing Signature/ Co- (in box below note signature missing date in question) (in box below note date in question) 1. Addressograph area complete = all documentation (Name, NR#, DOB) 2. Patient Information Record 3. Initial MD Orders / 4; Consent for Treatment 5. Outpatient Clinical Assessment 6. Addendum(s): / lJ 7. Initial Plan of Care 8. RecertlUpdatedPOC (minimum 30 days) A , " 9. Daily Notes ? 10. Weekly Notes 11. Flow Sheets 12, Discharge Suromary Reviewer's Signature: / 1 r w Dater Clinic Manager's Signature (if income items): Date: The above items are unable to be completed because (enmlovee) Has moved out of the area Is m longer employed with HEALTHSOUI'fi Is other Internal Dacuman£ far-.QET. crpwav,:Only-- D.b:.Nat'Qnv or Release with Medical Record .lwile in?Corres?vnd?nce Sectcon? ASLAM MUHAMMAD ?j D08: 02106/43 (M) DR: ARMSTRONG AGR: 59 ADMIT: 07105106 RM: 516 ACT: 712546 MRN:204568 HEW HSOUTH. II(Illllilll11111111111111111(llililllll Occupational Therapy Flow Sheet Patient Name:. < Precautions: Goals: Pain Level BP ?, ?S4?ILl (O 5 Y ?l 0 Il -/z S"`, a hc[ FI± (,CJ C r r 'j CZJ S k d 5;3-rc. 3 ? 75 be K2 m M r? Pc?? pmk E4L7 7iSOU77? ? ASLAM MUHAMMAU DDB: 02/06/43 (M) DR: ARMSTRONG AGE: 58 ADMIT: 07/05/06 RM:516 ACT: 712546 MRN:204568 I lilt fl ill II III fl III II III ii III II III I IIII Occupational Therapy Flow Sheet- - - - - - - - -- - - Patient Name: U ., ed Dx: Precautions: --? .77) /tn /51 d1.. I n ) Goals: , , 7 1 Gtr ?7 GIO P evel 4( L PC, + v i -e+ / L C`? 51? 1 ?! c olo G ,4 1 d r?v?v?r I 3 ? -V u ! u F? ?y 1 l a ©r 1 // c f kt v N f- C4L ?? (Z G 17? S11 1 51ti1d ( Ll, 0- PV X 2 - Ab Ain P!-ey- k L TOwzl Skis, J 1 m ,CC5 lv It ??I IA. ?.?-?, (%ej t Z?b? r,. l MI ?- `-rr}? C.S - (o?r1r??"' I?+v rg. / P-S 1„ °G ? , r C elm, \ , L( pyL.tir t G k 1 Ol f C W, ddlk it.Z4 L i? Rio n?- ,? vu?c? ? k Nv1.(!?h G?' L.???^Pil'l ? f ?/?1 ?l ? 7 ?(/? Sports Medicine Advisor 2005rozen Shoulder Exercises: Illustration Frozen Shoulder Exercises ... External rotation Shoulder tle)don _TM Shoulder extension Shoulder abduction r ?. r J i internal rotation Scapular range of motion Pec.toralls stretch Biceps stretch Copyrl¢RY 0 2001 t"10"On Hoa:1n &oWr OnS LLC. All no1vF. rMarvou. Page 1 of 1 MW C/. NDDNN .? moa3 ?. ?J°C °'zy ?' C Tt.4111 ?-& Rotation with •..? External Rotation in Corner 6- Pendulum Exercise Bend over at the waist so that the arm tans away troth tfte kody and a reaxad dangles In way. Use your body to MIllste a clraular motion. Make small alrolee while keeping the shoulder relazed Do this for 2 to S minutes at a time. Table-top Arm Slides Bit In a chair ad)acerd to a smooth able top UK the Involved arm with the uninvolved arm and place the hand and forearm on the able, Band forward et the waist allowing the hand and arm to slide forward 00 to repetitions Supine Neutral External Rotation - Lie on your back. Keep the arm and elbow light against your aide. "` Koop the elbow at ¦ 80 s y degree angle. Push the stick into the hand of the Involved ann to make the ann rotate away from the body. Do 10 repetltlons Supine Passive Forward Flexion • Lie on your back Using a stick (ffgtre A.), or using the ` strength of the uninvotved arm (figure B.)• raise the involved arm up and / then backward (as If to reach overhead) Do 1D repetitions Wall Climb Stretch sand haft a wall, place the band of the dtected am on the wall. Slide the hand up the wail, allowing the hand y and arm to go upward. \ An you era able to v stretch the hand and arm higher, you should move your body closer to the wall. Koid the stretch for 15 to 2D seaonda. Do 1o repetitions. Internal Rotation Behind-the-Back Stretch Sitting in A chair or standing, place the hand of the affected, arm behind your balk at the waistline. Use your opposite hand to help the other hand higher toward the shoulder blade of the opposite shoulder. • Do 10 repetitions r t r t s DDQ); ?Imm(j i JL.n •? N on ?t Z4 gw?C rnm>.* ?t3n?t: O1Z? G) 1 JUL-03-2006 HON 01:35 PH HMC SPORTS MEDICINE FAX NO. 717 531 4640 P. 02 .rciviv2IHi t o AMA (Mo HAMMAD WM Milton S. Hershey Medical Center AGE: 59 ADMIT: 07/05/06 ARMSTRONG 516 College of Median iACT: 712546! IMIR14:I2I04I56I8 II Orc?p?ib„?( THERAPY REFERRAL Ill?l?llll?IIIII{I4?I11I1IIII?1II?f1l{1I Admisaion Date: Patient's Name: V?$ Age: Outpatient: Inpatient: l Fom Numm Doctor: tAntr.acn Service; Phone: Diagnosis: 4 5 I?e ,t! Rx E'requency: ° EVALUATION AND TESTING PROCEDURES C?itisuit Activities of Daily Living Evaluation Cardiac Rehabilitation _ Cybex Ganiometry/ROM _ JOBST Measuremerd Manual Muscle Test Splint Fabrioation Static Dynamic Other MODALITIES Cold Pats Contrast Baths - Diathermy Electrical Stimulation "(TENS, HUGS, Lwow volt, Electrostirn 180) Hot Pacs Ice Massage l , JOBST Compression Massage Moistaire Paraffin ...r. Traction - Cervical - Pelvic - Ultrasound - Ultraviolet/Cold Quartz Whirlpool _ Other - *TENS: Transcutaneous Electrical Nerve Stimulation; HVGS; High Volt Galvanic Stimulation Prosthetic Training.._ M ROM -Active - ActiveAssistive THERAPEUTIC EXERCISE Coordination/Balance Gait Training Full Weight Bearing _ Partial Weight Searing Toe Touch Weight Bearing Non Weight Bearing ?. Home Exercise Program Isokinetic Exercise Muscle Re-education _ Neuromusoular Facilitation Posture Training Pre-prosthetic Training and Stump Conditioning - Progreasive Resistive Exercise - Passive Tilt Table Wheelchair Skills - Other COMM TS: rr ^ti '"-??? VT 1 {Gies} OCC. , A,'0-6 THERAPY REFERRAL PENNSTATE ® Milton S. Hershey Medical Center NAME: ASLAM, MUHAMMAD C YCS MO: ARMSTRONG APRIL - MAN: 7002936 NA DOB: 0210611947 INS; WORKER'S COMP AD- LOC: ORT2 PAT OOSN: 6595180 J„ . Penn State Milton S, Hershey Medical Center P.O. Box 850, Hershey, PA 17033-0850 (717) 531-8521 MON; 24865 SEX: M HT STANDARD - VISIT DATE: 06/2812006 _ INDICATION DATE TE ® Label All Prescriptions +t O l ^ Refill Times lC ` J NprA I i int Chris D. Bryce. M.D.. NAME (Plense Print) M.D./D.O. su T TUTION PERMISSIE .O, IN ORDER FOR A BRAND NA MT-183777 PRODUCT TO BE DISPENSED, THE LICENSE PRESCRIBER MUST HANDWRITE "BRAND NECESSARY" OR "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. D.E.A. REG. NO. AB AMjRHAMMAD AGE: 59 ADMIT: 7/05/06 RM: 516 ACT: I lC T l: 712546 l l(l lM l R I (N ` :: l 2 t D I? 4 5 I6 I8 I t I II?III 1?? 1111 I?III?I {II II In?I1IlI III HEAUNsou?'H, HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 DISCHARGE ASSESSMENT 01* ASLAM MUHAMMAD DOB: 02(O6f4? (M) DR: ARMSTRONG AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712546 MRN:204568 111111111111111flllllllliilllill llllflll ADORE55UGRAPR Oleo Date: 0 Functional 13 Hand C3 Woe nd E3 Wheeich& Q j 0 LE Addendum ID Voice ? Lymphadema ? Vestibular 1 Admission Date; ? UE Addendum O CogntWe ? Pulmonary Rafe ffft R"bT4444444 -1 !1z ? ArrkieJFoot ? Cammunlcstloh ? Amputee Primary clan: ? CW*W U Dysphagta ? Urinary W=n1hence Number of Tana! MaW 40 __j ? t umber ? Vleual.peroaptuel,l_-14fFter . ? _ Number Ot No-Show/CenceUatione: Asdstiw Dwfcam ? Standard W"r C] Rolling Welker ? Heml Walker ? Quad Cane, Large / Smell Base n Straight Cane O Other !)A ? None Bathroom Accsssor9es ? None ? Grab Bars ? Shower Cdr ? lUb Bench ? Raised Toilet Seat ? BSC NI/} Other Bouloment ? Nane ? HospUei Bed ? Wheelchair ? Cushion ? Other Pain ? No 'Yes too 3 6 9 7 B 1 K Yes, location: ?- Pain Scale (0 - 10) Now Bmt W _ Pain 5ymptoma: ? Sharp ? Bxrdng ? Referred ? Numbness ? Radcx.thar ? Throbbing ? Other (Use comment section for detailed dsscdption) Frequency ? No Pain ? Less Than Defy Dal ? Multiple Daily Episodes ? Constant ? Medlcatton/Procedure &Z& rU &fid_".4AU4 ? Relaxation Techrt-uee N ? ModskjAgilyhy that decreases pain: -C'? In Gh ? Modatity/AcWfty chat incre Lases pain: y 6K ? Daly - increases throughout daY ? Night Pain Cl Disturbed Sleep Comments; C Training cescripbco Training Provided: TresUrrrt R ived; f Summary of Progress: - -- ,® .. / F I l fs LJtiOzed REASON FOR O/C: ? Goals Met ? Medical Candttion ? Reached Maximal Potential an ? Objective Endings Inconsistent with patient's complaints and/or diagnosis, ? Non Co lience her RECOMMENDATION, ? Equlpment needs ntinue with HEP as issued TheraPY otfow up with physidan 0 Other COMMENTS: 4-4 D TE S ATUR 1TL CIATE SIQNATURElTiTLE 7 bn'm nl ? v .? ""I'i . 16 . / J, n "' JUL-05-2006 WED 02:03 PM H C SPORTS MEDICINE 67!8512086 18:57 717-214-2987 "HpoM* w"Tww"oho 4:106 EW 7findh RW PA 17065 IV.w 214.1 Pea1214-&W pwn t M" KAf?! pv Trrtni.a poo pat wm.p L7 F-m1?1 rat 24wd Q Pair FAX NO. 7131 4640 P, 03 H-, COUNTRY W-AWWS PACE 02/02 ASLAM MAUNA AD owl ? A M?r1I•' i OS eta ???t?o4aea AN rime par wand Jpg=* Prom ?.- -? SCI wA Plain nM 10,4U riC:._._To "am txWMA mom 0 4 Ir 6k ROM p ? idn1 *p"Wwwm a of Li 4.0? belfhli? C i moon m C M! 290% ?._.....-.-_ a wks y D 1 trtglMlr om o r,?.r C7 caflnam d. - M ant ap ookro + a VI1tm1 pM0lpgcrt ARM" Q m ear¢ ANON n?dbuPlc c Pos"U OWWA ?1 fl' 17 MWPa? ?b WOOW G R?d6111i 9! n.r 00 >r ¢?Cirraral?'FpM 0 ? Coadrrllon 0 Otl1er - aloft ` dim. 10-, Paltlr?r Iw*N MO ahruid nf/h to adart p11R ?wAs 4117 r.Rlrn J%L1 A, 10% lpt,/ t1Ng1lwrlr ? 1. Pda It vY ?-pow va . O a 9 Pa?iwk rr?k off ' A?a 4` PON YA i xt d- W L J S ffkarr" I Petlalt M1? 0 , ( . t „?,?? tYeeMa 1. W16 1 p1111D ?. -1o aloer k? 11. 0 M11PaA.W&"ft 1 0 MGM 111d1Yf11t nFi?¦0? m ad"dw br1161dkM+11 **not ? 4, Ivy- -o MRI a/a P fdOa1p 14 G ftpm ?ft MM 4, Mo1MilRlld?1 lunbianN/Wlss?lla 14 171tpotkwmalerd???0llryaka?tAalouftw _..,..?-. a o erwall to o?awr?eMk M aYI1M?asd 6M...... r. 1L G MY R 411rRY1M>4?r6fq tderwe?ia 16 Q i; pwlde>r>t * a" i t h Wino "a 11p14ea IM1R auNn p?oOArIF 1a 0`oNw 1K 4", 1t1 R tplaplrP?o6?11 end ref boat = ;. C W* VIMh A">tfq oft. M. Q OMner tAaR1wR1aoM1N"aS.=`r,rr -i- - r? 13 &OL ""V In a?iprrx? 4"*"M 1K at voftoAt q? 0 Oo9dINe tlkn1 " as art 37 t?dalna _ ?,4: Q CAW C1RMM Tmumb* Dp1~ _ _I --wm ka C 1 x Mb wow w cart. Do" T1ewap* ewe M7t iw fl1fllMe< Flwt d Cen w1Cr ms /erttarrAC+r1hM? lIL?At,771sDil7t/ Rehab Ca?rt4y Mawdowe 4005 East TYWn, RZM MROMi ,sbufg, PA 1700 Phan 21 4.1775 FOX 214-2907 HE4LTHSOUTHe HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 Phone 214-1775 Fax 214-2907 INITIAL PLAN OF CARE OCCUPATIONAL THERAPY Patient Name:. Physician: PrimaryDlagnosls: Treatment Dlagnos1s(es):46Q5hd Ac Rehab potential: ? Excellent 121tood ? Fair Patient _Probla a fr ea4rnentt OlaonQSis: 2"Pain In d ? 1 cognition [ ? 1 bed/mtf mobllity statue ? 1 nack-tunk ROM [ ? OBAculty ambulating ? 1 respiratory capacity r ? 1 w/c moblUty, ? §kin breakdown I ? 1 tranater status CY1 R &B UE strength [ ? Abnormal tone ? 1 neck/trunk strength f ? Abnormal movement ? j endurance I ? Atrophy WTArnited P9B UE ROM I ASLAM MUHAMMAD DOB: 02/D6/4? (M) OR: ARMSTRONG AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712546 MRN:204568 ADDRE9a04FAPH Onast Date: J10SvI 1 CG _ Begin Date: (for cr anent From to -0 WA 090cation period, From [? 7 (Reason for rsfarraq Joint hypennabillty of Joint hypomoblllty of I Jdnt InstabIft of I Contracture of Soft tisane dysfunction I Postural dysfunction I Improper body mechaNcs I 1 Coordination Short Term 13ogls: 2- Weeks Short term gods are wrftten to address patient problems and should relate to long term goals. 1. Patient wW: 2. Patient will 3. Patient will: 4. Patient wit: 3tlr- S. Patient will: Long MRrm duets- _ Weeks 1. Checraeae pain to ---Y?- to slow for 2. ? Increase bed/rat mobility to 3, ? Increase tranaler ataure to 4. ? Increase sere tion/propriocepllonMaual perception to Improve functonal ADLN such me 6. ? Improve balance to decrease risk of falls as evidenced by 8. ? Increase l u atlonal atending tolerance to minutes, T. ? Improve skin htegft e. ii m? eas rengteeae FiOM of??v10, atient to demonstrate proper poehue and safe body mechenlce with ADUa and lifting. Patient Goals; TO ?? 1??? ce "tunctlonef ecW. ADL/work skills ? 1 fine motor/dexterity ? 1 sensatkxn/propdbceptlon ? ( Visual perception ? Edema of ? Other ? Other 11. ? Improve balance/coordlnadon for functional akills such as 12. tun to work at rnodi ted/normal dudea. 13. ? Perform normal hauaehold ADL'a. 14. ? Improve fine motor akile for funcWrtal ADL's such an, 15, ? Famly/ceragNer Independent with care of patient In these areas 16, etlent with Home axerdas program, 17, 0 Other 19. 6d'Other Ogg ?? r- 4r-, t 6,%Q rV Ka N CI 19. ? Other 20. ? Other 21. ? Other : Skilled Intervention may include the follawing: ModeWas S_ @'8trengthening Exercises ? Visual perceptual training ? Transfer training ? Aquatic exercise 0 ADL training 94%adent/lamly training ? j.1euramuscular Re-education P'Fosture and/or Body Mechanics al-ReAblltty/Stretching CrAROM/PROM ? 