Hand therapy prescription

PATIENT________________________ DATE_______________________

DATE OF INJURY _______________ DATE OF SURGERY__________

DIAGNOSIS/HISTORY______________________________________________

THERAPY BEGIN DATE___________ FREQUENCY/DURATION___________

DATE OF NEXT SCHEDULED OFFICE VISIT______________

_AROM ______________ _AAROM _____________ _PROM/JOINT MOBILIZATION __________

_PERCUSSIVE DESENSITIZATION _FRICTION MASSAGE _SENSORY REEDUCATION

_WOUND CARE

_REMOVE POSTOP DRESSING

_WHIRLPOOL

_REMOVE REMAINING SUTURES AFTER _____ WEEKS POSTOP

_DEBRIDE WOUND AT THERAPIST'S DISCRETION

_EDEMA CONTROL _SILICONE SHEET SCAR DRESSING _ELASTOMER MOLD SCAR DRESSING

_ADL _JOBST MEASUREMENT _ARTHRITIS PROGRAM

_RSD / STRESS LOADING PROGRAM

SPLINT FABRICATION

_I _M _R _S MALLET

_I _M _R _S PIP RINGS: ALLOW FLEXION, BLOCK EXTENSION PAST _______ O

_I _M _R _S HAND BASED PROTECTIVE POSITION (MP@80O, IP'S@0O)

_I _M _R _S DISTAL PHALANX PROTECTIVE AQUAPLAST CAP, DIP FREE

_I _M _R _S HAND BASED ANTICLAW (MP 60 DEGREES, IP JOINTS FREE)

_WRIST 30 DEGREE DORSIFLEXION SPLINT

_HAND BASED ABDUCTION THUMB SPICA, LEAVE IP FREE

_FOREARM BASED THUMB SPICA, IP FREE, ALLOW PENCILGRIP

_3 FOREARM STRAP WITH 2 Dia X Thick FELT DISK OVER ECRB

_NIGHTTIME SOFT ELBOW FLEXION BLOCK SPLINT

_CYLINDER SPONGE PEN/PENCIL BUILDUP

MODALITIES

_HOT/COLD PACK _FLUIDOTHERAPY _WHIRLPOOL _ULTRASOUND/PHONOPHORESIS _EMG BIOFEEDBACK _TENS _FUNCTIONAL ELECTRICAL STIM OF __________________

_ADDITIONAL MODALITIES AT THERAPIST'S DISCRETION

_ COMPLEXITY OF PROBLEM REQUIRES TREATMENT BY A CERTIFIED HAND THERAPIST

PLEASE CONTACT ME IMMEDIATELY

IF THERE ARE ANY QUESTIONS REGARDING THIS PRESCRIPTION

IF THE PATIENT DOES NOT FOLLOW THERAPY GUIDELINES

IF THIS IS A WORKER'S COMPENSATION CASE, NOTIFY THE ADJUSTOR IMMEDIATELY

IF THE PATIENT DOES NOT FOLLOW THERAPY GUIDELINES

IF THE PATIENT DOES NOT COME TO SCHEDULED APPOINTMENT FOR ANY REASON