PINotes™V2
Wellness Healthcare Clinic Corp
Florida PIP · Initial Evaluation Engine
📂
⚙
Patient Data Input
F
Armando Falcon, M.D.
FL #ME 84789 · NPI 1447295126 · RenuviaMD PLLC

Patient

🪪
Upload Patient ID
Driver's license · Passport · Insurance card · Photo
Scan ID

Accident Details

Patient Seen Before This Visit?
Prior Symptoms Before Accident?
Did the patient have any of the current symptoms prior to the accident?
✓ Causation statements will be included in the report.

Past Medical History

Hypertension
Diabetes
Heart Disease
Asthma/COPD
Arthritis
Prior Spine Surgery
Cancer
Depression/Anxiety
None

Chief Complaints

MD
Neck pain
Mid-back pain
Low-back pain
Right shoulder pain
Left shoulder pain
Right elbow pain
Left elbow pain
Right wrist pain
Left wrist pain
Right knee pain
Left knee pain
Right ankle pain
Left ankle pain
Right hip pain
Left hip pain
Headache
Dizziness
Chest wall pain
Rib pain
Abdominal pain
Right hand pain
Left hand pain
Foot pain
Sleep Difficulty
Anxiety/PTSD
Depression
1
2
3
4
5
6
7
8
9
10
Immediate
Within hours
Next day
Gradual over days

Assessment — ICD-10 Diagnoses

0 codes

Plan — CPT Codes

0 codes

Vital Signs

HEENT

Neurological Screening

General Examination

Spine Examination

RegionTendernessSpasmROM
Cervical
Thoracic
Lumbar
⬇ Chin to Chest"Look down — touch chin to chest."Normal: ~50°
WNL Limited Cannot perform
⬆ Look at Ceiling"Look up at the ceiling."Normal: ~60°
WNL Limited Cannot perform
➡ Ear to Shoulder (R)"Touch right ear to right shoulder."Normal: ~45°
WNL Limited Cannot perform
⬅ Ear to Shoulder (L)"Touch left ear to left shoulder."Normal: ~45°
WNL Limited Cannot perform
↩ Look Over Shoulder (R)"Turn head — look over right shoulder."Normal: ~70°
WNL Limited Cannot perform
↪ Look Over Shoulder (L)"Turn head — look over left shoulder."Normal: ~70°
WNL Limited Cannot perform
🧎 Fingertip to Floor"Slowly bend forward — reach toward floor."Normal: ~60°
WNL Limited Cannot perform
🧍 Backward Lean"Hands on hips — lean backward."Normal: ~25°
WNL Limited Cannot perform
◣ Side Bend Right"Slide right hand down right leg."Normal: ~25°
WNL Limited Cannot perform
◢ Side Bend Left"Slide left hand down left leg."Normal: ~25°
WNL Limited Cannot perform