'Rne motor/dexterity ? Edema management by anal Therapy ? 13 Equipment evaluation t,u?r-?? iQ ri A d L-?:.- [}'Other 1 atlent/caregiver participation in ? Spllnthg/arthotics ? Other development of treatment plan. ? Cognitive retraining ? Other Raiment Frequency;- TimasMleek Duration. _ Weeks ? i x visit I certify the need for these services fumfshed under this plan of treatment and while under my care, Physlc/an Signature Date Therapist Signature (establishing P ? v x?- Ll / r ? V !tell /mil Date S1 /?Zi c_I F My theraplat has reviewed my Plan of Care with ma Patiant/Caregiver Signature 1_1(0j_ > > n 'r ?- -? ASLAM M)) UHAMMAD AGE: 59 ADMI4M071 5106 RMT516NG ACT: 712546 MRN:204568 HEALTHSOUTH(NTERDISCfPLINARY PROGRESS NOTE IIIiIIIIIIIIIIIIIIIIIIIIIIIIIiiIiIIIIIIi Patient Name: a „1 a ?, zzz,/," DISCIPLINE UATE PROGRESSNOTE PIF, FA b i r T- , ?17A C _ J-7) -RIO- )k ?a I lu Gr m . ?Lo I t L ti 16 t h'! I TW NOTE, ALL ENTRIES MUST BE SIGNED AND DATED. Page i of 'DHRC 2001 Revised 02101 708• Int. Progress Nate i 1.1 til ?J tIM G _ Milton S. T- cm .?j, Medical. Center College of Medicine THERAPY REFERRAL 41. Admission Date: Patient's Nance: M v T" ,q C( 6= 041 J Age: Outpatient: Inpatient: N,R0O/1, , Doctor: service: Phone: Qiagnosls: k l d Rx Frequency: EVALUATION AND TESTING PROCEDURES Consult ?. Activities of Daily Living Evaluation _ Cardiac Rehablittation Cybex y Goniometry/ROM _ JOBST Measurement Manual Muscle Test Splint Fabrication - Static Dynamic Other MODALITIES Cold Pacs Contrast Baths Diathermy - Electrical Stimulation (TENS, HUGS, Low Volt, Electrostim 180) Hot Pacs Ice Massage JOBST Compression Massage Molstaire Paraffin -Traction _.__ Cervioal ._ Pelvic Ultrasound Ultraviolet/Cold Quartz Whirlpool _ Other "TENS: Transcutanaous Electrical Nerve Stimulation; HVGS: High Volt Galvanic Stimulation THERAPEUTIC EXERCISE - Coordination/Balance j n m°m U Gait Training ,._. II I S N N 0 l=ull Weight Bearing Partial Weight Bearing "-- o $ _.._ Toe Touch Weight Bowing Z~p _ - Non Weight Bearing ' = ?y3 _..- Home Exercise Program lsokinetic Exercise f Z C Muscle Re-education Neuromuscular Facilitation Posture Training Pre-prosthetic Training and Stump Oundltioning Progressive Resistive Exercise Prosthetic Training _ ROM Active __ Active Assistive Passive Tilt Table _ Wheelchair Skills Other 00MMENTS: %jy&,r PT 1 (8/60) ` PRYW AL THERAPY REFERRAL e*k HEALTHSOUM, PATIENT INFORMATION RECORD/HISTORY ASSESSMENT HEALTHSOUTH Rehab Country Meadows 4905 East Tdndle Road Mechanicsburg, PA 17055 000?0?9 1/10/06 ASLAM. Mt! MAD G DOB: 2/0614M) DR: ARMSTRONG AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712546 MRN:204568 IIIIIIII8111111111111111111111111111111 ?:? ?? .- ??? Nana Bax ? F Martial Status ? Single -e Married .? Widowed ? Divorced Name of Parent/Guardian Relationship HornWftrli Phone 01-,q S' 7q Social Security Number 1-6 1.- a ? 3'-3 Pri??y Care Physician P Vag ?'A A? t ASSvc??C ., Phone Address q 9 of A G l? r ?t (L??, e1 City W? t.c 1,. , State ? A Zip I7os Occupation _L -.e u- feet Day Worked I a - i t - 0 5 Employer_!fZQ s U ^c. Address 6., [ K• t Phone 341 W1-1 Primary Lang Bann Spoken 1 - Emergency Contact M nth 4 al ` o __t Relationship e- Home Phone 2-0;--187 Work Phone ?,s? - 2iS a t Callular Phone/Bee er What Is the problem that brings you to therapy? 7-rcN.?+ m Q -f i C'. A--14+1 Gvt In your condition due to ? Auto Accident ? Fail Work Injury ? Other Date of onset i b v 5 Prior therapy for this condition: ? Inpatient Rehahllltation ? Yea &rNo ? HealthSouth Facility ? Yes cvNo ? Outpatient Rehabilitation ? Yee I52,No ? Other ? Yes I YNo it this Is a workman's comp injury, where were your working when the injury occurred? e s if your primary Insurance Is Medicare and you have sustained an Injury, please describe In detail how and where this Injury occurred Date of Birth: o e: Primary Caregiver/Support System: Phone: Known Allergies: Adverse Reactions to Medlcatlonw. DRUG DOSAGE/FREQUENCY DRU DOSAGE/FREQUENCY ?o\ve? cK ?[l!fx Yes Tuberculosis CM) No Comments Yea No Comments Diabetes Mellitus ti Respiratory (COPD) ? Cancer ASTHMA ? Kidney/Urlnary ? High Blood Pressure I/ Epilepsy/Seiwna Low Blood Pressure ? Stomach/Gastrointeatlnal DbWness ? Heart Attack Heart Disease ? Stroke ? Clrculation/Yascular ? Sldn Problems ? Arthrlds L/ Pacemaker Osteoporonla Intastinal Trauma - Joint Replacement ? Psychiatric History ° Pregnancy i Other Major surgical procedure w ith the last 80 days (e.g., cranlotomy, larnlnectomy)? ? Yes ? No List Prior 5urgerlea/Hospitailzrftlpn Dg _q 'It'I?i ,x`71 ? !?Q D? HEALTHSOUTHe PATIENT INFORMATION RECORD/HISTORY ASSESSMENT HEAL THSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 000; -'19 1/10/06 A SL 4'. tt)HAMMAD C ASLAM MUHAMMAD DOB: 02/06/43 (M) DR: ARMSTRONG AGE: 59 ADMIT: 07105106 RM: 516 I ACT: 712546 MRN:204568 Jim 111,1111 Do you have problems %v tr. Yes No Comments Do you have problems wlth Yes No Comments Bowel Control Depression ? Bladder Control Sleeping ,,/ Headaches Fatigue V Slurry Vislort/Doubie Vision V Weight Loss or Gain ? Shortness of Breath ? Chest Pain ? Skin ? Nausea or Vomiting V Cough/Sneezing Swelling/Edema Do you smoke? ? No E;rY&s How Much? csc Ht4 Do you drink alcohol? ? No Yaa How Much? 0 C Cott- Specify any rellglcuslcultural considerations: COMMENTS: Is there anything we need to know that Is not covered on this tomn7 No It so, please explain: Patient's Goals For Treatment: Only for those patients In pediatric program (Under ago J: What childhood diseases has your child had? ? Measles ? Chicken Pox ? Mumps ? Rubella Has your child been exposed to any of these In the past three weeks? ? No ? Yes Explain: Check Immunizations that are In the process of completion or have been completed for your child: ? TOx 3 ? IPV ? Vartoella ? Hepatitis E Series ? MMR Please provide us with two people other than yourself who are authortzed to pick up your child from therapy and a password for them to use. We will not release your child to any one also but those you list here. Please update us with any changes Immediately. Name Home/!Nork Phone CelllBeeper Phone Name HomwWork Phone. CeIIIBeeper Phone Password In order to reach your optimum rehabllltadon, It Is essential that you loilow your physicians Prescribed treatment and the treatment plan established by your therapist. If you must cancel an appointment, please natfly ua as Som as posslUe so that-we can reschedule 'your misssed appolntmentwithln cite week: We appraclate nodflradon of cancellations 24 hours prior to scheduled appointments, this allows us to utflize your appolniment dine for other patlenW. We are obVated to record all canceUadons and no shows In your medical record. If you are covered by worker's compensation, we are obligated to report cancelled and to show' appointments to your insurance carrier. ? Petient/caregiver unable to complete farm; Information reviewed and completed by therapist. InFdals Nam 1 Completing Form: ?u a m ? ?? _ l ?1Di yn Date: \2 ? ? ? ? t z ? )5 iG(v -> 1?,t4?' Into o Clinical Slgnature/Title/Inltiels Date Clinical Slgnatune/Tinellninals Dale AN HEUTHSOUTH® HEALTHSOUTH Rehab Country Meadows 4905 East Trindle Road Mechanicsburg, PA 17055 UE ASSESSMENT ADDENDUM OIr>ftlal ? Re-eval ? D/C A SL ,&M, Mo HAMMAD AGE: 69 ADMIT' 07/05/06 ARMSTRONG 516 ACT: 712546 MRN:204568 1111111111111111111111111111111111111111 KEY, ROM Is passive unless indicated otherwise with an W. Use standard nwtsais teat grades for strength. WFL , t1111thin Funotlonal UrnItS NIT a Not Tested NIA a NOT APPLICABLE LE I= T ROM/STRENGTH RIG HT ROM WRENGTH ACTION ROM STRENGTH SHOULDER FLDtlON 180° SHOULDER EXTENSION 60° ° ° u f 9 SHOULDER EX, ROTATION 90° O ° SHOULDER IN. ROTATION W ° ? S SHOULDERABDUC110N iB0° ELBOW FLEXION 160° LL) r-L_ ELBOW E(TENSI:)N FOREARM SURNATION SO° ?- FOREARM PRONATION 80° WRIST FLEXION 60° WRIST EXTENSION 7(° OTHER OTHER OTHER OTHER COORDINATION UPPER EXTREMITY LEFT RIGHT Comments Uar 1W re ujW GROSS L 8-WFL ? kmalred ? Impaired FINE Q'W 1. ? Im Ind ? Im Ired COMMENTS! GRIP STRENGTH HAND DOMINANCE Ciro e LEFT RIGHT L Comments Gross Gres µ w 41 47 4 a Pont Pinch -a ) Z 10 7 15 A? Z Point Pinch p Lateral Pinoh 1 11,7 2 p E NSAT10N N a Normal NIT a Not Tested I ¦ im lmd A ¦ Absent Shoulder Upper Ann Foraam! Hand Shoulder Elbow Wet Fin am L R L R L R L R L R L R L R L R Lt. Touch Pro How tlon Sharp-Dull ' SI. nosh T'J Local ton Comments: (Ton4, vsm?ent Pattemo, Pain, Reflexes). a!1 U f- fr x.n ?1- (Y1C??Cr ?ti ?? fib. (_ " M nc21 g1_Ci --d ) m©,, l?- GNT OBSERVATIONS: ? Normal ? Antal io Arm Swln p JOINT DEFORMITY O ? YES If ea describe: SUBLUXATION! O ? YEa Left: am Right Cm STRUCTURAL 0B9ERVATION Occiput. Shoulders 1_-y1<_n Scapula Clavicles Cervical Lordosis Thoracic Kyphosls Lumber Lordoals Posture/Obvious mechanical stress points Date Signature / Title Date Signature / Title 7 H,Es+o® OUTPATIENT CLINICAL ASSESSMENT a P Therapy ? Speech Therapy ? Other @'> sttinnsl Therapy ? Neuropsychology/F*chology Patient Nemw At V-n ?ON oS oAM1?Mp HAMMo D AGE: 59 ADMI : 07/05/06 RM: 516 ACT: 712546 MRN:204568 1111111111111111111111111111111111111111 DOB: Age: 5 !' Date of Evalualfon V? Referring Physiclan 7:15 Precautions: ?Wunctlonal ? Hand ? Wound ? Wheeldielr ? LE Addendum ? Volce ? Lymphedama ? Vestibular E Addendum ? Cognttlve 17 Pulmonary ? AnWaftat ? Communicaflon ? Amputee ? Cervical ? Dyaphagid ? U irm incat 0-ce ? Dunbar ? Visual Perceptual ? Other Current Living Situation, ? Alone ? Assisted Living Q'FFimly/ReletNa O Careplver ? Other LMng Situation prier to lllnae -. ? Alone ? Assisted Livirsg 04r y/ReisWe O CaregNer ? Other Home SW-Up Issues Diagnostic Tests/Results 122Jn2 Q NO Gd YES CAD 00 az Qa ? ? 0 1 a a 4 e a 7 e a 10 Pain foals 1a-10 • Now. © seat 15 Worst V ye% lomfiort K ufKl Pain Symptomas mull ? ShBurning 17 Referred ? rrmbbing ? Numbness ? Rad m* r ? Other ptse canrnent section for detailed dascr"or?) Frsquenays ? No Pain ? Lase than dely ? Day, ? Dally-incmasea throughout day ? Mul?te daallyolaodae ? nstard ? Night Pain ? Disturbed sisep C'amer .5. ?.?° ?- J r° r ? .lI (-., MIEMENT PAIN HFURE MEMURE9 ? Madirtlon/Procedurs: ? Reiexatlon Techniques: 04/ 0dail y/AcUty that decreases pain: 1.? CyMOdeNy/Anthdlythst increases pain: CQMM3NM1 Goes patient currently haw aidn breakdown? ? YES 040 Is patient considered to be at rick for skin breakdown? ? YES ? NO GIfiT STAT111h Height weight FMUCA-nCNAL NMMS Laval of Education: F'edtert: Caregiver: ? 0.7 l3t-12 ? Col e ? N/A ? 0-7 ? 8-12 ? College ? WA Pedent // ? Low i?'Mad ? Ceragwer. ? Low ? Mod ? Hgh Patt O ers Qa None tmalbM ? C1' Language ? ? Madical Condition ? ? MentallEnmdonal ? ? Vision ? ? Hewing ? ? Religious ? ? 111terate' ? C] Other. ? V ifNterste, all aducatlon material should be geared to non-reading ? Reaming' ? ? Video 13 ? Hearing ? ? Return Demo ? ? Other ? 