PATIENT DETAILS SCREEN
Patient Name
Date of Birth
Gender
Height
Weight
Dominant Hand
Address
City
State
Zip
INSURER/ATTORNEY DETAILS SCREEN
Insurer
Address
City
State
Zip
Adjuster
Law Firm
Address
City, State, Zip
Attorney
ADDITIONAL DETAILS SCREEN
Patient Number
Name of Insured
Date of Loss
Tate of First Treatment
Medical Specials
Income Loss
Property Damage
Claim Status (Complete, In Treatment)
Medical Assistant
Time Spent
PHYSICIANS SCREEN
Physician 1 Name
Type of Physician
Billed Amount
All Records Received ?
Treating Physician?
PHYSICIANS SCREEN (CONT.)
Physician 2 Name
Type of Physician
Billed Amount
All Records Received ?
Treating Physician?
Physician 3 Name
Type of Physician
Billed Amount
All Records Received ?
Treating Physician?
Physician 4 Name
Type of Physician
Billed Amount
All Records Received ?
Treating Physician?
Physician 5 Name
Type of Physician
Billed Amount
All Records Received ?
Treating Physician?
COMPLICATIONS SCREEN (this may come from the injuries screen, infra)
Wound infections/Ulceration
Delayed wound healing
Non-Union
Thrombosis (venous or arterial)
Pulmonary embolism
Fat embolism
Avascular necrosis
Peripheral nerve injury
Osteomyelitis
(Other Injuries Discussion Tab at bottom opens narrative writing area)
INJURIES SCREEN
Injury Name (opens Injury Details Sub-Screen)
Physician who diagnosed it
IDC-9 Codes (all used for all diagnoses for all doctors)
CPT Codes (all used for all doctors & treatments)
INJURY DETAILS SUB-SCREEN
Physician
Last Date This Injury Noted
Injury Type (Need this subscreen)
Duration (for THIS Injury)
1-3 months
3-6 months
7-12 months
12+ months
Prognosis (for THIS Injury)
Undertermined
No Complaints/No Treatment Recommended
Complaints/No Treatment Recommended
Complaints/Treatment Recommended
Guarded
COMPLAINTS SUB-SCREEN(checkboxes for EACH Injury listed in Injuries Screen)
Range of Motion
Headaches
Dizziness
Spasms
Visual Disturbance
Radiating Pain
TMJ
Anxiety/Depression
TREATMENTS CHECKLIST SUB-SCREEN (check boxes for EACH Injury listed in Injuries Screen)
Hot or Cold packs
Traction mechanical
Elec. Stimulation (unattended)
Vasopheumatic
Parafin bath
Microwave
Diathermy
Infrared
Ultraviolet
Unlisted Modality (specify)
Therapeutic Exercises
Functional Activities
Gait Training
Elec. Stimulation (manual)
Iontophoresis
Traction Manual
Massage
Contrast Bath
Ultrasound
Unlisted Procedure (specify)
Pool Therapy or Hubbard tank with therapeutic exercises, initial…
Myofascial release/soft tissue mobilization, one or more regions
Orthotics training (bracing, splinting), upper/lower extremity, i…
Kinetic activities, one each, initial 30 minutes
Training in activities of daily living, initial 30 minutes
Work hardening/conditioning, initial 2 hours, (prior authorize…)
Physical medicine treatment to one area, soft tissue mobilization….
Physical medicine treatment to one area, individual instruction
Physical medicine treatment to one area, joint mobilization
Physical medicine treatment to one area, taping
Individualized procedure requiring the application of compute….
