ELBOW T-SHEET
CC:
Elbow Pain R 
HPI:
Onset:
Mechanism of injury:
Location:
Radiation:
Yes 
Exacerbating factors:
Relieving factors:
L 
Both 
No 
Where:
ROS:
Fever  Chills 
Weakness  Night Pain 
PMHx:
Meds:
Allergies:
Chronic medical conditions:
Immunizations Current:
Yes  No 
Soc Hx:
Occupation and/or Activities:
Smoking status: Current  Past  Never 
IV Drug Use:
Yes  No 
PE:
Vital Signs:
BP:
Numbness  Paresthesias 
Weight Loss 
Amount_________
P:
Wt:
BMI:
RR:
General Appearance:
Skin:
Vascular:
Neuro:
ROM:
Redness
Yes 
Warmth
Yes 
Ecchymosis Yes 
Deformity
Yes 
Ulcers
Yes 
Distal Hair pattern:
No 
No 
No 
No 
No 
Location:
Location:
Location:
Location:
Location:
Normal 
Decreased 
Right
Radial Pulse: Nl    Absent 
Capillary Refill:
Normal  Slow 
Spurling’s Maneuver:
C6 Biceps:
Sensory Exam:
Nl  Abn  ________
Nl  Abn  ________
Nl  Abn  ________
Supination: Nl 
Pronation: Nl 
Flexion: Nl 
Extension: Nl 
Soft Tissue:
Olecranon Effusion:
(Palpation)
Olecranon (tender):
Lateral Epicondyle (tender):
Biceps insertion tendon
(tender - distally):
Abn 
Abn 


Yes 
Yes 
Yes 
Yes 
Painful 
Painful 
Painful 
Painful 
No 
No 
No 
No 
Left
Nl    Absent 
Normal  Slow 
Nl  Abn  ________
Nl  Abn  ________
Nl  Abn  ________
Nl 
Nl 
Nl 
Nl 
Abn 
Abn 


Yes 
Yes 
Yes 
Yes 
Painful 
Painful 
Painful 
Painful 
No 
No 
No 
No 
TREAT APPROPRIATELY
TREAT WITH CLOSE
FOLLOW-UP
(< 1 week f/u)
CALL CONSULTANT
THAT DAY
CONSULT
OR
REFER
Olecranon Bursitis ............................................... 726.33
Lateral Epicondylitis ............................................ 726.32
Medical Epicondylitis .......................................... 726.31
Pain in Elbow ....................................................... 719.42
Osteoarthritis ...................................................... 715.92
Contusion ............................................................ 923.11
Cubital Tunnel Syndrome...................................... 354.2
Cellulitis
Patients with decreased ROM
Patients with Normal X-ray
Distal biceps rupture
Suspected septic arthritis
Fracture
Limited ROM with no improvement over 1 week
Undiagnosed pain
Plan:
 Xray / Imaging
 Laboratory Eval
 NSAIDs
 Acetaminophen
 Other
 PRICE Protocol
 Physical Therapy
Disposition:
 Treatment initiated: Follow-up __________ weeks
 Treatment / Work up Initiated: Follow-up ≤ 1 week __________ days
 Immediate call to Dr.
 Consultation initiated with Dr.
 Referral to Dr.