Patient | Synergy Injury Care – Patient Narrative Form

Name *

First

Last

D.O.B. *

D.O.I. *

Description: *

Injury Impact *

Medical Concerns from Acute Injury

Medical Concerns

Patient was struggling with activities of daily living such as:

Dressing
Bathing
Toilet
Eating / Feeding
Household Chores
Sleeping / Staying Asleep

Dressing

Upper Body
Lower Body
Buttoning/Zipping
Putting on/take off shoes/socks

Bathing

Upper Body
Lower Body
In/Out of Bath
Brushing Teeth
Hair Care
Shaving

Toilet

Hygiene
Transfer

Eating / Feeding

Holding Utensils
Meal Prep
Opening Bottle / Jar
Opening Packages
Meal Clean Up
Dishes
Shopping
Carrying a Gallon of Milk

Household Chores

Laundry
Vacuuming
Sweeping/Mopping
Cleaning/Dusting
Taking out the Trash
Lawn Care

Sleeping/Staying Asleep

Getting in/out of Bed
Tossing Turning
Hurts to lay on back
Pain wakes you up

General

Child Care
Picking Up/Carrying
Helping with School
Patience
Playtime
Turning Key in Door
Opening Doors
Pet Care
Using Telephone
Watching TV
Computer Work
Reading
Writing
Getting around inside
Getting around outside
Forget Conversations
Poor Concentration
Remembering Appointments
Balancing Checkbook
Social Events

Patient has difficulty/limitations with:

Sleeping
Bending
Lifting
Pushing
Pulling
Reaching
Twisting
Sitting
Standing
Walking
Stairs
Transitioning
Childcare
School
Driving
Working
Job Tasks
Gripping

Other

Positive Diagnosis

Positive Diagnosis Includes:

Head

Injury of Head: S09.90XA
Injury of Face: S09.93XA
Contusion of Unspec Part of Head: S00.93XA
Concussion w/o LOC: S06.0X0A
Concussion w/ Brief LOC: S06.0X1A
Injury of Unspec Eye & Orbit: S05.90XA
Visual Discomfort, Unspecified: H53.149
Cervicogenic Headache: G44.89
Post-Traumatic Headache: G44.309
Jaw Pain: R68.84
Headache: R51.9

Other

Neuro

Paresthesia: R20.0
Dizziness: R42
Visual Disturbance: H53.9

Other

Cervical

Cervical Sprain: S13.8XXA
Annuler Tear(s): M50.80
C2-3, C3-4 Disc Displacement: M50.21
C4-5 Disc Displacement: M50.222
C5-6 Disc Displacement: M50.222
C6-7 Disc Displacement: M50.223
Spinal Stenosis, Cervical Region: M48.02
Cervicalgia: M54.2
Muscle Spasm: M62.838
Disorder of Ligament, Vertebrae: M24.28
Stiffness/Dec ROM: M25.60
Radiculopathy, cervical region: M54.12
Radiculopathy, cervicothoracic region: M54.13

Other

Thoracic

Thoracic Sprain: S23.3XXA
Intervertebral Disc Displacement Thoracic Region: M51.24
Intervertebral Disc Displacement Thoracolumbar Region: M51.25
Spinal Stenosis, Thoracic Spine: M54.6
Pain in Thoracic Spine: M54.6
Muscle Spasm Back: M62.830
Disorder of Ligament, Vertebrae: M24.28
Stiffness of Unspec Joint/Dec ROM: M25.60

Other

Lumbar

Lumbar Sprain: S33.5XXA
Other Intervertebral Disc Displacement, Lumbar: M51.26
Other Intervertebral Disc Displacement, Lumbosacral: M51.27
Spinal Stenosis, Lumbar Region: M48.061
Spinal Stenosis, Lumbosacral Region: M48.07
Sprain of Other Parts of Lumbar & Pelvis: S33.8XXA
Sprain of Sacrolliac Joint: S33.6XXA
Low Back Pain: M54.5
Muscle Spasm of Back: M62.830
Disorder of Ligament, Vertebrae: M24.28
Stiffness/Displacement ROM: M25.60
Radiculopathy, Lumbar Region: M54.16
Radiculopathy, Lumbosacral Region: M54.17
Annular Tear L4-L5: M51.86
Annular Tear L5-S1: M51.87

Other:

Right Shoulder

Sprain Shoulder Joint: S43.401A
Contusion of Shoulder: S40.011A
Contusion of Upper Arm: S40.021A
Bursitis of Shoulder: M75.51
Pain In Shoulder: M25.511
Pain In Upper Arm: M79.621
Effusion Shoulder: M25.411
Stiffness of Shoulder: M25.611
Ligament Laxity of Shoulder: M24.211
Tendinosis: M75.81
Complete Tear: M75.121
Partial Tear: M75.111
Impingement: M75.41