'I/readkV Is checked, d education metedals should be in the padentl caregiver's pranery language. Assistlve Devices; 2. One ? Standard Walker ? Rolling Welker ? Hem[ Walker ? Quad Cane, large / Small Base ? Straight Cane C1 Crutches ? Oxygen ? Splint/Brace ? Orthotics/Prosthetic ? Eyeglasses/Contacts on+., 11 Slanature /Title I Date it Signature / T1tle r"* NFAUHSOUTH HEALTHSOUTH Rehab Country Meadows 4905 East Trindie Road MachanicsFUNCTIONAL ASSESSMENT ADDENDUM 0 Initial ? Re-oval ? D/C o SL0AM1 tM DR-. AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712546 MRN:204568 1111111111111111111111111111111111111111 m INC a Independent MODt a edeMeendent Suft" ¦ r MIN a wIe> MOD a MAX ¦ Mod. Asai,tt Assist TD ¦ DDe 1 nd NR ¦ Twted PRIOR CURR ENT ' , B M Bl IND Moo I 6tir:fr9 MIN Moo MAX lm WT commim. INITALS Roft T S4 I To Sit - To - Supine Su ine - To - Sit Po TRANSFERS EQUIPMENT TYPE: 114MALS Bad Toilet Tub/Shower Car Other. AMBULATWN INITIALS Slt -To - Stand Stand - To - St Uwei Surface DeviceJDtetence; Bait Deviations: (dasplbe) Equiiituium Reactions; AM % Hip Stapping describe Stairs # of Stabs Other. DorMoft Type of Device; WHEELCHAIR MOBILITY PROPULSION TYPE: INITIALS Peft Management Long P ulsion Distance; Other. ACTIVITIES OF ONLY LIVING EQUIPMENT USED iNFMLS 1_etln Oroomin Bathkv V, UE Dressing LE Dressing Talletin Does Visual Pame teal AbIll /Co n ition A ear To Limit PunctlOn4 0 Q Yea ACTIVITY EQUIPMENT USED 1NrnALS m / Leon no Use o are Ghld Flmncial Management Other. Date Signature / Tale Ink lals Date Signature / Title In/tlais OUTPATIENT WORKERS' COMP C R E TIC ET Det Therepisl Number CX NIS Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Reports: OBJECTIVE: Area Treated: ROM'. Strength: Function: Comments: Cantu, Hand CneyMd NwCmb 880 882 895 884 SpaUd LIFE ChmHr Hrsny 885 886 888 691 Lakin ear Care 892 894 RJS ? No new complaints f ? e?eased In Fier lagt Increasedlf,Z 1 \ ! /' ASLAM 06/414M) MUHAMMAD O DOS : 02 ARMSTR AGE: 59/ADM1 0105/06 RM: 516NG ACT: 712546 MRW204568 ? patient pain level ® /10 Ecchymosis: SvcCd e c lion S-Ccl De c i ion 50119 PT Eval - 114 Hr 50167 Isokinetk Test -112 Hr 50029 Wheelchair Eva) -1/4 Hr 50165 IsaWnstic Training - 114 Hr 50077 CS Traction: Blanc_ In[ - ibs on _, ibs off _ min , 50130 LE Traction: Prone ^ Supin e _ Ibs on J Ibs off _ ndn _ 50036 Ultrasound Single conUpulse -- W/an ._min 50163 Ultrasound Comb contipulse _ , W1cm „min 50035 lontophorsats - 15 Min Q ,MA1MIn S M L 50037 Phonophoresis 50013 Jobst Comp alon 50128 Moist Heat X Min 50010 Cold Pack / toe Message X Min / 50014 WP a - FX _,min 50005 Stedle WP a! FX _ mtn 50028 PT -1/4 Hr 50017 PT individ -1 Hr (Aqua) 5D126 PT Group Thor - 1/4 Hr 50 2 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50164 Progressive Ex - 114 Hr 50127 Elec Stim 50166 Home Pgm/Family 50040 Tens Application 50024 Neuromusc Ra- d - 1/4 Hr 50012 Fluldotherapy 50011 Paraffin B S-Cd 05 261 SvcCd Description 50118 ? al -1/4 Hr 50119 OT Re•Eval - tl4 Hr 50168 ome Eva! -114 Hr 50029 Wheelchair Eval • 114 Hr 50169 Job She Eval -114 Hr 50170 Sealing Eval -114 Hr 50 6 ADL -114 Hr 50015 Community Mob Aurnt - 114 N 0030 Sensorimotor -114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgrrdFamlly Ed • 114 Hr 50167 Commun Re4nteg • 114 Hr 50165 Patient Ed • 114 Hr 50125 Group (23) - 114 Hr 50024 Nauromusc Re-Ed - 1/4 Hr 50154 Neummuac SUm -1/4 Hr 50012 Fluldotherapy -114 Hr 50163 Adjustment 50028 OT individ - 114 Hr 50050 Splint - Simple 50125 OT Group -114 Hr 50050 splint-Comp -- = 50011 Paraffin Bath 50112 PT Wrk Readl Evat - 112 Hr 50111 OT Writ Readl Eval -112 Hr 50113 PT Wrk Read) - 114 Hr 50112 07 Wrk Readl -114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 FT Writ Hard -1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT: STG Current Met: Yes I No LTG Currem; Reset: In: Weeks Reset: ? Patient tdlerated treatment well ? Home Exercise Program reviewed PLAN: Q Upgrade adivitlnqs4rn' ci/ er olocol ? Discharge From Therapy Comment: THERAPIST SIGNATURE: Mat: Yes I No In: Weeks ? The Exercise Program advanced as per flow sheet THERAPY MINUTES: -? ( TOTAL UNITS: evb HEA4THSOUTH Rehab of Mac OUTPATIENT WORKERS' COMP CHAR E TICKET Dot p2 ( L5r Therapist Number CX f? N/S Rx Expires: DAILY NOTE BUBJECTIVE: ? Unremarkable Patient Reports: CantOr Herd CnhyMd N.Cmb 880 882 895 884 SpfMd UPE ChmH1 Hrshy ASLAM ?? 885 886 888 891 D013 Sg2/A066/43 (Mp°HAMMAD Lobn Sal Cam ACT: 71254M6 h4 07/05j06RM: IRIS 516 1111111111111111111111111hi X588 892 894 IIIIIIIIIIII ? No new complaints ? Increased/Decreased pain after last visit ? Patient pain level ® /10 Area Treated: ROM: Strength: Function: Comments: OF THE SvcCd Description S-Cd Description 19vrCd D scd vc Dascdbllon 50119 PT Eval - 1/4 Hr 50167 Isokinetic Test - 112 Hr 50118 O vat - 114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isokinetlc Training -114 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Eva{ - 11/4 Ht 50077 CS Traction, Stalk- Inl _ Ibs on _ Ibs off _ min _ 50169 Job Site Evel -114 Hr 50170 Seating Eval -1/4 Hr 50130 LS Traction: Prone _ Supine _, Ibs on _ Ibs off _ min - 50 AOL -114 Hr 50015 Community Mob Assmt -114 Hr 50036 Ultrasound Single conupulea___W/cm _min 0030 Sensodmotor- 114 Hr 50163 Ultrasound Comb con//pulse _Wrcn `min 50020 Cog Retraining -114 Hr 50166 Home Pgm/Famlly Ed -1/4 Hr 50035 lontuptwreals -15 Min Q _MAJMin 5 M L 50167 Commun Re-Integ -1/4 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophwesis 50013 Jobat Co salon 50125 Group (2-3) -114 Hr 50024 Neummusc Re-Ed -1/4 Hr 50128 Moist Heat X Min 50164 Neuromusc Slim -1/4 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluldotherapy -114 Hr 50163 Adjustment 50014 WP Q _ FX -min 50028 OT indlvld • 1 /4 Hr 50050 Splint - Simple 50005 Sterile WP Q _ FX - rain 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT -114 Hr 5 17 PT Indlvid -1 Hr (Agua1 --''50011= Paraffin Bath 50126 PT Group Thar - 1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1 /4 Hr 50112 PT Wrk Readl Eval -112 Ht 50111 OT Wrk Readl Eval -1/2 Hr 50164 Progressive Ex • 4 Hr 50127 Else S8m 50113 PT Wrk Readl -114 Hr 50112 OT Wrk Readi -1/4 Hr 50166 Home Pgml mily Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hm 50024 Neuro sc Re-Ed -1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wtk Hard - 1 HT 50011 P ten Bath STG Reset: : Weeks Reset: In ? Patient tolerated treatment welt Exercise Program reviewed ? Home PLAN: ID Upgrade activities as toleral_qd /per protocol ? Discharge from Therapy Comment: _ Met: Yes/ No LTG Current: Met. Yes )No In: Weeks ? The Exercise Program advanced as per flow shoal THERAPIST SIGNATURE: THERAPY MINUTES TOTAL UNITS: evu OUTPATIENT WORKERS' COMP coma CHARGE TICKET 880 Z C Spr(Md Date - 885 2 clZ Therapist Number CX Rx Expires: DAILY NOTE 9USJ nremerkable Patient Reports: NIS R/S ? No new complaints Hand LnvyM NWCmb 882 895 864 LIFE clenH1 Hrshy A5LAM MUHAMMAD 866 888 891 DOB: 02106/43 ((M) DR: ARMSTRONG AGE: 59 ADMIT• 07/05106 RM: 516 Labn ealcam ACT; 712546 MRN:204568 892 894 ?IN11111111111111111111111111111111111 O Increased/Decreased pain after last visit L9' Patlent pain level V /10 5 LLC/ t," lL/ JO cCaLhuc l 0¢JECTIVE: Area Treated: Swelling?? ? ? ? ? Ecchymosls; 'J ROM: ?ir1 L ..?.C?C? ? R?2b n-? ? Z cr?.,...L $-'?' Function: Comments: 5vcCd Description ksw DescdpWn 50119 PT Eval -114 Hr 50167 Isokinetic Test -112 Hr 50029 Wheelchair Eval-U4 Hr 50165 IsokinaticTraining -1/4 Hr 50077 CS Traction; Static _ Int ` Ibs on _ Ibs on _ min 50130 LS Traction: Prone _ Supine _ Ibs on _ Ibs Of _ min _ 50036 Ultrasound Single conupulse ___W/cm _min 50153 Ultrasound Comb conupulse _ Wlcm --min 50035 lontophoresls - 15 Min Q `MA/Min 5 M L 50037 Phonophoresls 50013 Jobst Compression 50128 Moist Heat X Min 50010 Cold Pack I ice Massage X Mi n 50014 WP @ _ FX _min 50005 Stadia WP C _ FX min 50028 PT -114 Hr 50017 PT Indivld -1 Hr (Aqua) 50126 PT Group Thar-114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex -114 Hr 50127 Elec Slim 50166 Home PUndFamtry Ed 50040 Tens Application 50024 Neummusc Re-Ed -114 Hr 50012 Fluidotherapy 50011 Paraffin Bath vcCd Dee, ca notion Svc d Description 50118 OT Eval -114 Hr 50119 OT Re-Eval -1/4 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval -1/4 Hr 50169 Job She Eval -1/4 Hr 50170 Seating Eval -1/4 Hr 50016 AOL -114 Hr 50015 Community Mob Assail - 1/4 Hr 50030 Sensorimotor -114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgmiFamlly Ed -114 Hr 50167 Commun Re4nteg - 114 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) - 114 Hr 50024 Neuromusc Re-Ed -114 Hr 50164 Neuromusc Slim - 1/4 Hr 50012 Fluidotherapy -1/4 Hr 50163 Adjustment 50028 4;?-OT lndlvld -1/4 Hr 50050 Splint - Simple 50125 OT Group -114 Hr 50050 Splint • Complex 50011 Paraffin Bath _ 50112 PT Wrk Readl Evsl - 1/2 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl - 1/4 Hr 50112 OT Wrk Readi -1 /4 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT' STG Current: Met: Yes i No LTG Currant: Met: Yes I No /13eeet: In: Weeks Reaet: In: Weeks f9?Patlent tolerated treatment well ? Homo Exercise Program reviewed ? The Exercise Program advanced as per now shoat PLAN; ? Upgrade activities as tolerated /par protocol ? Discharge from Therapy Comment: C iooi?C ??E:- ?? THERAPY MINUTES: e , / TOT UNITS: THERAPIST SIGNATUI''??S C-V l f y 6 RW3ed 31241M HEALTHSOUTH Rehab of Mechanlcsb OUTPATIENT WORKERS' COMP CHAR E TICKET Oats alb Therapist Number CX Rx Expires; DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Rapons: - Area Treated: ROM: Strength: Function: comments: N/S V R/S Cerdor HeW CnayAr NwCmb 880 882 895 864 SWWd LIFE ChmH! Hnhy 885 886 888 891 Lebn Sal Care 892 894 ASLAM MUHAMMAD DOS: 02/06/43 (M) DR' ARMSTRONG AGE: 69 ADMIT; 07/05/06 RM: 516 ACT: 712546 MRN:204568 I Iif I it I{I II III I I III II II I I! Ilf If fll { 11II ? No new complaints ? Increasad/Decraesed pain after last visit 0 Patient pain level 0 !10 Swelling: Description vcC Description 50 9 PT Eval -114 Hr 50167 Isokinetic Test - 1/2 Hr 50029 Wheelchair Eval - 114 Hr 50165 Isokinetic Training - 114 Hr 50D77 CS Traction: Static„ W ` lbs on , Ibs oft, min 50130 LS Traction: Prone_ Supine_ lbs on , ibe off _ min 50036 Ultrasound Single cont/pulse-_ Wlcm _min 50163 Ultrasound Comb convpuise - Wien _min 50035 lontophoresls -15 Min C _MAIMIn 8 M L 50037 Phonophoresis 50013 Jobst prosslon 50128 Moist Heat X Min 50010 Cold Pack / Ice Massage X Min 50014 WP Q _ FX ,min 50005 Stadia WP Q _ FX ,___ _min 50028 PT -114 Hr 5001 PT Individ -1 Hr (Aqua) 50126 PT Group Thor -1/4 Hr 5 72 PT Group -1 Hr (Aqua) 50023 Massage- t/4 Hr 50164 Progressive Ex -114 H 50127 Else Slim 50166 Home PgrrJFamo d 50040 Tans Application 50024 Nouromusc R d - 114 Hr 50012 Ruidolherapy 50011 Paraffin h Ecchymosis: Svc DescA n 50118 OT Eval -114 Hr 50 8 Home Eval -1/4 Hr 0169 Job She Eval -114 Hr 50016 ADL -1/4 Hr 50030 Sensorimotor -114 Hr 50020 Cog Retraining -1/4 Hr 50167 Commun Re-Integ - U4 Hr 50125 Group (2-3) -114 Hr 50164 Neuromusc Slim -114 Hr 50012 Fiuidotherapy -114 Hr 50028 OT Indlvid -1/4 Hr 50125 OT Group - 114 Hr 50011 Paraffin Bath - SvCCd Descrioflon 50119 OT Re-Evai -114 Hr 50029 WhaelchatrEval -114 Hr 50170 Seating Eval -114 Hr 50015 Com munky Mob Assm1-114 Hr 50166 Home Pgm/Famlly Ed -114 Hr 50165 Patient Ed -1/4 Hr 50024 Neummusc Re-Ed -1/4 Hr 50163 Adjustment 50050 Splint - Simple 50050 Splint - Complex 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Readl Eval -12 Hr 50113 PT Wrk Readi -114 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr ASSESSMENT' STG Current: Met: Yes/No LTG Currant: R L In: Weeks Reset: ? Vent tolerated treatment well ? Home Exorcise Program reviewed PLAN: ? Upgrade activ la as tolerated /per protocol Discharge trom Therapy Comment: THERAPIST SIGNATU r Met: Yes / No In: Weeks Q The Exercise Program advanced as per flow sheet THERAPY MINUTES; TOTAL UNITS; eWfe ! HEALTHSOUTH Rehab o1 Mec OUTPATIENT WORKERS' COMP CHARGE TICKET 7 Date Therapist Number 1c;suury Centor - Hand CnuyAld NWCrrrb 880 882 885 884 SpWd LIFE ChrnHI Hrahy 885 886 888 891 Latin Bal Cm 892 894 RIG ASLAM MUHAMMAD DOB: 02/06/43 (M) DR: ARMSTRONG AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712546 MRN:204568 I{Illlllllllllllllliillllilllililllilll{ CX Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Reports: 6 O No new complaints ? IncreasedlOarraased pain after last vlsh anent pain level C / /10 oSA,6 OBJECTIVE; Area Treated: ROM: .11m ?,V C14 _a,,ja-le K L i-r:4 /?