SHOULDER T-SHEET
CC:
HPI:
Shoulder Pain R 
L 
Onset:
Mechanism of injury:
Location:
Pain below elbow: Yes 
Pain in posterior shoulder: Yes 
Radiation: Yes 
Exacerbating factors:
Relieving factors:
Both 
No  Where:
No  Where:
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:
Redness
Yes 
Warmth
Yes 
Ecchymosis Yes 
Deformity
Yes 
Ulcers
Yes 
Distal Hair pattern:
No 
Location:
No 
Location:
No 
Location:
No 
Location:
No 
Location:
Normal 
Decreased 
Right
ROM of Neck:
Nl  Abnl  ________
Spurling’s Maneuver:
Nl  Abnl  ________
Skin:
Neuro:
ROM:
Abduct 180°:
Extension:
Internal Rotation:
Active Eval:
Sulcus:
Apprehension:
Infraspinatus Strength:
Supraspinatus Strength:
Crossover Test/AC Joint Pain:
Impingement Test: Neer:
Hawkins:
Posterior capsule/dislocation:
Labrum – Click or Clunk:
Left
Nl  Abnl  ________
Nl  Abnl  ________
Yes  No  Painful 
Nl  Abnl  Painful 
Nl  Abnl  Painful 
Nl  Abnormal 
Nl  Abnormal 
Nl 
Reduced 
Nl 
Reduced 
Yes 
No 
Nl 
Painful 
Nl 
Painful 
Nl  Abnormal 
Yes  No  Painful 
Yes  No  Painful 
Nl  Abnl  Painful 
Nl  Abnl  Painful 
Nl  Abnormal 
Nl  Abnormal 
Nl 
Reduced 
Nl 
Reduced 
Yes 
No 
Nl 
Painful 
Nl 
Painful 
Nl  Abnormal 
Yes  No  Painful 
Nl  Tender  Effusion 
Nl  Tender  Effusion 
Nl  Tender  Deformity 
Nl  Tender  Effusion 
Nl  Tender  Effusion 
Nl  Tender  Deformity 
(circumduction in abduction)
Soft Tissue:
(Palpation)
SC Joint:
AC Joint:
Clavicle:
TREAT APPROPRIATELY
TREAT WITH CLOSE
FOLLOW-UP
Shoulder Instability (AMBRI) ..................................... 718.81
Impingement ............................................................... 726.2
Osteoarthritis ............................................................ 715.91
Rotator Cuff Tear ........................................................ 840.4
Dislocation/Subluxation ............................................ 831.00
AC Joint Separation ................................................... 831.04
Rotator Cuff Tendinitis (supraspinatus) .................... 726.10
Rotator Cuff Tendinitis (infraspinatus) ..................... 726.19
Shoulder pain, nonspecific with negative exam ....... 719.41
Status Post dislocation
(< 1 week f/u)
CALL CONSULTANT
THAT DAY
CONSULT
OR
REFER
Dislocation
Fracture
Major Trauma
Suspected or Confirmed rotator cuff tear with no response to PT
Recurrent dislocations
Suspected labral tear
Radiculopathy
Young/Active patient with no response to 4 wks of PT or treatment
TUBS instability
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.