Other

Left Shoulder

Sprain Shoulder Joint: S43.402A
Contusion of Shoulder: S40.012A
Contusion of Upper Arm: S40.022A
Bursitis of Shoulder: M75.52
Pain In Shoulder: M25.512
Pain In Upper Arm: M79.622
Effusion Shoulder: M25.412
Stiffness of Shoulder: M25.612
Ligament Laxity of Shoulder: M24.212
Tendinosis: M75.82
Complete Tear: M75.122
Partial Tear: M75.112
Impingement: M75.42

Other

Right Elbow

Sprain of Elbow: S53.401A
Contusion of Elbow: S50.01XA
Contusion of Forearm: S50.11XA
Pain in Joint Elbow: M25.521
Pain in Forearm: M79.631
Pain in Arm: M79.601
Bursitis Elbow: M71.521
Effusion Elbow: M25.421
Stiffness of Elbow: M25.621
Ligament Laxity of Elbow: M24.221

Other

Left Elbow

Sprain of Elbow: S53.402A
Contusion of Elbow: S50.02XA
Contusion of Forearm: S50.12XA
Pain in Joint Elbow: M25.522
Pain in Forearm: M79.632
Pain in Arm: M79.602
Bursitis Elbow: M71.522
Effusion Elbow: M25.422
Stiffness of Elbow: M25.622
Ligament Laxity of Elbow: M24.222

Other

Right Wrist

Sprain Wrist: S63.501A
Contusion of Wrist: S60.211A
Pain in Wrist: M25.531
Effusion in Wrist: M25.431
Ligament Laxity Wrist: M24.231
Stiffness of Wrist: M25.631

Other

Left Wrist

Sprain Wrist: S63.502A
Contusion of Wrist: S60.212A
Pain in Wrist: M25.532
Effusion in Wrist: M25.432
Ligament Laxity Wrist: M24.232
Stiffness of Wrist: M25.632

Other

Right Hand

Sprain of Wrist and Hand: S63.91XA
Sprain Metacarpophalangeal Jt Unspec Finger: S63.659A
Contusion of Hand: S60.221A
Pain In Hand: M79.641
Pain in Unspec Fingers: M79.644
Effusion of Hand: M25.441
Laxity of Ligament Hand: M24.241
Stiffness Hand: M25.641
Sprain Thumb: S63.601

Other

Left Hand

Sprain of Wrist and Hand: S63.92XA
Sprain Metacarpophalangeal Jt Unspec Finger: S63.659A
Contusion of Hand: S60.222A
Pain In Hand: M79.642
Pain in Unspec Fingers: M79.645
Effusion of Hand: M25.442
Laxity of Ligament Hand: M24.242
Stiffness Hand: M25.642
Sprain Thumb: S63.602

Other

Abdomen

Contusion of Abdomen Wall: S30.1XXA
Generalized Abdominal Pain: R10.84

Other

Chest

Sprain of Sternum: S23.429A
Contusion of Front Wall of Thorax - R: 520.211A
Contusion of Front Wall of Thorax - L: 520.212A
Chest Pain Unspec: R07.9
Sprain of Ribs: S23.41XA

Other

Right Hip

Sprain of Hip: S73.101A
Sprain of Thigh: S76.911A
Contusion of Hip: S70.01XA
Contusion of Thigh: S70.11XA
Pain in Hip: M25.551
Pain in Thigh: M79.651
Effusion Hip: M25.451
Bursitis Hip: M71.551
Laxity of Ligament Hip: M24.251
Stiffness of Hip: M25.651
Sciatica: M54.31

Other

Left Hip

Sprain of Hip: S73.102A
Sprain of Thigh: S76.912A
Contusion of Hip: S70.02XA
Contusion of Thigh: S70.12XA
Pain in Hip: M25.552
Pain in Thigh: M79.652
Effusion Hip: M25.452
Bursitis Hip: M71.552
Laxity of Ligament Hip: M24.252
Stiffness of Hip: M25.652
Sciatica: M54.32

Other

Right Knee and Leg

Sprain of Knee: S83.91XA
Contusion of Knee: S80.01XA
Bursitis Knee: M71.561
Pain in Leg: M79.604
Pain in Knee: M25.561
Pain in Lower Leg: M79.661
Effusion Knee: M25.461
Stiffness of Knee: M25.661
Abrasion w/o Infection Knee: S80.211A
Abrasion w/o Infection Lower Leg: S80.811A
MCL Tear: S8.231A
ACL Tear: S83.31XA
ACL Sprain: S83.511A
Med. Meniscus Tear: S83.241A
Lat. Meniscus Tear: S83.281A
Complex Lat. Meniscus Tear: S83.2471A
Contusion Lower Leg S80.11XA

Other

Left Knee and Leg

Sprain of Unspec Site of Knee: S83.92XA
Contusion of Knee: S80.02XA
Bursitis Knee: M71.562
Pain in Leg: M79.605
Pain in Knee: M25.562
Pain in Lower Leg: M79.662
Effusion Knee: M25.462
Stiffness of Knee: M25.662
Abrasion w/o Infection Knee: S80.212A
Abrasion w/o Infection Lower Leg: S80.812A
MCL Tear: S8.232A
ACL Tear: S83.32XA
ACL Sprain: S83.512A
Med. Meniscus Tear: S83.242A
Lat. Meniscus Tear: S83.282A
Complex Lat. Meniscus Tear: S83.2472A
Contusion Lower Leg S80.12XA