-<t1o0z, Strength: 12 1,7 a I/ ?4 Function: Comments: SvcCd Description SvcOd es tion SvcCd Descriplion S-Cd Dgyclptip 50119 PT Eval - 1/4 Hr 50167 Isokirartlc Test - 112 Hr 50118 OT Eval -1/4 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isokinetic Training -114 Hr 50168 Home Eva[ -114 Hr 50029 Wheelchair Eval -114 Hr 50077 CS Traetion; Static _ Int _ Ibs on , Ibs off - min - 50169 Job Site Eval -1 14 Hr 50170 Seating Eval -114 Hr 50130 LS Tracilon: Prone ! Supine _ Ibs on _ Ibs off _ min - 50016 AOL -1/4 Hr 50015 Community Mob Assmt -114 Hr 50036 Ultrasound Single contipulse _ W/cm !min 50030 Sonsotimotor -114 Hr 50183 Ultrasound Comb contlpulse ! W/cm. _min 50020 Cog Retralri tg -114 Hr 50186 Home Pgm/Famlly Ed -1/4 Hr 50035 lontophoresls -15 Min ® _MA/Mln S M L 50167 Commun Ra-Integ -114 Hr 50165 Patient Ed -1/4 Hr 50037 Phonophoresis 50013 Jobst Compresslon 50125 Group (2.3) - 1/4 Hr 50024 Neu mmusc Ra-Ed - 1/4 Hr 50128 Moist Heat X Min 50154 Neurornusc Stim -1/4 Hr 50010 Cold Pack / Ice Massage X Min 50012 Fluldotherapy -114 Hr 50163 Adjustment 50014 WP a _ FX _min 50028 1:7_ OT individ - 1/4 Hr 50050 Splint - Simple 50005 Sterile WP Q _ FX , min 50125 OT Group -114 Hr 50050 Splint - Complex 50028 PT -1/4 Hr 50017 P7 Indlvid -1 Hr (Aqua) 50011 -paraffin Bath 50126 PT Group Thor -1/4 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Read[ Eval -112 Hr 50111 OT Wrk Read[ Eval -1/2 Hr 50164 Progressive Ex • 1/4 Hr 50127 Elec Slkn 5D113 PT Wrk Readl -1/4 Hr 50112 OT Wrk Readl -114 Hr 50166 Horne PgmlFamlly Ed 50040 Tans Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hm 50024 Neuromusc Ra-Ed - 114 Hr 50012 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath STG Current Met: Yes/No LTG Cunant; Mel: Yes / No /RaaL In; Weeks Reset: In: Weeks g'Palient tolerated treatment well ? Home Exercise Program reviewed /?The Exercise Program advanced as per now shoe[ PLAN: ? Upgrade aciNNles as tolerated !per protocol ? Discharge from Therapy Comment: THERAPIST SIGNATUR r f 1 ! ?. THERAPY MINUTES: TOTAL UNITS: _ ew X24100 HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP CHAR E TICKET 21 Date Therapist Number CX NIS R/S Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkabl ? No new Patent Reports: ?l b ?QQld Cantu, Henri Cn Nwcmb 880 882 895 884 SpnMe UFE Chmill Hrahy 885 886 688 891 Leba eat Care 892 894 Area Treated: Swelling: ROM: Strength: Function: Comments: AOS DOE: 02106/4M) AM; tMo HAMMAD AGE: 59 ADMIT' 07/05/06 ARMSTRONG 516 ACT: 712546 MRN:204568 {11111{111111{iIIIIIIIIIillliillllllilll pain akr last visit tlent pain level ® / Ho Ecchymosis: t r9 -,oz it I4,a G Z/a-trtr r SvcCd Description SvcCd Descriotlon SvcCd Description ve d Descrlotlon 50119 PT Eval -1/4 Hr 50157 Isokinetic Test - 112 Hr 50118 OT Eva) -1/4 Hr 50119 OT Re-Eva[ - 114 Hr 50029 Wheelchair Eval - 1/4 Hr 50165 Isokinetic Training -114 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50077 CS Traction: Static _ Int ` Ibs on _ Ibs off_ min - 50169 Job Site Eval -1/4 Hr 501 TO Seating Eval -1 /4 Hr 50130 LS Traction: Prone r Supine - Ibs on _ Ibs off _ min_ 50016 ADL - 1/4 Hr 50015 Community Mob Assmt -1/4 Hr 50036 Ultrasound Single contipulae _ Wlcm _min 50030 Sensorlmotor -114 Hr 50163 uttrasoum Comb con/pulse _ ,Wtcm -min 50020 Cog Retraining -114 Hr 50166 Home PgnVFamlly Ed - 114 Hr 50035 lontophorasis -15 Mtn Q _MA/Mln S M L 50167 Commun Re-Integ - 114 Hr 50165 Patent Ed - 1/4 Hr 50037 Phonophoresis 50013 JobatCompression 50125 Group (2-3) -114 Hr 50024 NauremUSC Re-Ed -1/4 Hr 50128 Moist Heat X Min 50164 Neummusc Sfim -114 HT 50010 Cold Pack / Ice Massage X Mi n 50012 Fluidotherapy -114 Hr 50163 Adjustment 50014 WP Q ^ FX ,min 50028 = OT Indlvid -114.Hr 50050 Splint - Simple 50005 Sterile WP C _ FX _ min 50125 OT Group - 114 Hr 50050 Splint - Complex 50028 PT- 1/4 Hr 50017 PT Individ - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar - 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Read[ Evat -112 Hr 50164 Progressive Ex - 114 Hr 50127 Elac Stim 50113 PT Wrk Readl -114 Hr 50112 OT Wyk Read[ - 114 Hr 50166 Home PgrNFamtly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Mrs 50024 Neurumusc Re-Ed - 114 Hr 50012 Fluidolherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath STG Current:, Met: You / No LTG Current: Met: Yes I No Reset: to Weeks Reset: In: Weeks ? atient tolerated treatment wall ? Homo Exercise Program reviewed ? The Exercise P gram advanced as per flow sheet PLAN: ? Upgrade activities as tolerated Iper protocol ? Discharge from Therapy Comment: z 'Ore THERAPIST SIGNATUR THERAPY MINUTES: 3o TAL UNITS: 3 U eWe HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP Cantor Hand curry NWCmb CHARGE ICKET 880 882 895 884 SpdMd LIFE chmHi H r3hy Date 885 886 888 891 Labn bat Cara Therapist Number 892 894 CX Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable Patient Reports: NIS V' R/S ? No new complaints ? Increased/Decreased pain after last visit Area Treated: ROM: Strength: Function: Comments: EcQ?tgoSir vcCd Oes tlon SvcCd bast ion Svc d DOeecrlotion v do Description 50119 PT Eval - 1/4 Hr 50167 Isoldnetic Test -112 Hr 50118 OT Eva) - 1/4 Hr 501 1 OT Re Evai -1/4 Hr 50029 Wheelchair Eval -114 Hr 5D165 Isokinatlc Training -114 Hr 50168 Home Eval -1/4 Hr 3 2 50029 Wheelchair Eval - 114 Hr 50077 CS Traction; Static_ Inl _ Ibs on _ ibs oft _ min _ 50169 Job She Eval J4 Hr 50170. Seating Eval -114 Hr 50130 LS Traction: Prone _ Supine _ Ibs on Ibs off _ min _ 50016 AOL -11 r 50015 Community Mob Assml -114 Hr 50036 Ultrasound Single conbpulse __Wlcm _min 50030 5 dmotor - 114 Hr 50163 Ultrasound Comb contipulse `W/cm _min 50020 Cog Retraining - 114 Hr 50166 Home PgmTamily Ed -114 Hr 50035 lontophoreals -15 Min ® _MA/MIn S M L 50167 Commun Re-integ - 1/4 Hr 50165 Patient Ed -114 Hr 50037 Phonaphoresis 50013 Jobst Compression 50 Group (2-3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 5D128 Moist Heat X Min 0164 Neummusc Slim - 1/4 Hr 50010 Cold Pack / Ice Message X Min 50012 Fiuldotherapy - 1/4 Hr 50163 Adjustment 50014 WP C _ FX _min 50028 OT IndIvId -114 Hr 50050 Splint - Simple 50005 Startle WP ® _ FX ,min 50125 OT Group - 114 Hr 50050 Splint - Complex 50028 PT - 114 Hr 50017 PT I vid - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Ther - 1/4 Hr 50172 T Group - 1 Hr (Aqua) 50023 Massage -1/4 Hr 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Readl Eval -1/2 Hr 50164 Progressive Ex - 1/4 Hr 501 Elec SUM 50113 PT Wrk Readi - 114 Hr 50112 OT Wrk Readl - 114 Hr 50166 Home PgnVFamily Ed 040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neummusc Re-Ed - i/ r 50012 Fluldotherapy 50174 PT Wilk Hard - 1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Parafttn Bath ASSESSMENT: STG Current: Met: Yes/No LTG Cunsnt: Reset In: Weeks Reset: ? Patient tolerated treatment well ? Homo Exercise Program revievied PLAN: ? Upgrade activities / r protocol ? D charge from/herapy Comment: THERAPIST SIGNATURE: C?- AoSLAM3 (MDUHAMMo D AGE'. 59 ADMIT: 07105/06 W 516 ACT: 712546 IIIIIIIIIII ? Patient pain level a to In: _ ? The Exercise Program advanced as per now sheet Mel: Yes/ No Weeks THERAPY MINUTES: TOTAL UNITS: KM W OUTPATIENT WORKERS' COMP CHA E T CKET 7//3)0, - Dat n Therapist Number CX N/5 Rx Expires: DAILY NOTE SUBJECTIVE: ? Unremarkable r Patient Reports: csuur II Candor Hand ntryMd wCmb 880 882 895 884 SP,Wd LIFE Chmmi Hrshy 885 886 886 891 Leba Bel Care 892 894 Pis oS oA6M (Mp HAMMAD AGE: 59 ADMIT: 07/05106 RM: 516 ACT: 712546 MRN:204568 11111111111111 TIN 111111111111111111 Area Treated: ROM: Strength: Function: Comments: SvcCd Description Svc d Description 50119 PT Eval - 1/4 Hr 50157 Isokinetlc Test -112 Hr 50029 Wheelchair Eval -1/4 Hr 50165 Isokinstic Training -114 Hr 50077 CS Traction: Stalic _- In( - Ibs on _ Ibs off _ min _ 50130 LS Traction: Prone_ Supine_ Ibs on Ibs off min 50036 Ultrasound Single conUpulse! _W/cm _min 50163 Ultrasound Comb conupulse _ Wlcm _min 50035 iontophonssis -15 Min Q _MA/MIn S M L 50037 Phonophoresis 50013 Jabal Compression 50128 Moist Heat X Min 50010 Cold Pack / Ice Massage X Min 50014 WP Q _ FX ^min 50005 Sterile WP a! FX _ min 50028 PT -114 Hr 50017 PT Indivkt - 1 Hr (Aqua) 50126 PT Group Thar -1/4 Hr 50172 PT Group -1 Hr (Aqua) ? No paw complaints ? Increased/Decreased pain after last visit Patlent pain level 0 -1-/10 2/,-A c r "ec( S-Cd DeBeft-tion BY= Description 50118 OT Eval -1/4 Hr 50119 OT Re-Eval -114 Hr 50168 Home Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50169 Job Site Eval - 1/4 Hr 50170 Seating Evat -1/4 Ht 50016 ADL - 114 Hr 50015 Community Mob Assmt -114 Hr 50030 Sensodmotor- 114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgmlFamlly Ed -1/4 Hr 50167 Cornmun Re-tnteg - 1/4 Hr .50165 Patient Ed -1/4 Hr 50125 Group (2-3) -1/4 Hr 50024 Neuromusc Ra-Ed -1/4 Hr 50164 Neuromusc Stim- 1/4 Hr 50012 Ftuidotharapy -1/4 Hr 50163 Adjustment ?f 50028 ; 0 OT Indivld - V4 Hr 50 50 Splint - Simple 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paratfin Bath 50023 Massage - 114 Hr 50112 PT Writ Read) Eval - 112 Hr 50111 OT Wrk Readl Eval -1/2 Hr 50164 Progressive Ex -1/4 Hr 50127 Elec Slim 50113 PT Wrk Readi - 94 Hr 50112 OT Wrk Readl - 1/4 Hr 50166 Horse Pgrn/Family Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50174 PT Wrk Hard - I Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Bath A33ESSMENT: STG Current: Met: Yes 1 No LTG Current: Met Yes I No Reset: In: Weeks Reset: In: Weeks ? Patient tolerated-ireatment wall ? Home Exercise Program reviewed ? The Exercis rogmm advanced as per flaw sheet PLAN: /H'Upgrada activ Issas tai led !per protocol El Discharge from Therapy Comment / n THERAPIST SIGNATURE THERAPY MINUTES: U TOTAL UNITS: e ? -0 =7 -? D HEALTHSOUTH Rehab of Mechanlcsburg OUTPATIENT WORKERS' COMP Cent[), Hand CntryMd 77 K ET CHAR E T? 8 80 882 895 884 (o _7 11 SFAMd LIFE chm" Hrshy Date 885 866 888 891 ASLAM MUHAMMAU RMSTRONG 3 (M) DR: A DOB: 02/06/4 6 0 Latin Bat Gm 07105106 RM: 516 Therapist Number 892 894 AGE: 59 ADMIT: ACT: 712546 MRN,204568 N/S R/Expires: S IIIIIIIIIIIIIIIt114I111114111141111U111 DAILY NOTE _ ° _ _ _ - -- - -- - - - SUBJECTIVE: ? Unremrkak?e? _ , ? No new complaints ? Increased/Decreased pain after last visit ? Patient pain level ®/10 Patient Reports (: Area Treated: V ! ROM: ' _ Strength: ?IZIIAU (A' 'A -4 Function: Comments: Ecchymoals: 4L A, ? L SvcCd Description lsu Description 50119 PT Eval -114 Hr 50167 isokinatic lost -112 Hr 50029 Wheelchair Evel -114 Hr 50155 lsokhtstic Training -114 Hr 50077 CS Traction: Static _ Int _ Ihs on the oft _ min 50130 LS Traction: Prone ^ Supine _ Ibs on _ the off _ min 50036 Ultrasound Single conypulas _ W/cm _min 50163 Ultrasound Como cont/putse --- _W/an _min 50035 lontophoresls -15 Min ® `MA/Mln 5 M L 50037 Phonophoresis 50013 Jobst Compression 50128 Moist Heat X Min 50010 Cold Pack / ice Massage X Min 50014 WP ® _ FX ___-min 50005 Starke WP 0! FX _ min 50028 PT -114 Hr 50017 PT indivld -1 Hr (Aqua) 50126 PT Group They -114 Hr 50172 PT Group - i Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive EX - 1/4 Hr 50127 Elec Slim 50166 Home PgmlFamlly Ed 50040 Tens Application 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluldotherapy 50011 Paraffin Bath SvcCd Description S-Od Descdption 50118 OT Evai - 114 Hr 50119 OT Re-Eval - 114 Hr 50168 Home Eva) -1/4 Hr 50029 Wheelchair Eval -114 Hr 50169 Job She Eval -114 Hr 50170 Seating Evol -1/4 Hr 50016 ADL - 114 Hr 50015 Community Mob Assmt - 1/4 Hr 50030 Senscrintotw -114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgmlFamAy Ed -114 Hr 50167 Commun Re-Intag - 114 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) -114 Hr 50024 Neummusc Re-Ed -114 Hr 50164 Neuromusc Slim -114 Hr 50012 Fluidotherapy-1/4Hr 50163 Adjustment 50028 OT Individ - 114 Hr 50050 Splint - Simple 50125 OT Group -1/4 Hr 50050 Splint -complex 50011 Paraffin Bath 50112 PT Wrk Raadl Eval - 112 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl - 1/4 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 His 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard - 1 Hr 50180 OT Wyk Hard -1 Hr U!IU/ ASSESSMENT: STG Current: Mat: Yes I No LTG Current: Met: Yes / No Reset: In: Weeks Resat: _ in: Weeks agent tolerated treatment well ? Home Exercise Program reviewed QTihe Exercise Program anted as per flow sheet ?X) PLAN: pgrade activities as tolerated /per protocol ? Discharge from Therapy Comment: C-V- THERAPIST SIGNATURE THERAPY MINUTES: 'i_J TOTAL UNITS: ftAsed r (T ?0 W« - Don? %? HEALTHSOUTH Rehab of Mechanlcst OUTPATIENT WORKERS' COMP CH RGE TICKET 1111) l? Therapist Number CX NIS RIS Rx Expires: DAILY NOTE SUBJECTNE: C3 Unremarkable Patient Reports: Area Treated: ROM: Strength: Function: Comments: eN cordD, Hand Ca0yNd NwCmb Sao 882 895 884 spnwd LIFE chmH/ Nrrhr 885 886 888 891 Lebn eaI Cam 892 894 Dos L AM (MUURHAMMAD AGE: 59 ADMIT: 07/05/06 RM: 516 ACT: 712546 MRN:204568 1111111III11IIIIIIII11111IIIII11III11111 ? No new complaints . ? Increased/Decreased pain after last viall ? Patient pain level 0 I10 Swelling: Ecchyrwsla: SvcCd escrt ion Svccd Description vcC ton SvcCd Description 50119 PT Eval -114 Hr 50167 Isoklnetlc Teat -112 Hr 50118 Eval - 114 Hr 50119 OT Re-Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50165 Isoldnetic Training - 1/4 Hr 50168 Horne Evai -114 Hr 50029 Wheelchair Eval - 114 Hr 50077 CS Tracllon: Static- In1 _ Ibs on _ Ibs off _ min _ 50169 Job Site Eval -114 Hr 50170 Seating Eval -114 Hr 50130 LS Traction: Prone ` Supine - Ibs on _ Ars off •_ min _ 500 AOL -114 Hr 50015 Community Mob Asamt -114 Hr 50036 Ultrasound Single corNpulse___Wlcm `min 030 Sensortnwtor - V4 Hr 50163 Ultrasound Comb cont/putse _W/cm ____min 50020 Cog Retraining -114 Hr 50166 Home Pgm/Femlly Ed -1/4 Hr 50035 lontophorests -15 Min Q _MA/MIn S M L 50167 Comntun Re-Integ - 114 Hr 50165 Patient Ed - 114 Hr 50037 Phanophoresis 50013 Jobst Compreast 50125 Group (2.3) -114 Hr 50024 Nsummusc Re-Ed -1/4 Hr 50128 Moist Heat X Min 50164 Neuromusc Stlm -114 Hr 50010 Cold Pack / Ice Massage X Min 50012 Mufdotherapy -114 Hr 50163 Adjustment 50014 WP ® ^ FX _ rrOn 50028 OT IndMd -114 Hr 50050 Splint - Simple 50005 Sterile WP (to _ FX _ min 50125 OT Group -114 Hr 50050 Splint - Complex 50026 PT -1/4 Hr - 50017 PT Individ -1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thar - 114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Writ Readi Eval - 112 Hr 50111 OT Wrk Read[ Eval -1/2 Hr 50164 Progresslva Ex -114 Hr 5 27 Eiec Sdm 50113 PT Wrk Readl -114 Hr 50112 OT Wrk Readi -114 Hr 50166 Hame PgmlFamlly Ed / 040 1 Tens Application 50173 PT FCE - Z Hrs 50179 OT FCE - 2 Hrs 50024 Neurumusc Re-Ed - 1/ , 0012 51 Fluldotherapy 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr 50011 Parathri Bath ASSE,§$MENT J STG Current: 1/ Met: Yes/No LTG Current Reset:_ I In: Weeks Reset: ? Patient tolerated treatment well ? Home Exercise Program reviewed PLAN: ? Upgrade actlvtiles as tolerated lper protocol O Olsch"a from Therapy Comment: THERAPIST SIGNATURE In: _ ? The Exercise Program advanced as per flow sheet Met. Yes / No Weeks THERAPY MINUTES: TOTAL UNITS: Kefted W74100 OUTPATIENT WORKERS' COMP CHA GE TICKET Date Therapist Number CX N/S Rx Expires: DAILY NOTE NEJECTWE: ? Unremarkabj}? Patient Repona: ,??v/ Il rr Area Treated: ROM: Strength: Function: Comments: 'AIN ranlDr Hand MryAr Nwcmb 680 682 ela5 884 ASLAM MUHAMMAD SWWd UFE HI Hrshy DOB: 02/0614 (M) DR: ARMSTRONG 885 886 888 891 AGE: 59 ADMIT: 07/05106 RM: 516 ACT: ``712546 II IMRN:21I04568 II II Lem 8al C" 892 B94 94 III?IIII??I?IIII?III?IIIIIIII?I??Illfi?? No n w comdalnts ? 