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Documentation of Hot/Cold packs PT/OT

msingh23

Guru
Messages
131
Non E&M ... hope sone can assist...

I will appreciate some input on the documnetaion for MH, objective notes states treatment done however I will like to know if time in minutes must be documented or Not, listed two Scenarios

Modalities:
MH to: wrist

Manual:
STM/MFR:
STM/MFR scar and edema massage
Joint Mobs to: wrist - distraction and oscilation of carpals

Therapeutic Activities & Therapeutic Exercises: heat and stretch, PROM - wrist flex, ext, sup, pron, uln and rad dev, manual resistance against pt motion, PRE's #4

Summary:
Scenario 1
Ther Ex: 30 min
Manual: 10 min
Hot pack 5 min
Total Time: 45 min
Time in: 4:30
Time out: 5:15


OR
Scenario 2
Ther Ex: 30 min
Manual: 10 min
Total Time: 45 min
Time in: 4:30
Time out: 5:15
 
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