Other

Right Ankle

Sprain of Ankle: S93.401A
Pain in Ankle and Joints of Foot: M25.571
Effusion of Ankle: M25.471
Ligament Laxity Ankle: M24.271
Stiffness of Ankle: M25.671

Left Ankle

Sprain of Ankle: S93.402A
Pain in Ankle and Joints of Foot: M25.572
Effusion of Ankle: M25.472
Ligament Laxity Ankle: M24.272
Stiffness of Ankle: M25.672

Right Foot

Sprain of Foot: S93.601A
Contusion of Foot: S90.31XA
Pain in Foot: M79.671
Pain in Toes: M79.674
Effusion Foot: M24.474
Stiffness of Foot: M25.674

Left Foot

Sprain of Foot: S93.602A
Contusion of Foot: S90.32XA
Pain in Foot: M79.672
Pain in Toes: M79.675
Effusion Foot: M24.475
Stiffness of Foot: M25.675

Other

Acute Stress Reaction: F43.0
Sleep Disorder: G47.9
Difficulty in Walking: R26.2
Weakness: R53.1
Constipation: K59.00
Muscle Weakness (Generalized): M62.81
Fatigue: R53.83
Nausea: R11.0

Other

Medical Concerns / Positive Findings:

Diagnostic Positive Findings:

* Full Radiology read reports attached. Please request images if needed.

Duration (From):

From:

Duration: (To)

To:

Total Sessions Including Physical and Occupational Therapy the following service provided:

Total Sessions Including Physical and Occupational Therapy the following service provided:

Treatment Received

Electrical Stimulation: 97014
Hot/Cold Packs: 97010
Traction: 97012
Iontophoresis: 97033
Paraffin: 97018
Manual Therapy: 97140
Therapeutic Exercise: 97110
Home Management: 97535
Hydrotherapy: 97039
Aqua Therapy: 97113
Neuromuscular Re-education: 97112
Sensory Integrative Technique: 97533
Custom Splinting UE: 29105
Custom Splinting LE: 29505
Massage Therapy: 97124
PT Evaluation: 97161
OT Evaluation: 97165
Therapeutic Activity: 97530
Cognitive Skills: 97129
Ultrasound 97035

Strapping

29200 - Thoracic
29240 - Shoulder
29260 - Wrist/Elbow
29520 - Hip
29530 - Knee
29540 - Foot/Ankle
29799 - Unlisted
96132 - Impact

Other

Durable Medical Equipment Issued

Other

Work Status

Referral

Current Prognosis

Future Treatment Medical Expectations

Treatment - Modalities

Cryotherapy
Thermotherapy

Duration

1-12 Months
2-3 Months

Frequency

As needed
1+
1-2x per week
3-4x month

Reason/Goal

Decrease Inflamation
Control Edema
Modify Pain

Treatment - Therapy

Physical Therapy
Occupational Therapy
Massage Therapy

Duration

1-12 Months
2-3 Months

Frequency

As needed
1+
1-2x per week
3-4x month

Reason/Goal

Resolve functional deficits
Promote flexibility
Educate patient on home program
Return to normal ADL's
Soft tissue mobilization to decrease tension and stress
Increase tissue extensibility and blood flow

Treatment - Physician Follow-Up

Physician Visits
Specialist
Concussion Care

Duration

1-12 Months
2-3 Months

Frequency

As needed
1+
1+ times as needed weekly
2-3 times as needed
1-2x per week
3-4x month

Reason/Goal

Following the acute injury into the chronic phase for medical oversight
To help reduce pain and improve function
If functional deficits do not improve more invasive treatment may be required.
If concussion symptoms do not improve more invasive treatment may be required
If functional deficits do not improve further studies would be required.

Treatment - Procedures

Dry Needling
Trigger Point Injections
Joint Injections

Other

Duration

1-12 Months
2-3 Months

Frequency

As needed
1+
1+ times as needed weekly
2-3 times as needed
1-2x per week
3-4x month

Reason/Goal

Decrease tightness, pain and increase blood flow
Decrease stiffness, increase ROM and blood flow to accelerate healing
To help reduce pain and improve function
If functional deficits do not improve further studies would be required.

Treatment - Diagnostics

X-Ray
MRI
MRI w/Contrast
CT Scan

Duration

1-12 Months
2-3 Months

Frequency

As needed
1+
1+ times as needed weekly
2-3 times as needed
1-2x per week
3-4x month

Reason/Goal

Following the acute injury into the chronic phase for medical oversight
If functional deficits do not improve further studies would be required.

Estimated Cost

Total Estimated Cost

Final Notes:

Provider Signature:

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