1 reasad/Decreased aln after last visit ? Patent pn level Q /1o (S Cd tam L IF . Swelling: Ecchymosis: '.? , rt >irY? ,dQ -Q b-l , , h ?; n.? r G?J R/S SvcCd Descrlollan S-Cd Description 50119 PT Eva[ -1/4 Hr 50167 Isoldnedc Test -112 Hr 50029 Wheelchair Eval -1/4 Hr 50165 Isoldnettc Training - 114 Hr 50077 CS Traction: Static,- Int _ Ibs on Ibs off min 50130 LS Traction: Prone , Supine _ Ibs on Ibs off _ min _ 50036 Ultrasound Single contipulas _ W/cm -min 50163 Ultrasound Comb conVpulse _ W/an -min 50035 lontophoresis -15 Min ® _MA/Mln S M L 50037 Phonophoresls 50013 Jobst Compression 50128 Molst Heat X Mln 50010 Cold Pack / Ice Massage X Min 50014 WP a _ FX _min 50005 Startle WP 0 _ FX _ min 50028 PT -114 Hr 50017 PT Individ -1 Hr (Aqua) 50126 PT Group Ther -114 Hr 50172 PT Group - t Hr (Aqua) 50023 Massage - 1/4 Hr 50164 Progressive Ex -114 Hr 50127 Else Stlm 50166 Home Pgm/Famlly Ed 50040 Tans Application 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Fluldolharapy 50011 Paraffin Bath A99FSR41FNT- SvcCd Deacdotion v d ascd on 50118 OT Eval - 1/4 Hr 50119 OT Re-Eval -114 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Eval -114 Hr 50169 Job She Eval • 1/4 Hr 50170 Seating Eval -114 Hr 50016 ADL -114 Hr 50015 Community Mob Assmt -1/4 Hr 50030 Senaorimotar - 1/4 Hr 50020 Cog Retraining - 114 Hr 50166 Home PgnVFamhy Ed -114 Hr 50167 Commun Re-Integ - 1/4 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) -114 Hr 50024 Neummusc Re-Ed -114 Hr 50164 Neuramusc Slim -1/4 Hr 50012 Fluldotherepy- 114 Hr 50163 Adjustment 50028 OT I d I 5 0 n Iv d - 1/4 Hr 0 50 Splint -Simple 50125 OT Group -1/4 Hr 50050 Splint - Complex 50011 Paraffin Bath 50112 PT Wrk Reads Eval - 112 Hr 50111 OT Wrk Readf Eva[ - 1/2 Hr 50113 PT Wrk Readi - 1/4 Hr 50112 OT Wrk Reads - 1/4 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hm 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - i Hr n STG Current: Met: Yes I No LTG Curve Met: Yes I No Reset: In, Weeks Reset: W C C) Patient tolerated treatment well ? Home Exercise Program reviewed p road ncerltb4? ettd5t PLAN: ? Upgrade actlvl es as tolerated /per protocol 1-1 Discharge from Therapy Comment: THERAPIST SIGNATUR THERAPY MINUTES: TOTAL UNITS: erleer C 7 1 f f I / ? ? ? /'yIl t1 . OUTPATIENT WORKERS' COMP C RG TICKET n Do 0 Therapist Number CX NIS Rx Expires; DAILY NOTE 8U8JECTIVE; ? Unremarkably Patient Reports: 1 Area Treated: ROM: Stranglh: Function: Comments: - ? SveCd De r tl n SvcCd Description 50119 PT Eval -114 Hr 50167 lsokinalic Test -112 Hr 50029 Wheelchair Eval -114 Hr 50165 Isokinalic 7relning -114 Hr 50077 CS Trecucm Static_ Ink _ -__ Ibs on _ ibs oft - min - 50130 LS Traction: Prone _ Supine _ Ibs an _„ los on - min 50036 Ultrasound Single conUpulse - W1cm lmin 50163 Ultrasound Comb mnllpulse - _Wlcm min 50035 lontophoreais -15 Min ® _MA/Mln S M L 50037 Phonophoresis 50013 Jobst Compression 50128 Molst Heat X Min 50010 Cold Pack / Ice Massage X Min 50014 WP ®., FX -min 50005 Sterile WP ® _ FX - min 5DO28 PT -114 Hr 50017 PT IndIvId -1 Hr (Aqua) 50126 PT Group Thar - 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec sum 50166 Home Pgm/Famlly Ed 50040 Tens Application 50024 Neuromusc Ra-Ed - 114 Hr 50012 Flukiotherapy 50011 Paraffin Bath SvcOd Deacdotion vc d Description 50118 OT Evol -1/4 Hr 50119 OT Re-Eval -114 Hr 50168 Horne Eval -114 Hr 50029 Wheelchair Eval - 1/4 Hr 50169 Job She Eval -114 Hr 50170 Seating Eva) -114 Hr 50016 ADL -114 Hr 50015 Community Mob Assmt -114 N 50030 Sensortmotor -114 Hr 50020 Cog Retraining -114 Hr 50166 Home PgnVFam%y Ed -114 Hr 50167 Cornmun Re-Integ - 114 Hr 50165 Patient Ed -114 Hr 50125 Group (2.3) -114 Hr 50024 Neuromusc Re-Ed -114 Hr 50164 Neuromusc Stlm -1/4 Hr 50012 Fluidatherapy -114 Hr 50163 Adjustment 50028 OT Indivld -114 Hr 50050 Splint - Simple 50125 OT Group - 114 Hr 50050 Splint - Complex 50011 Paraffin Beth 50112 PT Wrk Readi Eval - 112 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl - 114 Hr 50112 OT Wrk Readl - 114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard - 1 -Hr 50180 OT Wrk Hard - 1 Hr AssESSMENT: STG Current: ?uf M et: Yes/ No LTG Current: old zl??4J` Met: Yes/No Reset: it U I n: Weeks Reset: 47 V in: Weeks ? Patient tolerated treatment well ? Home Exercise Program reviewed ? Tha !Tclsee Program ad cod as per flow sheet a L PLAN: ? Upgrade activities as tolerated /per protocol ? Discharge from Therapy Comment: l " THERAPIST SIGNATURF,,-e? / THERAPY MINUTES: TOTAL UNITS: L_ Ro'&ed M14100 30 Min i 1 " 3v rvk, l r? Cen1Dr Hurd CntryMd Mvcmb 880 862 895 884 Sp Wd LIFE ChmHl HrShy 885 886 888 891 Lebn 921 Care 892 894 Pis ASLAM MUHAMMAO DOB: 02/06/4 DR: AGE. 59 ADMI4 0705106 RM:T516 G ACT: 712546 MRN:204568 Illlllllllll111I111111111111111111111111 ? No new complaints ? Increased/Decreased pain suer last visit ? Patient pain level ® 110 *ON HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP canlor Herd Nwcmb CHARC TICKET 880 882 884 t ASLAM MUHAMMAD SprrMd LIFE phmHl Hrahy Date 885 886 888 891 DOB: 02/06/43 (M) DR: ARMSTRONG AGE: 59 ADMIT: 07/05106 RM: 516 2 - Leon cal care ACT: 712546 MRN:204568 Therapist Rumber 892 894 11111111111111111111111111111111111111 IN CX N/S R/S Rx Expires: DAILY NOTE SUBJECTIVE; ? Unremarkable ? No new complaints ? Increased/Decreased pain after last visit ? Patient pain level ® /10 Patent Reports:) 3 M r. ?? (? ?'Y1 O V _Lr OBJECTIVE: I , r Area Treated: U G Swelling: Ecchymosis: ROM: Strength: Function: Comments: SvcCd Description EMCAd Description 50119 PT Evel -114 Hr 50167 Isoklnelic Test - 112 Hr 50029 Wheelchair Eval -1/4 Hr 50165 Isoklnelic Training - 114 Hr 50077 CS Traction: Static _ Ind _ Ibs on _ Ibs off _ min _ 50130 LS Traction: Prone _ Supine _ Ibs on _ ]be off _ min 50036 Ultrasound Single contipuise _ Wlcm _min 50163 Ultrasound Comb contipulse _ W/cm _min 50035 lontophoresis - 15 Min Q _MA/Min S M L 50037 Phonaphoresis 50013 Jobst Compression 50126 Moist Heat X Min 50010 Cold Pack/ Ice Massage X Min 50014 WP ® _ FX _min 50005 Sterile WP ® _ FX _ min 50028 PT - 1/4 Hr 50017 PT Indivld -1 Hr (Aqua) 50126 PT Group Ther -114 Hr 50172 PT Group -1 Hr (Aqua) 50023 Massage -114 Hr 50164 Progressive Ex - 1/4 Hr 50127 Elec Sum 50166 Home Pgm/Famlly Ed 50040 Tens Application 50024 Neuromusc Re-Ed -114 Hr 50012 Fluldotherapy 50011 Paraffin Bath ARRFRrtMFWT- SvcC Description aygQd 50118 OT Eval -114 Hr 50119 50168 Home Eval -114 Hr 50029 5D169 Job Site Eval -1/4 Hr 50170 50016 ADL -114 Hr 50015 50030 Sensodmotor-1/4Hr 50020 Cog Retraining - 1/4 Hr 50166 50167 Commun Re-Integ -1/4 Hr 50165 50125 Group (2.3) -1/4 Hr 50024 50164 Neuromusc Sum - 114 Hr Description OT Re-Eval - 114 Hr Wheelchair Evai -1/4 Hr Seating Eval -114 Hr Community Mob Assmt -1/4 Hr Home Pgm Fomlly Ed - 114 Hr Patient Ed - 114 Hr Neuromusc Re Ed -1/4 Hr 50012 Fluldotherapy-114 Hr 50163 Adjustment 50028 OT indivld -114 Hr 50050 Splint - Simple 50125 OT Group -114 Hr 50050 Splint - Complex 50011 Paraffin Bath 50112 PT Wrk Readl Eval - 112 Hr 50111 OT Wrk Readl Eval -112 Hr 50113 PT Wrk Readl =114 Hr 50112 OT Wrk Readi -114 Hr 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50174 PT Wrk Hard -1 Hr 50180 OT Wrk Hard -1 Hr STG Current Met: Yes/ No LTG Current set: In: Weeks Reset: Pedant tolerated treatment well ? Home Exercise Program reviewed PLAN: ? Upgrade activities as tolerated /per protocol ? Discharge from Therapy Comment: Z.FPC) THERAPIST SIGNATURE: In: ? The Exercise Program advanced as per now shoal Met: Yes / No Weeks THERAPY MINUTES: , V TOTAL UNITS; - avlae (V xnmo (Clinic Natne) Phone: (Clinic Phone) Fax. (Clinic Fax) N MUHAMMAD ASLAM DOB: 08/07/06 (F) DR: ARMSTRONG, MD AGE: 0 ADMIT: 08/07/06 RM: 501 ACT: 713224 MRN,'204195!! `` (Therapist Natnea I o I ?.?? j n? 0 1 ?. i t9 ?risia[c: LINE REPORT.' g033 RECQ'MMEPD_&TIQN_ _ Based on the results of this Fusictional Baseline Report, we would .recommend the following: (Name) was referred to Hr.AI,TI-fS(XJTH Rehabilitation Canter of(C:linic. Name) The. •patient is a year -,old ma The client's :ury o -urr cm« ? this tune, the s:liertt reports (jam -litTicult_y withrj '("' ?/ _ D \;_-. diiig to the cli tile e crrk 0,;;I ? #t es 'h .. 8c L ? f A.:csuding to the client., rhix work fatly into the "S enta v' `?:?rk: {'Ia i . anon Cate ,a,y ? 'I'l?e a owing phrsscal dernands were noted in this ,: valuation ??Q>vzE';'•R?C Tl?s?l-?N(; ?..? . C:oeflieicat , C:onsistrent .(in of vatrixnce ('%) I Efibrt Lift Aver-age if -S !,, Isometric ?y CWN EN'TS: A 0-200!n cc cient of variation is considered a consistent effort. 'i'he patient was consistent in S out. Of' ? test", DYNAMIC ii..dU NG: POS WZCRANCES: U A+ 0 ?gl1(o 61- ? 4 /n 1 ric"I rx'-> crv , i® HEALTHSOUTHRehab - Century Drive MUHAMMAD ASLAM 920 Century Drive DOB: 08107106 (F) DR: A MSTRONG, MD 1Aecbaricsbur0, PA 17055 AGE: 0 ADMIT: 08/07/O6 RM: 501 Phone 691-3260 Fax 691-5564 ACT: 713224 MRN204195 MEDIDATION/DIAGNOSIS UPDATE I A111111 IUIEr1ICATION I DIAGNQSIS CHANGES Data; 0 No c Skxft n of hemplat Date; Slglwkurn 01 therapist- No Cry .u inn ?•;?;. ? .iu',? tl ::'.;1 Gat H: -----.-------------_._.__.- _-- 0 Ho Change Sig u b" of 4*rapL%t CHANGE OF EMERGENCY CONTACT EML.AQENCY RQNLtiM Name _ peiatSonslr>R: _ Homo Number:. Work Number; Ce?lk.iar.Phanex...... ............ • ... _ . ...... .......... _ .. ..... _ ......... , ... .... . EFFEGTK..0ATF--. RaWse with updpted Plan of Cara or at a minimum of every 30 days- per patlcy ALTHSOUTH Rehab - Century Drive 920 Century Drive; Mechanlcsburg, PA 17055 Phone 691-3260 Fax 691-5564 TELEPHONE LOG DATE C MENT INITIALS r ^ GAO _ 1 ? Data COllwtioll 4. A`en MUHAMMAD ASLAM DOB: 08/07/06 (F) DR: ARMSTRONG, MD AGE: 0 ADMIT: 08/07106 RM: 501 ACT: 713224 MRN:204196 1110011111111 'l'est Ttia}k (f'tmnds of fame) Trial I friui Trial 3 Averago Standani lkviutioo coemaient or Variation' Istmx trio F'e?h ?? ? .? dQ, 7aw t1.0 0.00 IZero Divide Ismetric Pull 0. 0.00 0 ( 1.0 0.00 (Zero Divide Grip Le -A I•land ^- ? +1.0 _ 0.00 !Zero Divide Csrip Right fland _ 0 0.0 0.00 (Zero Divide 0.WK 0.00 000 0.0 0.00 IZero Divide _ _?._. L - --- 001 0.00 000 Ilcro . -- 1. IBS Is Not In - - IIt•S Ix Not In - .1 ,_ ._.?..?_y r++' /? , /1 (..L.... i? - v? ?? ?, ? - ?-fix -? P #?U7He PATIENT INFORMATION! RECORD/HISTOPY ASSESSMENT HE.ALTHSOUTH Rehab - Century Drive 920 CenUY Ddve MU NAM D, ASLAM MD AGE: 0 ADMIT: O a/07/06 RM: 501 ACT: 713224 MRN:204195 ININ"0111 r? • 0 - -- - Cl 0 Single &Uirriocl 0 Wldowod 0 Dimmed Nmrnd of PWWWO .tsrdlrn Hwwoftk phone em s ? ? l ti,..._'kYp ' ' ?NJ a? .? p? Addr* ??{ so - e 1 CRY , f'l offhw ` ,? C ?7 ? 2? i 1 - rI om 1.xM Day Worked ? •- _ w ossa r, Cw?le?eer V?. / t Phone I PAWWWnyooftact v A, I 1 r A; ftdWivrr d* Horne lahorra. k Ph W CW dor PhomAkoper f -? - J ' , M or?s or What it the • *aR brie4p yeas ? iher4!p?'#` ? r _ Q y?c rw. W your oonditlon due to O Auto Aakki N O F Wok +rytay ? Other Date of onset Prior ltierapy for thin oondidorr: ? Inpall"t ? Yes ? No ? HealthSouth FeotAty ? Yes .? No p O Yee O No ? Gather ? Yes ? No if this is a workman's comp k", wiars were yvwr woft Q v4ori the If" ooourrad? If your primary insurance is Medicare and you have suslelnsd an Injury. please describe in detail how and where this inlury occurred Date of Oft: r Age: P Mary Caregver/Suppott System' Known Allergies: Phone: Adverse Reactions to Medications: fi `p t %,_ - - 011 0 is I i 10--_ 1 t DOSAQFIMEQUENCY- DRUG DOSAGE/MEQUENCY DRUG _ ID kllk 1?sa lhar No Cornmerds {Cppp) Canosr Prvwsur+ ? LMW NOW rh'.i o e + DWdrars ?