Get the free Shoulder Chart History - bbahriorthobbcomb

GEORGES A. BA HRI, M.D. LADY A. BA HRI, M.D. FARID HAKIM, M.D. KAMAL BONSAI, M.D. BA HRI ORTHOPEDICS & SPORTS MEDICINE CLINIC, P.A. Shoulder Chart History Created 05×12/2009 Name: Date: Age: Shoulder

How to fill out shoulder chart history

How to fill out shoulder chart history:

1. Start by gathering the necessary information: Before filling out the shoulder chart history, collect all relevant details about the patient's shoulder condition. This can include medical history, previous injuries or surgeries, current symptoms, and any limitations or difficulties experienced.
2. Begin with personal information: Make sure to include the patient's full name, date of birth, contact information, and any other required personal details at the top of the shoulder chart history form.
3. Document the chief complaint: Ask the patient about their primary reason for seeking shoulder treatment. Record the specific symptoms, when they started, and any triggering events that may have caused the issue.
4. Record medical history: In this section, document the patient's significant medical conditions, such as diabetes, heart disease, or any other relevant health issues. Include details on current medications, allergies, and previous surgeries.
5. Note previous shoulder injuries or treatments: Ask the patient about any prior shoulder injuries, surgeries, or specific treatments they have undergone. Record the dates, details, and outcomes of these interventions.
6. Assess shoulder symptoms: Use the shoulder chart history to gather detailed information about the patient's shoulder symptoms. Ask about pain levels, location, duration, and any factors that exacerbate or alleviate the pain. Record information regarding range of motion limitations and any associated numbness, tingling, or weakness.
7. Ask about daily activities and lifestyle: Understand the impact the shoulder condition has on the patient's daily life. Ask about any difficulties in performing specific tasks, such as lifting, reaching, or participating in recreational activities. This information will help assess the functional limitations caused by the shoulder issue.
8. Include imaging and diagnostic tests: If the patient has undergone any relevant imaging or diagnostic tests, such as X-rays, MRIs, or ultrasound scans, make sure to include the results or attach copies to the shoulder chart history.
9. Obtain relevant consent: If required, ensure that the patient provides consent for accessing their medical records or sharing information with other healthcare professionals involved in their care.

Who needs shoulder chart history?

1. Orthopedic Surgeons: Shoulder chart history is essential for orthopedic surgeons to understand the patient's shoulder conditions, previous injuries, and relevant treatment history. It helps them make informed decisions about surgical intervention, rehabilitation, or other treatment approaches.
2. Physical Therapists: Knowledge of the patient's shoulder chart history allows physical therapists to design appropriate rehabilitation programs tailored to the individual's specific needs. Understanding previous injuries, limitations, and symptoms aids in formulating effective treatment plans.
3. Primary Care Physicians: Primary care physicians utilize shoulder chart history to gain a comprehensive overview of the patient's health conditions, assisting in the management of their overall care, coordinating referrals, and ensuring appropriate follow-up.
4. Sports Medicine Specialists: Athletes and sports enthusiasts often require shoulder evaluation and treatment. Shoulder chart history provides sports medicine specialists with valuable information to diagnose and manage sports-related shoulder injuries and customize treatment plans.
5. Occupational Therapists: Occupational therapists utilize shoulder chart history to assess the impact of shoulder conditions on the patient's ability to perform daily activities, work-related tasks, and participate in occupational roles. This information guides the development of targeted interventions and adaptations for enhancing functional abilities.

Remember, filling out the shoulder chart history accurately and comprehensively is crucial for healthcare professionals to provide appropriate care and ensure effective communication among the healthcare team.

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What is shoulder chart history?

Shoulder chart history is a record of past shoulder injuries, treatments, and progress.

Who is required to file shoulder chart history?

Healthcare professionals, such as doctors and physical therapists, are required to file shoulder chart history for their patients.

How to fill out shoulder chart history?

Shoulder chart history can be filled out by documenting the patient's shoulder injuries, treatments received, and progress made over time.

What is the purpose of shoulder chart history?

The purpose of shoulder chart history is to track the progress of shoulder injuries, treatments, and recovery over time.

What information must be reported on shoulder chart history?

Information such as the date of injury, treatments received, range of motion, pain levels, and any other relevant details must be reported on shoulder chart history.