Patient education (organized group instruction programs (tw…)
Delay or Gaps in Treatment
Confined to Bed
Immobilization
Prescribed Medication
Hospitalization
Tens (at home)
Nursing/Convalescent Home
Walking Aids
Traction
Aspiration of Hematoma
Surgery
Injections
Arthroscopy
Dressings
Suturing
Transfusion
Oxygen
Catheter
Plastic Surgery
Debridement
Home Traction
Pallectomy
Fasciotomy
Arthrodesis
Arthroplasty (prosthetic replacement)
Release of adhesions
Bone Graft
Reduction
Removal of internal fixation
Meniscectomy through arthroscope
Arthrotomy, Meniscectomy, cruciate
Ligament or Ten…. Arthroscopy, Arthrotomy
Percutaneous insertion of intra-medulary nail (femur only)
Other Significant Treatments
Duties Under Duress
Loss of Enjoyment
Extremity Adjustment
Electrical Stimulation
Manual Traction
Myofascial Release
Chiropractic Manipulation
Other Chiropractic Treatment
Bed Rest
TREATMENTS DETAILS SUB-SCREEN (drop-down boxes for EACH injury listed in Injuries screen)
Treatment #1
Physican who did #1
Last Chart Date Tx #1
Initial Treatment? (check box)
Treatment #1
Physican who did #1
Last Chart Date Tx #1
Initial Treatment? (check box)
Treatment #2
Physican who did #2
Last Chart Date Tx #2
Initial Treatment? (check box)
Treatment #3
Physican who did #3
Last Chart Date Tx #3
Initial Treatment? (check box)
Treatment #4
Physican who did #4
Last Chart Date Tx #4
Initial Treatment? (check box)
Treatment #5
Physican who did #5
Last Chart Date Tx #5
Initial Treatment? (check box)
Treatment #5
Physican who did #5
Last Chart Date Tx #5
Initial Treatment? (check box)
Treatment #6
Physican who did #6
Last Chart Date Tx #6
Initial Treatment? (check box)
Treatment #7
Physican who did #7
Last Chart Date Tx #7
Initial Treatment? (check box)
Treatment #8
Physican who did #8
Last Chart Date Tx #8
Initial Treatment? (check box)
Treatment #9
Physican who did #9
Last Chart Date Tx #9
Initial Treatment? (check box)
Treatment #10
Physican who did #10
Last Chart Date Tx #10
Initial Treatment? (check box)
Treatment #11
Physican who did #11
Last Chart Date Tx #11
Initial Treatment? (check box)
Treatment #12
Physican who did #12
Last Chart Date Tx #12
Initial Treatment? (check box)
Treatment #13
Physican who did #13
Last Chart Date Tx #13
Initial Treatment? (check box)
Treatment #14
Physican who did #14
Last Chart Date Tx #14
Initial Treatment? (check box)
Treatment #15
Physican who did #15
Last Chart Date Tx #15
Initial Treatment? (check box)
THERAPIES SUB-SCREEN(check boxes for EACH Injury listed in Injuries Screen)
Physical Therapy
Massage Therapy
Acupuncture
Self-Exercise
Gym
TESTING SUB-SCREEN (for EACH Injury listed in Injuries Screen)
Physician (opens drop down menu for list of physicians on case)
Last Chart Date this test was done (only list this for positive ones)
Test Type (opens drop down menu)
X-Ray
MRI
CAT scan
Discogram
Myelogram
Ultrasound
Other
Test Result (opens drop down menu)
Positive
Negative
COMPLICATIONS SUB-SCREEN (check off boxes for EACH Injury listed in Injuries Screen)
Wound infection/Ulceration
Delayed wound healing
Delayed bony union
Non-union
Thrombosis (venous or arterial)
Pulmonary embolism
Fat embolism
Avascular necrosis
Peripheral nerve injury
Osteomyelitis
(Other Injuries Discussion Tab at bottom of all Injuries screens opens narrative writing area.)