/ Heart 1>Fttrrok Heart owmass r $idrt.f?t+ibtlNna Artlritlri oornskw ont"Poroeis 1"WA UW Tro »ne Jok* Replacement PsYot>arfttb Y Prepnanoy ?' other Major surgical procedure with the last eo days (e.g„ cranlotvmY, IsminectamY)? ? Yes G No list Prior 5urgedealHospiwflzatlon Dates -- PATONT INFOR?IAMIN LI ORDMIS'TORY ASSM MHNT HEAILTHSOUTH Rehab - Century Drive 920 Century Drive PA I'M ss No Cotrimsrtla v Oartena V, 17 POY VMW#D=be 1AMon VOftft Lars or oak, d 9realh ?' { E Fria ? v OOYW 0 nlas4 ? No ?. Yea H ow Mt scti? 00 " dMrticAkdW ? No E3 Vas How Much? ie there anyfl•dttp we need 10 know tact is not wmW an lift imm? If no, Pisces explaln: Patient's Coale For Treatment: p a^ fW? pv? ?( - _ pOh's *x in . 01W for #"* Pam In pediatric prop IM Ill Ww gee ? 1; What ctUldhood diseases has your child had? ? Measles ? Chicken Pox ? Mumps ? Rubella Has your child been exposed to any of these in the past Three weeks? p No ? Yes Explain: Chesil immunizations that are in the process of completion or have been completed for your child: ? TDx 3 ? IPV ? Vadc4Ua ? HapaM B Series ? MMR Peaces provide us whh two people other than yo=O who we wAvorhod to pick up your child hone thorapy and a password for them to usa. We will Pat reieaae.your child to any one else but'rxm you.Nst,here. Phwoe update us with any-chanpsa knmedlsiely. ban" HcntelNkxic.Phau CerYBsaper Phone lame HarttanNork Phone OsM/e"W FUlone (Peasward I0eff 04V 10 cyou mhabilbbon, It is onantW OW you NOW Yom physkAanW Ww wit wd heabn&W and Ow fraaf nanf plan If you mLWcarrcai an #ppak rnen4 please Wormy us ao a xl ad-Pc Obb ao #W we cairn rasdhedu?M your moved appolnarr # ***i Ih9 weals Wk; OMAWSfo wwcinilorl or CarWOOSSOM 24 ftouf3 pvAar b adwdW@d FPPQ#gmsnle; 1* allow us yb u*m your appoirtATier t *w for ofrier pafienkL Ws Am ob4Pfed to record aN conpall6ft a aqd no shoo An your MOW rooord 11 you am covwwd by worker's ocrrpararatkri, we am obNyatsd to nspod sd and OW elbow" *pdMiw* b Ya' w tiar&*" oonfor. ? PaIllwW axwplver unable to oompiels form; 6dortrrallan rrlriwrad and ooaipkKed by therapist. IMti#la { (? ad&A Name of Person Own,"ft Form: \'1n`nfl, *Y•?^-? a IM I 'kkx Data: CUnlc4 Signature/TWOWjtigais Date ClinlrA SWatunarffira ale Date clink* Sigr?atura/iltiftimals ? Date S/ ?? IN-OUN16 920 Century Drive Phone: 717-691-3260 Fax: 717-691-5564 MUHAMMAD ASLAM DOB: OWT106 (F) DR: 4MSTRONG, MD AGE: 0 ADMIT: 08/07/06 RM: 501 ACT; 713224 MRN:204195 Iillilunlllll Name: Muhammad Aslam Th ist: Donna Skotek, OTR/L Employer: Gas, INC. Physician Dr. April Armstrong In'u Date: 10/16'2005 Inswronae: Erie Insurance Eval. Date: 08/07/2006 HS .ID #: T:;X xx 7033 FUNCTIONAL BASELINE REPORT RECOMMENDATIONS: Based on the results of this Functional Baseline Report, we would recommend the following: Work Conditioning/Hardening, 3-5 times per week, in an effort to improve patient's physical and functional capabilities. Mr. Aslam is scheduled to begin his therapy program on Wednesday, 08/09/06, at 1.0 AM. His sessions will continue until his follow-up with his physician on 08/23106. A re-evaluation will be completed with Mr. Aslam prior to this scheduled appointment. Muhammad Aslam was referred to HEALTHSOUTH Rehabilitation Center of 920 Century Drive The patient is a 59 year-old male. The client's injury occurred on 10/16/2005. At this time, the client reports difficulty with "lifting, driving, and bathing". According to the client, the work of a store clerk requires "rising the cash register, stocking shelves, and mopping the floor According to the client, this work falls into the ''Medium' Work Classification Category. The following physical demands were noted in this evaluation: ISOMETRIC TESTING: Lift Average (in lips,) coefficient of Variance (%) Consistent Effort Isometric Push 28 <20% Yes Isometric full NT _ N/A Isometric Grip Streggttk M& 93 <20 Yes Isometric Grip Strength, Left 64 <20% Yes COMMENTS: A 0-20% coefficient of variation is considered a consistent effort. The patient was consistent in 3 out of 3 tests. His RUE grip strength (average of three trials) fails within the norm for his age and sex, as the RUE norm equals 68-120 pounds. His LUE. grip strength (average of diree trials) also falls within the norm for his age and sex, as the LUE norm equals 61-112 pounds. His I_,UE grip strength; however, is at the lower end of the norm. A gross musculoskeletal evaluation revealed the following LUE AROM measurements: left shoulder flexion 95 deg. left shoulder extension 35 deg. left shoulder abduction 61; deg. (thumb up); 80 deg. (palm down) MU HAMM) A DdRASRLAM MD AGE: 0 ADMIT: 0$!07/06 RM: 501 ACT: 713224 MRN:204195 left shoulder IR 60 deg, left shoulder ER 60 deg. All left elbow, forearm, wrist, and digit AROM found to be WNL throughout. NflAIT left shoulder as follows: flexion 3/5, extension 3-x-/5, abduction 2+/5, IR 3/5, and ER 3/5; elbow, forearm, and wrist grossly 3+ to 4/5, RUE AROM found to be WNL throughout, witlt 5/5 strength throughout, Patient reports his current/best pain rating to be 0 out of 10, "without movement", He further reported his worst pain rating at 4-5 out of 10, "with movement". lie described his primary symptoms as "a sharp pain when I move it any way" DYNAMIC LIFTING: Maob9t..+tted MS.) 36b 94quir..emeid C1410-04.) Adequate for. Job Ftoerto-Vl? ' #. 20 50 No I{nuttk161?=Io- .' r 15 40 No Stioullkr=..to . , d 15 30 No 100 ft. cg:. W" mot 20 25 No His current maximum, occasional capabilities place him into the LIGHT work classification category, according to the U.S. Dept. of Labor Standards. Data Collection Test Trials (Pounds of Force) Taal I Trial2 Trial3 Average Standard Deviation Coefficient of Variation' etric Push 33.00 22.00 29 0.0 0.00 lZere Divide etric Pull l 0.00 0.00 0 00 0.0 0.00 tZero Divide Lett Hand c i 62.00 6300 66.00 0.0 0.00 !Zero Divide Right Hand a 94.00 92 00 94.00 0.0 0.00 IZero Divide 0.00 0.00 0.00 0.0 0.00 IZero Divide 0.00 0.00 0.00 1Zero 118 Is Not In !n Is Not In 2- Dorina Skotek, OTR/L Occupational Therapist TELEPHONE LOG 7 DATE CON YMNTS INITIALS 77?'7 all-7 0-rk k) ,?.., s ; i r E----- _ ?_- Ao /7 -- L - - _ -. Q6 , e0o Ao - ONs MU HAMMAD ASRLoAM MD AGE: 0 ADMIT: 08107!06 RM: 501 ACT: 713224 MRN:204195 INIIIII I IIIIIIII t t..t14ty v C wi ft, 9 w paver `o Nem.: m v SVALtlOMON AND ` WM0 PRl3CEOUFM _...._.. Consult AC*AOO 01 Daily Lh" "ustion C4rdWc paw Cyr Goniometry1ROMl JOBST M"Bumm", Manuel mu sew Test Soht ? Suft -- DPW""-- 00wr Adn"Gion Do": t Age: ouvoomit i Phorw. ,.3 FtX Pr QOOW- - Gait Twin" Full ? l To 1. 0 31 prow Flom MQDAI.MES _ Pastur+ Cold Pass -- Pre-pt+ Carttrast Baths iJb mw" ?- 'o , Hyam, LOW VOW, 1360020M ISM Hot ho t - we Mam"9a Pomt i?n 'TraCWn OWKI W P *40 UltmooUnd Uhmgiolowcdd ouartt WMripuol ether ,rg , Try EvaO* t*m gtxnc+tatlm?% Nvas: vo4t c ?ic *Vmu*1111 Yve 7ift Taw httfaN dwr Sidils Other C71+ woo: C n t'n d PT 1 {6180) ""'p}'iySWAL THir??PY ?? "dld 1 X11 lf'j4 t C I stn t r~ nt rt r . + + + Mg HALM U?AbLoAN M MD AGE: 0 ADMIT: 0&07/06 W 501 ACT: 713224 MRN:204195 MmMiN11N1l11 ?n otgv M 1.11. tlln )104 AUG-09-2006 WED 06:00 PM HMP-"PORTS MEDICINE 08/87/2006 :18;39 717-691-5554 HEr'?LTHSOUTHMCaee? N" 920 Cmtwy Drive Mwbwnic 0mM PA 17035 Phew - 717-691-3?. ffsx - 717-.691.5364 MUHAMMADASLAM ARMSTRONG, MD AGE: 0 ADMIT: 08107106 RM: 501 ACT: 713224 MRN:204195 11111-millillmill now PON" 46 ?-M ?IS.tt pta? W ,'? o ,.5?'" ? n?'c.?s f Fee- A&, some", x4z- is5- Tom Gows: b / /(io r 1-0 di it 162 -6 w Tam Goilim Vltit a DaAtyt to Axhlr t: t 6k% An AJV 4)Pd.A, a Jul IF. I AN L 9t~" Fp*W god* 44 mThempist 9fpatum /-7 Da Pats tuxe Date P'h ' i"tuft Date Phyaklan Rec datigm, 920 c'm"y a2 Alrcfmm?ct>iwyF Wit 170 1s cpfio r??-?sr r?o _ rr?•??? t? FAX NO, 717 -7-)l 4640 P. 05 H5 CENTLPY IJRIVE PAGE 94104 MU HAM MA D?ASRLAM AGE: 0 ADMIT: 0 07/06 RM: 501 ' ACT: 713224.. MRN:204196II Patient:` HS File #: Physician Insurance: Dlagnosl Onset Date: Employer: Occupation: Therapy Start Date: ( O Sessions Completed to Date: Medication: ' 0--ro 'a -a d Subjective Re of P lent; rr AA A40 A V A, Treatment: r r 0 ? ? 7 /Il HealthSouth Fadflbr Therapl?t: ?- L ate: lY i!J V W?(?lild '' Heaitnsouth Rehab Center 920 Century 0'r.. Mechanicsbur 9 PA 17055 M U HAMMAD AS LAM 7 DOB: 08/07/06 (F) DR: ARMSTRONG, MD AGE: 0 ADMIT: 08/07/06 RM: 501 ACT: 713224 MRN:204195 ?? wc? /pw ti.10 Sf?tw ewG 1 w w?(O djo `? ouw 3; a3 ?p 17, fn 0 ?ro Rte) a?(?w? M oe L . o?rw r ?2 ?, Ff Heaii,Esouth Rehab Center 920 Century Or. Mechanicsburg, PA 17055 -.- D ? o 0 iq 7(7 MUHA MM A D?RASRLoANM AGE; 0 ADMIT: 08/07/06 RM: 501 ACT: 713224 MRN:204195 1 1ION11-N1N1111 Reha #bn C.enter-CenturyDnve MUHAMM))AU ASLAM DOB: 0 A8/07108 (F R: DMM Og107/06 RM: 601 MD ACT: 713224 MRN:204185 I INIININIIII PATIENT'S NAME: 61 ll?? ff., PATIENT'S I.D. N4.: rf( 3 y) 11 t DATE: oC ??/(off Dear Dr, I Discharge Summary was last seen #t H thSouth CentmY Drive Center for physical therapy/occupational therapy on At that time. the treatment consisted of ' -'I.-. ) and has, therefore; b ischarged from physical therapy/occupational therapy Thank you for the referral of this patient. Sincerely., 920 Century Drive , Mechanicsburg, PA 17055 • 717 691-3260 Failed to show up for further scheduled appointments ? ?2 Called to cancel further appointments Failed to schedule further appointments OUTPATIENT WORKERS' COMP SjE TI T O`C! ? `1 _( TheraplttNumber CX Rx Expire;: HWd GUyhra NWCmb n P 880 882 895 884 spew ufE Hnhy 885 888 861 N/S __Zr R/S DAILY NOTE UMLMCTNL 0 Unrornr•rkable Patient Reports: Area Trawled: ROM: Strarmth: Funotlon: Comments: kn&g 3voCd DwQdcdm IMPA AV= D"CrIVII 501 19 PT Eval - 1 /4 Hr 50167 Isokkhebc Teat - 112 Hr 50116 OT Eval -114 Hr 50119 OT Re-Evel - 114 Hr 50029 Wheelchair Evai - 1/4 Hr 50185 IsotchhaUc Training - 114 Hr 50168 Home Eval - 114 Hr 50029 Wheelchair Evel -1/4 Hr 50077 Cs Traction: Static i IN on ` be or ,-_ min 50169 Job She Eval -114 Hr 50170 Seating Evel - 1 /4 Hr 50130 L5 Traction: Prons _ Supine , on _ Ibs off- mot , 50016 AOL - V4 Ht 50015 Community Mob Asamt - 114 Hr 50036 UthuK red singe conllputas _ w - _min 50030 Sanwrtnwtnr -114 Hr 50163 Ultrasound Coft cons wu _ ,mm 50020 Cog Relrakhing -114 Hr 50166 Horns Pgm/Family Ed -114 Hr 50035 lortlop wrews. - f5 Min a _ MA/Mln M L 50167 Conmun Re-tnteg - 114 Hr 50165 PadaM Ed -114 Hr 50037 Phonoptwesls 50013 I Jobst Compression 50125 Group (2-3) -1/4 Hr 50024 Nomomwo Ra-Ed -114 Hr 50128 _ Moist Hest X Min 50164 Neuromusc Slim - 114 Hr 50010 Cold Pack 1 los Massage X , Min 50012 FluldnMl4apy - 114 Hr 50163 AdluatmW 50014 WP Q _ FX _min i 50028 OT individ - 114 Hr 50050 SPI(rd - Simple 50005 Stadia WP FX _ min 50125 OT Group - 1/4 Hr 50050 Splint - Complex 50028 PT - 114 Hr 50017 PT Individ - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thor - 114 Hr 50172 PT Group- 1 50023 Massage - 114 Hr 50112 PT Wrk Rsadi Ev*I-1/2 Hr 50111 OT Wrk Readl Eval - 112 Hr 50164 _ Pmgnsaalve Ex - 1/4 Hr 50127 Elec Slim 50113 PT Wrk Raadi - 1/4 Hr 50112 OT Wrk RaWl - 1/4 Hr 50166 Horne Pgrn/Family Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Neusomux Re-Ed - 114 Hr 50012 ofp6rapy Fluki 50174 PT Wrk Hid - 1 Hr 50180 OT Wrk Hard - 1 Hr 50011 Paraffin Bath / NV STG Current: Met Yes I No LTG Curtnrd: Met: Yes I No Reset: In: Weeks Reset: In: Weeks ? Patianl tolarated treahnent wall 0 Home ExwrcUe Program rwAewod ? The Exercise Program advanced as per flow slheel ? Upgrade act lper ocoF 0 Discharge h'om Therapy Comment: THERAPIST SIGNATURE: THERAPY MINlJTES?? TOTAL UNIT ? No new complaints ? Increaaed/?acreassd pain after last visit MU HAMM A Dd ASRIAM o ACHE: 0 ADMIT: 08/07/06 RM: 501 ACT: 713224 MRN:204195 INNOW1111111I1 ? Patient pain level Q l10 Ecchyrnosis: HE44THSOVrH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP cw. CHA GE TIC 880 T a sr.wd sea ? •rI Tllerspist Number GX NIS ,Z R/S Rx Expires: Heed Gn"w Mrcevr I 882 BOB Su 1 uFE Hanby 888 891 DAILY NOTE sunizame ? Unrernarkabie Patient Reports: ? No new oomplelnta ? Ines wWoeoressed pain aRer last vtan MUHA#MMAD ASLAM ppg; 08!07106 (F) DR: ARMSTRONG. MD AGE: 0 ADMIT: 08107106 RM: 501 ACT: 713224 MaIuN d Paliant pain level a 110 A Area Treated: - y ROM: Strongth: Function: _ Comments: ` Ecdwmoai?fr 94 4 wed 212& pawAtift lmg? p2gaption `3yQd Dwown 50119 PT Eva( - 114 Hr 50157 laokinatic Tsar - 112 r ir 50118 OT Evel - 114 Hr 50119 OT Re-Eval - 114 Hr 50029 WhaetctWr Eve( - 114 Hr 50165 Isokinetic Training - 114 Hr 50188 Homo Eval -114 Hr 50029 Whaelchalr Eval - 114 Hr 50077 CS Traction: Sink_ Int _ be on _ Ibs off _, min 50169 Job Site Eval - 114 Hr 50170 Sealing Eval -114 Hr 50130 LS Traction: Prone `Supine _„-- lba an - ba off - min 50016 AOL - 114 Hr 50015 Cormmnlty Mob Assrnt -114 Hr 50036 _ tllbaaound Skw4 oantipul" ----Wlcm _rNn 50030 Sw*Wrnotw -114 Hr 50163 Ubuaxrd Comb oonupWaa Wkm 50020 Cog RatralMng • 114 Hr 50166 Home Pgrnll amlly Ed -114 Hr 50035 lalbphoreais -15 Min 9 __ _MAIMln S M L 50167 Carat= Ra-kaag -114 Hr 50165 Patient Ed - U4 Hr 50037 Ptwrwptbrssfs 50013 Jobst Compression 50125 Group (2-3) -114 Hr 50024 Neuromuse Re-Ed - 114 Hr 50128 Moist Hew x Min 50164 Nelaorrtusa Stim -114 HT 50010 Cold Pack / Ice Msssep X ! Min 50012 Fiuldodwspy - 114 Hr 50163 Adoximeni 50014 WP Q _ FX _min 50028 OT Irafivid -114 Hr 50050 Splint - Simple 50005 Stadia WP a _ FX „ min 50125 OT Group - 114 Hr 50050 Splint - Compiax 50028 PT - 114 Hr 50017 PT Indivki - 1 Hr ( ) 50011 Pasaftkl astir 50126 PT Group Thor - 1141-r - --- ? 