Molly Gallagher

00022 
 Maple Grove Clinic 
 2147 Haley Orchard
Lopezborough, NH 82867 
 Tel: 921-828-6878 
 Maple Grove Clinic 
 Fax: 315-582-1958 
 www.landswickpt.com 
 PHYSICAL THERAPY. INC. 
 Quick SOAP 
 patient name (ID 1 birth date): Molly Gallagher (cazaresa I 1998-04-26) 
 Treatment Date: 2019-10-28 11:30 AM 
 Insurance: 
 Gallagher Bassett Services - California 
 Visits: 
 2 
 Episode: 
 R elbow 
 Re-Eval Due: 
 Referrer: 
 Dr Alexa Silva MD 
 Next Follow-up: 
 Diagnosis Codes: 
 Peptic Ulcer (E11), Myocardial Infarction (K52), Thyroid Disorder (J45)
 SOAP 
 Subjective 
 Pt reports that she was a little sore after last session.
 Objective 
 Tx: STM triceps, wrist extensors, wrist supinators, biceps; CFM along medial and lateral epicondyles; 
 Plan 
 Cont per POC. 
 EXERCISE FLOWSHEET 
 See hard copy for list of exercises. 
 CHARGESHEET 
 Time Information 
 Total Direct Time 
 30 Minutes 
 Billing Codes 
 Code 
 Description 
 Units 
 Comments 
 82499 
 Joint Mob/STM/Manual Therapy 
 2 
 Electronically Signed by: Alyssa Mcconnell, PT, DPT (Random_7_digit_number) 
 Date: 2017-03-28 
 (This document was electronically signed on 2017-03-28 by Alyssa Mcconnell) 
 Note written with MWTherapy I Patient ID/patient name (birth date): cazaresa/Molly Gallagher (1998-04-26) I D.O.S: 2017-03-10 11:30 AM 
 Page 1 of 1 
 82499 
 82493373306 
 Received 2019-07-24
