Sample Treatment Plan Of Care Template Page 2
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2_____ Initial Tx Plan
NAME/ADDRESS of CLINIC/PROVIDER
_____ Updated Tx Plan
TREATMENT PLAN OF CARE
2 2 2 2
Date___________ Patient _______________________________ Patient DOB_______________
SPECIAL INSTRUCTIONS
Home Instructions: Ice______ Heat______ Hot Soaking _______ Lying On Back, Legs Up _________
Sleeping Position _____ Cervical Pillow _____ Wearing Supports _____ Auto position _____ Lifting____
Changing Positions: Bed ______ Auto ______ Seated Position ______ Other _____________________
Pamphlets: Speedy Recovery _____ After Neck Injury _____ Bad Back ______ Other ______________
Patient Education: Back School ________________ Other ____________________________________
PATIENT EMPLOYMENT
Off Work:
From _______ To _________ Home: Rest ______ Bed Rest ______ Guarded ________
Light Duty: From _______ To _________ Description _______________________________________
Lifting Restrictions: ____________________________ Special ________________________________
Other
__________________________________________________________________________
__________________________________________________________________________
LIFESTYLE/DIET MODIFICATION/NUTRITIONAL SUPPORT
_____________ None Recommended
_____________ Recommendations:________________________________________________________
_____________________________________________________________________________________
CONSULTATION
_____ None recommended at this time.
Scheduled
/
/
Time:
:
AM/PM
_____ Referral to ____________________
Provider___________________________________________
For:
Confirmed with Patient
___________________________________
By _______________________________________________
___________________________________
ADDITIONAL DIAGNOSTIC TESTING
_______ None recommended at this time
_______ Following additional studies recommended
Diagnostic Imaging
Electrodiagnostics
Laboratory
_____ Arthography
_____ Brain Electrical Activity Mapping
_____CBS
_____ Computer Tomogrophy (CT)
_____ Brain Stem Auditory Evoked Response
_____ESR
_____ Contrast Enhanced CT
_____ Electroencephalography
_____SMAC12
_____ Contrast Enhanced MRI
_____ Electronystagmography
_____SMAC24
_____ Diagnostic Ultrasound
_____ EMG (Needle)
_____Urinalysis (DS)
_____ Discography
_____ Magnetoencephalography
_____ Urinalysis (Micr)
_____ Fluoroscopy
_____ Nerve Conduction Velocity
Profiles
_____ Magnetic Resonance Imaging (MRI)
_____ Peripheral Electrodiagnostics
_____Anemia
_____ Positive Emission Tomography (PET)
_____ Somatosensory Evoked Potential
_____Cardiac
_____ Radionuclide Bone Scan
_____ Surface Electrode EMG
_____Hypertension
_____ Thermography
_____ Visual Evoked Response
_____Joint
_____ Videofluorography
_____ Other
_____Lipid
_____ Other______________________
_____ Liver
_____ Other______________________
_____Metabolic Bone
Rehabilitation
_____Pancreas
Scheduled
/ /
Time:
:
AM/PM
____ Evaluation
_____Pregnancy
Provider________________________
____ Referral
_____Skeletal Mus
Confirmed with Patient
/
/
_____Thyroid
By___________________
_____Urinary Tract
_____Other
Reviewed/Prepared by: Print Name of Provider
Provider Signature ____________________________
Treatment Plan
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