“Connecting the right patient, with the right surgeon, and the right pathway.”



Date of This Visit

Visit Type


Last Name of Patient

First Name of Patient

Date of Birth

Date of Surgery

Wound: Dressing

Wound: Sutures

Wound: Drainage

Wound: Redness

Inspection/Palpation: Knee Swelling

Inspection/Palpation: Calf Swelling

Inspection/Palpation: Calf Tenderness

Inspection/Palpation: Thigh Swelling

Inspection/Palpation: Thigh Tendernss

Motion: Straight Leg Raise

Motion: Knee Flexion (Please put a number)

Motion: Knee Extension (lack of full extension is a positive integer- for example a 20 flexion contr

Motion: Hip Flexion

Motion: Hip Extension- Is there a flexion contracture?


Function: Bed to Standing

Function: Standing to Chair

Function: Chair to Standing

Function: Stairs

Function: Gait

Function: Assistive Device Preferred

Pain: Did patient take pain medications prior to visit?

Pain: At Start of Session

Pain: At End of Session

Function: Check Those That Apply


Medications: General

Medications: Anticoagulation

Medications: Pain pill number

Medications: Pain pill frequency

Progress: Rating

Communication: Check Those That Apply


Communication: Contact Number to Call

Plan: Anticipate Further Visits

Discharge: Check Those That Apply


Discharge: Date of Surgeon Follow-up

Discharge: Date of OT/PT Follow-up


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