PRIOR/SUBSEQUENT INJURIES SCREEN
PRIOR INJURY SUBSCREEN
Prior injuries (narrative box to list them all)
Date of last treatment prior to accident
Any proration (check box if yes)
Percentage (of proration)
Physician (opens drop down list of physicians on the case)
Last Chart Date
SUBSEQUENT INJURY SUBSCREEN
Prior injuries (narrative box to list them all)
Date of last treatment prior to accident
Any proration (check box if yes)
Percentage (of proration)
Physician (opens drop down list of physicians on the case)
Last Chart Date
(Prior/Subsequent Injury Discussion tab at bottom opens narrative writing area)
MEDICATIONS/MEDICAL SUPPLIES SCREEN
#1 Type (opens drop down list or can write in if not listed)
#1 Item (opens drop down list or can write in if not listed)
#1 Amount:
#2 Type (opens drop down list or can write in if not listed)
#2 Item (opens drop down list or can write in if not listed)
#2 Amount:
#3 Type (opens drop down list or can write in if not listed)
#3 Item (opens drop down list or can write in if not listed)
#3 Amount:
#4 Type (opens drop down list or can write in if not listed)
#4 Item (opens drop down list or can write in if not listed)
#4 Amount:
#5 Type (opens drop down list or can write in if not listed)
#5 Item (opens drop down list or can write in if not listed)
#5 Amount:
#6 Type (opens drop down list or can write in if not listed)
#6 Item (opens drop down list or can write in if not listed)
#6 Amount:
#7 Type (opens drop down list or can write in if not listed)
#7 Item (opens drop down list or can write in if not listed)
#7 Amount:
#8 Type (opens drop down list or can write in if not listed)
#8 Item (opens drop down list or can write in if not listed)
#8 Amount:
#9 Type (opens drop down list or can write in if not listed)
#9 Item (opens drop down list or can write in if not listed)
#9 Amount:
#10 Type (opens drop down list or can write in if not listed)
#10 Item (opens drop down list or can write in if not listed)
#10 Amount:
#11 Type (opens drop down list or can write in if not listed)
#11 Item (opens drop down list or can write in if not listed)
#11 Amount:
DENTAL/ORTHODONTIC TREATMENT SCREEN
Dentist/Doctor (drop down list)
Date of First Tx
Date of Last Tx
# of Visits
Amount Paid
Future cost of Dental/Ortho treatment: $
(Dental/Ortho Discussion tab at bottom opens narrative writing area)
DISFIGUREMENT SCREEN
Physician (drop down list)
Last Chart Date
Amount expected to be awarded for patient’s disfigurement: $
(Disfigurement Discussion tab at bottom opens narrative writing area)
IMPAIRMENT SCREEN
Physician (drop down list)
Last Chart Date
Whole Body Impairment %
Body Part (drop down list)
DUTIES UNDER DURESS SUBSCREEN TAB (at bottom)
Work (check box)
Hobbies (check box)
Domestic Duties (check box)
Household Duties (check box)
Chart Note (for Duties Under Duress)
Physician (drop down list)
Last Chart Date (for any Duties Under Duress)
LOSS OF ENJOYMENT OF LIFE SUBSCREEN TAB (at bottom)
Domestic Duties (check box)
Household Duties (check box)
Hobbies (check box)
Sports (check box)
Work/Study (check box)
Chart Note (for Loss of Enjoyment of Life)
Physician (drop down list)
Last Chart Date (for any Loss of Enjoyment of Life)
DISABILITY SCREEN
Physician (drop down list)
Last Date Noted
(Disability Discussion Tab at bottom opens narrative writing area)
DEPRESSION/ANXIETY SCREEN
Physician (drop down screen)
Duration
Last Date
Treatment Prescribed (list of check boxes below this)
Exercise
Meditation
Counseling
Avoid Certain Activities
Referral to Specialist
TMJ SCREEN
Physician (drop down screen)
Duration
Last Chart Date
Treatment Prescribed (list of check boxes below this)
Physical Therapy
Massage Therapy
Splint Therapy
Acupuncture
Self-Exercise
Gym
Retainer
Relaxation
Soft Food/Liquid Diet
Surgery
(TMJ Discussion tab at bottom opens narrative writing area)
INCOME LOSS SCREEN
Physician (drop down list)
Last Chart Date
Employer Type
Future Loss? (check box)
Employer
Duration
Loss Amount
Future Income Loss
Actual Income Loss
(Income Loss Discussion Tab opens narrative writing area)
FUTURE MEDICAL COSTS SCREEN
Physician (drop down list)
Last Chart Date
Treatment
Amount
Future Medical Costs
Actual Medical Costs
(Future Medical Costs tab at bottom opens narrative writing area)
LETTER DETAILS SCREEN
Introductory Paragraph (tab opens narrative writing area)
Closing Paragraph (tab opens narrative writing area)
Exhibit Listing (type in & it will print a cover page for each exhibit listed below)
Medical Providers Tab
Billing Tab
Income Loss Tab
Property Damage Tab
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