501 T2 _ PT Group -1 Hr ( ) 50023 Massage - 114 Hr 50112 PT Wrk RaWl Eval - 112 Hr 50111 OT Wrk Reedl Eval - UZ Hr 50164 Progres0a Ex - 114 Hr 50127 Eiec Stint 50113 PT Wrk Read) . 1l4 Hr 50112 OT Wrk Read( - 114 Hr 50186 Horne PgrrdFamlty Ed 50040 Tarn ApplWOlon 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hra 50024 Neuromusc Rs-Ed -114 Hr 50012 Fluldotllsrapy 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Paraffin Both I STG Current: Reset: ? Patient toweled treatrrwrrt well PIA& ? Upgnadepativifeel„ THERAPIST Met: Yes (NOV LTG Currant. In: Welker Reset: ? Home Ewndw Program rsvlswed 1 ? Dt owye from Therapy C _l 7 Metz Yes I No W ) ?D HEAL7HSOU7H Rehab of McOMOn sW OUTPATIENT WOR RS' COMP CUAROETICIRET L.? 0 77arooW /Number CX NIS R/S Rx Expires: _ Harrel Cn&yMd Mw,00 882 895 884 SpWd UVE want' 885 886 891 DAILY NOTE a tJnrentt.rluf><e .?r]-' - n No Patient Reports: 1 r + ?? Arse Traded: ROM: Strength: Functlw: Commar ks: 0 Patient pe awl 1 /10 Ecdwnm r %1:999 Doacrivillon b cQ V DescriOllon ftu M=Ion $Y9.GS1 Descrioll 50119 PT Ewi -114 Hr 50167 lookktatic Ted - 112 Hr 50118 OT Eval • 1/4 Hr 50119 OT Re-Evel -114 Hr 50029 Wheeidwtr Eval -11411, 50185 lookindic Training - 114 Hr 50188 Home Eval -1/4 Hr 50029 Whesldwir Eval -114 Hr 50077 CS Traction: Static ! 'ru _ ms on _ lbs err _ min i 50189 Job Slh Eval -1 /4 Hr 50170 Seating Eval -1 /4 Hr 50130 LS TrWAOM: Prom ____ Supine _ IDs nn _ be off _ min - 5001E AOL • 1 /4 Hr 50015 Communtty Mob Assml -114 Hr 50036 Ultrasound SWgM eorp Wkw - _Wlr+n - _mm 50030 5erworlmotor - 114 Hr 50163 1.111swurd comtr corlt PA" _Wkm _min 50020 Cog Retraining - 114 Hr 60166 Home Pgm/Famlly Ed - 114 Hr 50035 _ iw tophoraala - 15 Min * _NIAIMIn S M L 50167 Common Re-IMag - 1/4 Hr 50165 Pubent Ed - 1/4 Hr 50037 a 50013 Jobat Gompraesbn 50125 Group (2.3) - 1/4 Hr 50024 Nerrumm Re-Ed - 114 Hr 50128 X In " 50164 Ndromuec stm - 114 Hr 50163 50010 oq Maalag0 X. In 50012 f )uMdtrarapy -114 Hr ?7 _Adjustment 50014 WP a _ FX __M n 50028 Y70T individ - 1M Hr 50050 Splint - Simple 50005 'senile WP 12 _ FX __min 50125 07 Grab -114 Hr 50050 Splird - Complex 50028 PT - 1/4 Hr 50017 PT Indivld - 1 Hr (Aqua) 50011 Pwaf9rt Batt 50126 PT Group Thar - 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 1/4 Hr 50112 PT Wrk Reads Eval - 112 Hr 50111 OT Wrk Reads Evel -112 Hr 50184 "reaalve Ex - 114 Hr 50127 Elec Stlm 50113 PT Wrtc Readl - 114 Hr 50112 OT W rk Reath -114 Hr 50166 Home PgmlFamlly Ed 50040 Tens ApplicAdon 50173 PT FCE - 2 Km 50179 OT FCE - 2 Hre 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldofherepy 50174 PT Wrt Hard - 1 Hr 50180 OT Wrk Hard -1 Hr 50011 Pwamn Beth AlaxwMaff; STG Current: Met. Yes I No LTG Current Roast _ In: _ Weskp Reset; ?lilc Palled tot well 0 Home Ex erolse Program reviewed PLOW, ? Upgrad /$aas towf aw /per from Therapy Commient: THERAPIST SIGNATURE: I / I/ Ut f? L/[ ICJ V i ' V L/l?\ d MU HAMM A D?ASRLoAN M B MD AGE: 0 ADMIT: 08/07/08 RM: 501 ACT: 713224 MRN:204195 11 I 1 IMIN 111111 Islet Swelling Met; You I No 1n: Weeks i? D The Exercise Prop advencod as per flow T( BIAPY MINUTES: WL.4-- 9 Ai 1TOTAL UNITW, ._.i _., HEAL7HSOUTH Rehab of Mechanicsburg I OUTPATIENT WORKERS' COMP , ,Cw H&W cnsyw mvcrro CHARGE' TICKET Lvv/ e80 882 896 884 < U A spftw UPE Hr ny 086 885 886 891 Thwvp& Number Cy: N/S R/S Rx Expires,: DAILY NOTE ??Unreernarltabls D No now complaints, 13 1 Patient Reports: ll \/f? ,(,.( I(At g&Q ill .W-4 L ? 0- i /1 f f . Area Treated: ROM: St th renp : Function: Corrmanla: .7 M U M/ABM MAD U ASRL o M D AGE: 0 ADMIT: 0 /07/06 RM: 501 ACT: 713224 MRN:2D4195 f???NIN?NI?I? agar last t ? .dark pain level - 10 Ec? -If 7_11 &V9149 QualoWn %Sc A Ducrictlon ay= DaKepliall 91119 PT Eval -114 Hr 50167 lsokkrouc Test - 112 Hr 50118 OT Eval - 114 Hr 50029 V woftelr Eval - 1/4 Hr 50165 looldnellc Training -114 Hr 50168 Home Eval - 1/4 Hr 50077 CS Traalon: Staao _ Int __- ,-- Ibs on _ los off _ rotn ____ 50169 Job SM Eval - 114 Hr 50130 LS Traetion: Promo _ Supine _ be on _- Ibs of(- min 50016 ADL - 114 Hr 50036 Ultrasound Single corwpulse _ Wkm -min 50030 9ansorimotor - 1/4 Hr 50163 Ultrasound Comb cerdrpube _ Wlcm _MIn 50020 Cog Retraining - 114 Hr 50035 lonropharasis -15 Min a _ MA/MM S M L 50167 Co inun Re-Integ - 1/4 Hr 50037 Ptwtwphor ems 50013 Jobat Compretalon 50125 Group (2-3) -1/4 Hr 5C1128 X Min J 50164 Netaomusc Stun - 114 Hr 50010 CoW P ! irxs Msaspte X Min . 2 Flukk*wropy -'114 Hr 50014 _ FX _min ~ 1 .. 28 OT Individ 1l4 Hr 50005 Sterile WP a _ FX - min 50125 OT Group - 114 Hr 50028 PT - 1/4 Hr 50017 PT IndMd - 1 Hr (Aqua) 50011 Paraffin Bath 50126 PT Group Thor - 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 Massage - 114 Hr 50112 PT Wrk Read) Eval -112 Hr 50111 50164 Progrssslva Ex -114 Hr 50127 Eiec Stun 50113 PT Wrk Readl - 114 Hr 50112 50166 Homs PgnlFamlly Ed 50040 Tens Application 50173 PT FCE - 2 Hrs 50179 50024 Noman uac Re-Ed -114 Hr 50012 Fluldottlarapy 50174 PT Wrk Hard - 1 Hr 50180 50011 Peraft Bath Adjustment u SpIlrd - 51mp? /.1 D Splint - C OT Wrk Readl Evel - 112 Hr OT Wnc Read) - 114 Hr !OT FCE - 2 Mrs 6T Wrk Hard -1 Hr T6 Curterd: ?L Y lE® ( Met: Yes I No Raeat: In Weeks Revert— In: Weeks ?••pa?aam toknftd trsuun well ? Home Exercise Program nsviawed The Exorcise P fam advar"d an per sh T v 1}} Upg?lliiie s as taersned I I 7 echarge from Therapy- Cormbnt: A- ,f 0 3 THERAPIST SIGNATURE: THE PY MINUTES: OTAL UNITS: Q l? L 1 §%Q Destrlotlon ?.. 50119 OT Re-Eval - 114 HrHr 50029 Wheelchair Eval - Id Hr-l W 50170 Sealing Eval -114 Hr 5D015 Comaw lty Mob Asumt - 1/4 Hr '- AQoMly ? - 5D166 4- Home Pgm/1 emily Ed 114 50165 Patient Ed -114 Hr Y 50024 Nsummusc Ra-Ed ? 1 HH fl 50163 50050 50050 HE4LTHSDUTH Rehab of Mechanicab OUTPATIENT WORKERS' COMP ;/A7G4? I C K T AIV. Number Cx Rx Expires: DALY NOTE 0 Unremarkable Pnowd Reports: Area Treated: ROM: StrwVih: Function: Commords: ?j/" Ca.. HuW CaeyMd NwCmb (T 880 882 896 884 spruw UFe *MY 885 886 891 N/S R/S ? No new complaints t Ecchyntosis: J-P4 2TVA Deawlyt14n 1199d DMICIllobw 160 D*Kd ISO Desixivilon 50119 PT Eval - 1/4 Hr 50167 laakkutlc Teat- 112 Hr OT Eval -114 Hr 50116{ 50119 OT Re-Eva[ - 114 Hr 50029 Wheelchair Eval - 114 Hr 50166 lsokhWic TrakNng - 114 Hr S 501681_ Home Eval -114 Hr 50029 Wheelchair Eval -114 Hr 50077 CS Traction Stebc _ Int„ be on - i„ Ios M-_ min _. 501691 Job Sits Evat - 114 Hr 50170 Sealing Evel - 114 Hr 50130 is Trectlon Prone _ Supke T be on _ 10s oR _, min 50018 AOL - 114 Hr 50015 Community Mob Aunt - 114 Hr 50036 Ultrasermd skoe own ipww _Wran - -"In 50030 1 senaotimoW -114 Hr 50163 _ tNkawtvvl Corm conuaxase ,Wien ?mk 50020 Cog Ratraktltlg -114 Hr 50166 Home PgnVFamUy Ed - 114 Hr 50035 I0ft0 Drams - 15 Min 6 ^ MANin S M L 50167 Convraul Re-irltrag -114 Hr 50165 Patient Ed - 114 Hr 50037 Phorloptwresla 50013 Jobst Cornprexalon 50125 --ii?- -- Group (23) - 114 Hr 50024 Neutomuac Re-Ed - 114 Hr 50128 Moist Heal X Min 50164 i_l Ne rarrum Stim - 114 Hr 50010 Cold Pack I Ica Mossape x Min 50012 1 Fitddaeaerapy, - 114 Hr 50183 Ad)ualmem 50014 WP _ FX min 50028 l OT IndIvId - 114 Hr 50050 Splitt - Simple 50005 Sterile WP 0 _ FX T min 50125 OT Group - 114 Hr 50050 Spltm - complex 50028 PT - 114 Hr 50017 PT Indtvid - 1 Hr (Aqua) 50011 Pars" Bath 50126 PT Group Thor - 1/4 Hr 50172 PT Group - 1 Hr (Aqua) _ 50023 Message - 114 Hr 50112 PT Wrb Ream Eval -1/2 Hr 50111 OT Wrk Readl Eval - 112 Hr 50184 Progressive Ex - 114 Hr 50127 Elec Slim 50113 PT Wrk Readi - 114 Hr 50112 OT Wrk Read[ - 114 Hr 5066 Home PgmlFamky Ed 50040 Tens Application 50173 PT FCE - 2 Mrs 50179 OT FCE - 2 Mrs 50024 Neuromusc Re-Ed - 114 Hr 50012 Fluldolherapy 50174 Wrk Hard - I Hr 50160 OT Wrk Hard -1 Hr 50011 paraffin Bw V ST13 Current: Met: Yes I No LTG Curren. Met: Yes r W Raaet: In: Weeks React: In: Weeks ? Pa6am tolerated treatfnam won T ? Hone Exercise Program reviewe d [3 The Exefdse Program advanced an per flow street P ? Upgrade artivilI a 7t, I 0 Olachaw from Therapy Comment: i THERAPY MINUTE9?? TOT S' THERAPIST SIGNATURE: i 0 ? Inc eased/Oecxeased pain agar tact vlah MgUHAMM) A D, ASLAM MD AGE: 0 ADMIT: 08/07/06 ARMSTRONG, 501 ACT:713224 MRN:204195 I{OIIIMN IIIIIIIU O PaUavt pain level Q 110 OUTPATIENT WORKERS' COMP rl??o0 CHAR E T1C ET l//? lJq/a ' 885 Tba Number CM NIS RIS Rx Expitwa: Hand Cr*yAld NwCmb 682 896 8114 UPI! Hranr 886 891 DALY MOTE MAIMM, ? Umrmwkabie jJ ? No nmv Patient Reportt: II (/•{1?6•_ 4 . Area Treated: ROM: 3trart ft Function: Comments: IMU HAM A D?ASLAM D AGE: 0 ADMIT: 2107/06 RM: 501 ACT: 713224 MRN:204196 last ri}ti ? Patient el a BY20 Desadullon SVCCA DMIM&AW 2&Q9 Dewhation 50119 PT Eval - 114 Hr 50167 ItoklnMic Test - 112 Hr 50118 ' OT Eval - 114 Hr 50029 Wheelchair Eval -114 Hr 50165 Isokktetic Training - 114 Hr 50168 Home Eval - 114 Hr 50077 CS Traction: static ___. int - Its on _ Rm cif _ Mn , 50169 Job Site Eval • 1/4 Hr 50130 LS Traction: Prons - Supine ` lbs on _ lbr off _ min r_ 50016 ADL -114 Hr 50)36 Ufaasourd Slnpe convpulss _Wkxn _nan 50030 Senscrimokor .114 Hr 50163 Ultrasound Caro cw*fpubs __W/an ^ min 50020 Coq RMralning -1/4 W 50035 iartophor"s - 15 Min 6 _,MAIMIn S M. L 50167 Comntun Re-lift - V4 Hr 50037 Is 50013 Jobst Compresslon 50125 Group (2-3) - 114 Hr 50128 at Heat Min 1 ? 50154 0 2 Ne romuac Stim -114 Hr l4 50010 MJ6 (x ,,L/1/ Cold P_ Ire Massage X 1 v6Q Flukk%harapy - 1 Hr 50014 _ FX ____min 50028 OT Individ - 114 Hr 50005 Sterile WP Q FX -min 50125 OT Group - 114 Hr 50028 PT - 114 Hr 50017 PT tndWd 1 Hr (Aqua) 50011 Per:ABn Bath 50126 p q 4 Hr PT Group 1Aer - 1 50023 Massage -114 Hr 50112 PT Wrk Reodl Eval -112 Hr 50111 OT Wrk Readl Eval -112 Hr 501164 Progressive Ex -1/4 Hr 50127 Elac Stem 50113 PT W* Raadl - 1/4 Hr 50112 OT Wrk RaWi - i14 Hr 50166 Home PgrrVFamily Ed 50040 Tama Application 50173 PT FCE - 2 Hrs 50179 OT FCE - 2 Hrs 50024 Nerxomusc Re-Ed - 1/4 Hr 50012 FlUdOVWWY 50174 PT Wrk Hard -1 Hr 50160 OT Wrk Had -.1 Hr 50011 Paraft Bath _ - 1 Hr (A ua) 50172 P7 Grou ! STG Curtest: ReaM: Patient tolerated usabnerd well Fes'' A Upgrade aalvM ea as tolerate THERAPIST SIGNATURE: Mat. Yea I No LTG Crxrent: l• Q Mot: Yes / No In: Weeks Reset: In: Weeks ? Home ExwcLse Program reviewed /IX ThgErrordae Program advanced as per tow sh w dam,. 1?j ?0 .mod DoKfi 50119 OT Re-Eval - 114 Hr 50029 Wheeldwir Eva[ - 114 Hr 50170 Seagng Eval- 1/4 Hr 50015 Comrnwky Mob Aurnt -1/4 Hr 50166 Home PgmlFamlly Ed - 114 Hr 50165 Patient Ed -114 Hr 50024 Nawomusc Re-Ed -1/4 Hr 50163 Ad)wtment 50050 Splint - Simple 50050 Spiwd - Compbx HEALTHSOUTH Rehab of Mechanicsburg OUTPATIENT WORKERS' COMP ?y CHAR E T CKE The oW Number CX WS Rx: Expires: DAILY NOTE M Unremarkable Patient Reports: _ Area Treated: ROM: Strength: Function: comiments: Av2Qd 8VQQg DacmAlon 50119 PT Eval - 114 Hr 50167 lookinalk Test - 112 Hr 50029 Wtaalchelr Eval - 114 Hr 50155 Isokinatic TraWng - 1/4 Hr 50077 CS Traction: Static _ IM ` Ibs on _ Ibs off _ min _ 50130, LS Traction: Prom _ Supine _ be on ` Ibs off min 50036 Ultrasound 51046 -WW- _W/an _min 50163 Ultrasound Comb eawpuw _Wkm _min 50035 knophoreala-15 Min 0__ __"Min S M L 50037 Ptlorwphoresla 50013 Jobst ComprasNai 50128 Molst Heat x Min 50010 Cold Pack 1 ice Message X Min 50014 WP 0 - FX _min 50005 Sterne WP a- Fx _ min 50028 PT - 1/4 Hr 50017 PT IndIvId - 1 Hr (Aqua) 50126 PT Group Thar - 114 Hr 50172 PT Group - 1 Hr (Aqua) 50023 maw"e - 1/4 Hr 50164 Progressive Ex -114 Hr 50127 Else Stim 50166 Home Pgm/Famlly Ed 50040 Tens Apptioatlon 50024 Neuromusc Re-Ed - 1/4 Hr 50012 Muidotherapy 50011 Paraffin Bath STG Currerd: Reset: ? Patient tolerated tromunert well In: PLW ? UpgMda ,a/s?toW*od /per THERAPIST SIGNATURE: f f/ f % KJt'/?k Pis L ? No raw complaints qr.. "2nd CebyMd MMCGM 880 882 895 884 spraw uce Nnhy 885 886 881 / M U HAMMAD AS LAM a s l DOB: 08/07106 (F? DR. "STRONG, MD rI AGE: 0 ADMIT: Org/07/06 RM: 501 ACT: 713224 MRN:204195 I111UNIIININIII ? IrrvaessdlDerxeassd pain after last visit O Pahww pain level a '?2 110 - z1 _ ? '/ / /7 Svvetlln f ? ? E?o? - BY= Dacdotim 50118 OT Eva( -114 Hr 50168 Home Eval - 114 Hr 50169 Job Ske Eval - 114 Hr 50016 ADL -114 Hr 50030 Sansorimotor - 114 Hr 50020 Cog Rehalnkp -114 Hr 50167 Commas Re-Intag - 114 Hr 50125 Group (2-3) - 114 Hr 50164 Nauromuac Stlm -1/4 Hr 50012 Ffuidotherapy - 1/4 Hr 50028 OT Indivld -114 Hr 50125 OT Group - 1 /4 Hr 50011 Paramn Bath $1tsf4 j7escrtutiyq 50119 OT Ra-Eval - 114 Hr 50029 Wheelchair Eval -114 Hr 50170 Seating Eva) - 114 Hr 50015 Community Mob Assort -114 Hr 50185 Home Pgm/Fanrlly Ed -114 Hr 50165 Patlard Ed -114 Hr 50024 Neummusc Re-Ed -114 Hr 50163 Adjustment 50050 Spllyd - Simple 50050 Splint - Complex 50112 PT Wrk Readi Eval - 112 Hr 50111 OT Wrk Raadl Eval - 112 Hr 50113 PT Wrk Readl - 114 Hr 50112 OT Wrk Readl - 1/4 Hr 50173 PT FCE - 2 Mrs 50179 OT FCE - 2 Mrs 50174 PT Wrk Hard - 1 Hr 50180 OT Wrk Hard - 1 Hr Met: Yea 1 No LTG Current: Met: You / No Weeps Reset: In: Weeks xne E eroiae Program reviewed ? The Exercise Program advanced as per now sheet O.,'Dwd-W fromTharnpy Command: ERAPY MINUTES: TOTAL LINR M?'`DA?'o M° pp8'. ?Q?OR 95 : 5?1 AGF-: 0 AD pdRN:2? cl? 13724 I I ? ? ;III, t I ,, G } ? of ? •; •. I I •?- •? • ? ' I ? ?I o'? ? ? ??; ;' I , it •, ? c L V 11 II G m ?' ? I , t ? . ca III ? II .. , © U ?- ' 1 } I I ; tli ' , ! I f 4 I I I I I '; o ` w ? I ct? ?, ? ? ? z I I ? 1 1 ?, Ul C, J , }-- , ,- MUHAMMAD ASLAM DOB: 08107106 (F) DR: ,?RMSTRONG, MD AGE: 0 ADMIT: 0$107106 RM: 501 ACT: 713224 MRN:204195 W III r?t1 ? r m w cn cr- w w Q c cr- i. 4 w c-- © w o Z w i C fl w. w Q O c m U1 J a w o c ua a r- ua r- s- -' co ~ CI ??1 1318 W?tf)?8C1 0 14E= NAME. .___ -- MUHAMMADj,.,!SLAM AGE: DOB: 08/07/06ApMIT:(F08/07/06pR: /?RMSTRONG, MD 0 RM: 501 ACT; 713224 MAN:204195 PROGRAM WEEK` ACTIVITIES DATE ,,Y DATE: Y DATE: Y DATE: IRMWY DATE: Ll? .4 1 '44-0 [a 3 --- - - -- ....__........_. _. _._.... + -- -..._._.._.. S l© _--/?- _._-..... A -- --- 1 l x .? TIME _ -9 OF CIRCUITS PERFORMED ,, BODY MECHAI\JICS COMMENTS Health south Rehabilitation of " %chanicsburg 175 Lancaster Blvd Mechanicsburg,:Pa 17055 PAIN CLINIC 'Discharge Instructions The ysician performed the following procedure on you today: -Epidural Steroid Injection ,Lumbar / Cervical Discogram -Facet Joint Injection(s) _Spina( Card 5tim Trial ^5I Joint Injection(s) _IDET ,Trigger Point Injections ,Shoulder Injection Other General Instructions Resume Medications as directed by your J,amily physician. -Call your family physician for problems not related to today's procedure. Act V No strenuous, cTvi y for 24 hours. -Use armfs} / leg(s)jautiously.until numbness or unusua{ a ions subside. Normal diet as tolerated. -.Liquid diet for hours then `progress to normal diet as tolerated. Drink extra fluids. Comfort Measures ?'-A ply ice to the injection site, if desired. L Do not apply heat until tomorrow. IF USING HEAT OR ICE ;_AP-??.LY=2IN ON 20 MIN OFF. DO NOT USE EITHER CONTINUOUSLY). ?? Resume pain meds as needed. Sedation: "ror the next' I z hours: _Do nofdrive or operate machinery. _Do not ti vel alone. _ hol. Do not drink alp _Do not sign i / rtant papers or make important de/%.is ars. _Do not stca? alone. ?Do not /take responsibility for another person. Miscellaneous: Please -call the Pain Clinic if you Experience: - ??Headache not relieved by Tylenol or your usual eddache medication. `Excessive bleeding from the injection site. 9.i ?zziness or excessive weakness. .1! Signs of infection at the injection site (redness, swelling, discharge at the injection site or fever). -Other: To schedule anlappointment ).please call: 652-8670 1 MUM OT vperatLOA,.- Monday to-Friday 8:00 am to pm ( Phone: 717-691-3731 1 In case of an emergency, or after ktours: `Cgl l 717-730-3461 ask for the physician on call from Susquehanna Valley Pain Management to be contacted. I have been instructed in and understand the above _Rhizotomy ....._Nucleoplasty -Occipital Nerve Block ..-.Hip Injection 1nTOrrnaTIOYL Date: 7?/ Patient jn l / Physician: i 17 Health South Rehabilitation of h' ^chanicsburg 175.Lancaster Blvd Mechanicsburg, Pa 17055 PAIN CLINIC Discharge Instructions ! J J A. SLAM, MUHAMMAD C 2/06/19.47 059 M HAUE I SEN C 0 The Physician performed the following procedure on you today: 0 0 2 0 5 0 8 4 550 _/E.pidural Steroid Injection -Lumbar / Cervical Discogram _Rhizotomy -Facet Joint Injection(s) ,-Spinal Card Stim Trial -Nucleoplasty _5I Joint Injection(s) _IDET -Occipital Nerve Block Trigger Point Injections -Shoulder Injection -Hip Injection Other General Instructions )Resume Medications. as directed by your family physician. _Sall your family physician for problems not related to today's procedure. Activi /No strenuous activity for 24 hours, Use arm(s) / eg ) cautiously until numbness or unusual s ations subside. Diet -'Normal diet as tolerated. -Liquid diet for hours then progress to normal diet as tolerated. 'Drink extra fluids. Comfort Measures --,?Apply ice to the injection site, if desired. ?, bo not apply heat until tomorrow. IF USING HEAT OR ICE ; APPLY 20 MIN ON 20 MIN OFF. DO NOT USE EITHER CONTINUOUSLYI Resume pair, meds as needed. Please call the Pain Clinic if ou Experience .> Headache not relieved by Tylenol or your usual headache medication. -Excessive bleeding from the injection site. _'bizziness or excessive weakness. Signs of infection at the injection sit;, (redness, swelling, discharge at the injection site or fever). .Other: ?i -Do nofe. _Do not W'alcohoi. _Do not Do no ar im rtant deck ons o not stay alone- _„Do not take respons Miscellaneous: 2!90/06 PM _ i. 0M C , hIORMkN machinery, papers or make Pity for another person. To schedule an appointment please call: 2-8670 Hours of operation: Monday to Friday Phone: 8:00 am to 5:00 pm 717-691-373 In case of an emergency, or after hours: Call 717-730-3461 we for the physician on call from Susquehanna Valley Pain Management to be contacted. I have been instructed in and understand the above Inf ormation. - Date: >i L Patient: ` - Physician: . _,. 1 7 d r v lz 44 0041 --1 C , A'S JO wJ Plaintiff In The Court of Common Pleas of Cumberland County, Pennsylvania No.<:?17 - 45-( Z Defendant Civil Action - Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitution of this Commonwealth and that we will discharge the duties of our office with flj?qity. I -% I 4A, ig ture /ASignaturek& Sig P kvfgzas- Name (Chairman) Name Name 1-.4C? s Law Firm Address Cgd ( City, zip ?a rhig X. 7##M/ Law Firm 7?a X Ili Address ll V? !-Vd/ City, Zip PAJ4 I- C.. 2fkC, L*R-- P4- Law Firm &?o r MGGQ, 5T 2 NP FL Address K ppr 1-70 30 City, zip Award We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) U-A7- •t' %L +or tke r?L w( ,q "Aq -e vie r Date of Hearing: Date of Award: < G Q /-e57? -19 C 'Of ?• Z d?_ . A1bitrat0jsse sss (Insert name if applicable.) -? (Chairman) Notice of Entry of A Now, the day of -,2-0-L40---, at a 6 y , A-M., the above award was entered upon the docket and notice thereo given by mail to the parties or their attorneys. Arbitrators' compensation to be paid upon appeal: ::h?) a -f By: Prothonotary Deputy `? ?? tt , UO 2Ut0 ??'? t 2 ? COTCVY ? ? w. ~f ~F~E P ~ ~~~P~~3~ ~ ~,;,. ~~, Eal00C~ 28 P~ 2: ~-~ p~~~~~~ ~~. ~~,~ ~4ar W. Scott Henning, Esquire I.D.93229i3 HANDLER, HENNING & R03ENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-20005 ''~" ' Attorneys for Plaintiffs Fax..:.... (717)233.3029 E-mail: Henning~HMRLavM•com MUHAMMAD C. ASLAM and IN THE COURT OF COMMON PLEAS KULSOOM ASLAM, :CUMBERLAND COUNT, PENNSYLVANIA Plaintiff v. EDWARD M. SAVAGE, NO.07-1512 CIVIL ACTION -LAW Defendant STIPULATION TO LIMITATION OF MONETARY RECOVERY PURSUANT TO RULE 1311.1 To: Edward M. Savage c/o Seth T. Black, Esq. Summers, McDonnell, Hudock, Guthrie 8~ Skeel, LLP 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Muhammad Aslam &Kulsoom Aslam, Plaintiffs, stipulates to $25,000.00 as the maximum amount of damages recoverable upon the trial of the appeal from the Award of Arbitrators in the above captioned action. ~~~ ~~~~~ Kulsoom Aslam (Plaintiff) Respectf submitted, Muhammad Aslarrr'CPlaintiff) W. Scott He Attorney for Date: (d - I v ~ 1 ~ J y MUHAMMAD C. ASLAM and KULSOOM ASLAM, Plaintiff v. EDWARD M. SAVAGE, IN THE COURT OF COMMON PLEAS CUMBERLAND COUNT, PENNSYLVANIA NO.07-1512 CIVIL ACTION -LAW Defendant CERTIFICATE OF SERVICE On the 25th day of October, 2010, I hereby certify that a true and correct copy of Plaintiffs' Stipulation to Limitation of Monetary Recovery Pursuant to Rule 1311.1 was served upon the following by depositing in U.S. Mail; Seth T. Black, Esq. Summers, McDonnell, Hudock, Guthrie & Skeel, LLP 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 Very truly yours, HAS By: T "U' PRAECIPE FOR LISTING SASE fbA TRIAL (Must be typewritten and submitted n`trip icat TO THE PROTHONOTARY OF CUMBERLAND CO r? t I Please list the following case: X? for JURY trial at the next term of civil court. ? for trial without a jury. CAPTION OF CASE (entire caption must be stated in full) MUHAMMAD ASLAM and KULSOOM ASLAM, VS. EDWARD SAVAGE, VS. (Plaintiff) (Defendant) (check one) ? Civil Action - Law X? Appeal from arbitration (other) The trial list will be called on January 4, 201 and Trials commence on January 31, 2011 Pretrials will be held on January 19,. 2011 (Briefs are due S days before pretrials No. 07-1512 Term Indicate the attorney who will try case for the party who files this praecipe: Kevin D. Rauch, Esquire Indicate trial counsel for other parties if known: W. Scott Henning, Esquire This case is ready for trial. Signed: Print Name: /Kevin D. Date: October 29, 2010 C?r# a?lU3 ##9 12iwh Attorney for: Edward Savage, Defendant FJ,ff 0q.5 I ;)Do F L C OFD { it.E 3 2D 1G 19 Psi 153 *sJ iC ?J.?1?lF tld?MIf Y {^? I ..I' Y L\1 . O r e !? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 v. PRAECIPE FOR APPEARANCE EDWARD M. SAVAGE, (Jury Trial Demanded) Defendant. Filed on Behalf of the Defendant Counsel of Record for This Party: Kevin D. Rauch, Esquire Pa. I.D. #83058 Seth T. Black, Esquire Pa. I.D. #203075 SUMMERS, McDONNELL, HUDOCK, GUTHRIE and SKEEL, P.C. Firm #911 100 Sterling Parkway, Suite 306 Mechanicsburg, PA 17050 (717) 901-5916 #15441 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA MUHAMMAD C. ASLAM and CIVIL DIVISION KULSOOM ASLAM, Plaintiffs, NO. 07-1512 V. EDWARD M. SAVAGE, Defendant. (Jury Trial Demanded) PRAECIPE FOR APPEARANCE TO: THE PROTHONOTARY Kindly enter the Appearance of the undersigned, Seth T. Black, Esquire, of the law firm of Summers, McDonnell, Hudock, Guthrie & Skeel, P.C., on behalf of the Defendant, Edward M. Savage, in the above case. JURY TRIAL DEMANDED Respectfully submitted, SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. Seth T. Black, Esquire Counsel for Defendant s CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing PRAECIPE FOR APPEARANCE has been mailed by U.S. Mail to counsel of record via first class mail, postage pre-paid, this 18th day of November, 2010. W. Scott Henning, Esquire Handler, Henning & Rosenberg, LLP 1300 Linglestown Road Harrisburg, PA 17110 (Attorney for Plaintiff) SUMMERS, McDONNELL, HUDOCK, GUTHRIE & SKEEL, P.C. Setfii T. Black, Esquire Counsel for Defendant MUHAMMED ASLAM AND KULSOOM ASLAM, PLAINTIFFS V. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA EDWARD SAVAGE c C) , DEFENDANT mcp = 07-1512 CIVIL TERM °n= c„r-- Cn Ur n o° ORDER :r ° _ w °m AND NOW, this 25th day of January, 2011, after two fruitles --? N s settle ment conferences held pursuant to our pretrial conference order of January 19, 2011, the court suspends its attempt to dispose of this action short of trial and directs the parties to appear on Monday January 31, 2011, at 9:30 a.m jury, with trial currently scheduled to commence on Thursday February 3, 2011. By the Court, i Albert H. Masla d, J. W. Scott Henning, Esquire ?Po For Plaintiffs 'Seth T. Black Esquire DO For Defendant for the purposes of selecting a Court Administrator -in bin :saa