Extremity / Joint Examination

Shoulder (R / L)Normal
🙌 Raise Arm Overhead R"Raise right arm straight overhead."Normal: ~180°
WNLLimitedCannot perform
🙌 Raise Arm Overhead L"Raise left arm straight overhead."Normal: ~180°
WNLLimitedCannot perform
↗ Reach Behind Head R"Touch back of neck with right hand."Normal: ~90° ER
WNLLimitedCannot perform
↖ Reach Behind Head L"Touch back of neck with left hand."Normal: ~90° ER
WNLLimitedCannot perform
🔒 Tuck In Shirt R (IR)"Touch right hand to small of back."Normal: ~70° IR
WNLLimitedCannot perform
🔒 Tuck In Shirt L (IR)"Touch left hand to small of back."Normal: ~70° IR
WNLLimitedCannot perform
Elbow (R / L)Normal
💪 Touch Own Shoulder R"Bend right elbow — touch right shoulder."Normal: ~145°
WNLLimitedCannot perform
💪 Touch Own Shoulder L"Bend left elbow — touch left shoulder."Normal: ~145°
WNLLimitedCannot perform
🔄 Turn Doorknob R"Right palm up, then palm down."Normal: ~90° each
WNLLimitedCannot perform
🔄 Turn Doorknob L"Left palm up, then palm down."Normal: ~90° each
WNLLimitedCannot perform
Wrist (R / L)Normal
⬆ Bend Wrist Back R"Right hand back — bend wrist backward."Normal: ~70°
WNLLimitedCannot perform
⬆ Bend Wrist Back L"Left hand back — bend wrist backward."Normal: ~70°
WNLLimitedCannot perform
⬇ Bend Wrist Forward R"Right palm — curl wrist forward."Normal: ~80°
WNLLimitedCannot perform
⬇ Bend Wrist Forward L"Left palm — curl wrist forward."Normal: ~80°
WNLLimitedCannot perform
Hip (R / L)Normal
🦵 Flex Hip R"Bring right knee to chest."Normal: ~120°
WNLLimitedCannot perform
🦵 Flex Hip L"Bring left knee to chest."Normal: ~120°
WNLLimitedCannot perform
Knee (R / L)Normal
🪑 Rise from Chair R"Sit — now stand without using hands."Normal: ~135°
WNLLimitedCannot perform
🪑 Rise from Chair L"Repeat — assess left knee."Normal: ~135°
WNLLimitedCannot perform
🪜 Step Up Right"Step up onto this step — right leg."Normal: Stable
WNLLimitedCannot perform
🪜 Step Up Left"Step up onto this step — left leg."Normal: Stable
WNLLimitedCannot perform
Ankle / Foot (R / L)Normal
🦶 Heel-Toe Walk R"Walk heel-to-toe across the room."Normal: ~20° DF
WNLLimitedCannot perform
🦶 Heel-Toe Walk L"Same — assess left ankle."Normal: ~20° DF
WNLLimitedCannot perform
🦶 Stand on Tiptoes R"Rise up on your right tiptoes."Normal: ~50° PF
WNLLimitedCannot perform
🦶 Stand on Tiptoes L"Rise up on your left tiptoes."Normal: ~50° PF
WNLLimitedCannot perform
🔄 Ankle Roll In/Out R"Roll right ankle in, then out."Normal: ±30°
WNLLimitedCannot perform
🔄 Ankle Roll In/Out L"Roll left ankle in, then out."Normal: ±30°
WNLLimitedCannot perform

Assessment / POC

Diagnostic Imaging Orders X-rays auto-mapped from Chief Complaint
Select pain zones above — X-ray orders populate automatically.
MRI Orders w/o Contrast · Optional
70551 MRI Cervical 72146 MRI Thoracic 72148 MRI Lumbar 73221 MRI Shoulder 73221 MRI Elbow 73221 MRI Wrist/Hand 73721 MRI Knee 73721 MRI Ankle/Foot 73721 MRI Hip 70553 MRI Brain
CT Scan Orders w/o Contrast · Optional
72125 CT Cervical 72128 CT Thoracic 72131 CT Lumbar 73200 CT Shoulder 73700 CT Knee 73700 CT Hip 70450 CT Head
95907 EMG/NCV
Ortho
Neuro
Pain Mgmt
PT
Chiro
Psych

Plan of Treatment MD ORDERS

E/M Level — New Patient
99203 — New Patient · Low 99204 — New Patient · Moderate 99205 — New Patient · High Complexity
PT Orders · 5x/week × 4 weeks default (Initial Visit)
Frequency
5x/week 3x/week 4x/week 2x/week Daily PRN
Duration
4 weeks 6 weeks 8 weeks 12 weeks
PT Modalities
97010 Hot/Cold Pack 97012 Mech Traction 97014 E-Stim Unattend 97035 Ultrasound 97110 Therap Exercise 97140 Manual Therapy 97530 Therap Activities 97032 E-Stim Attend 97018 Paraffin Bath
Follow-Up
2 weeks 1 week 3 weeks 4 weeks PRN

Medications RX

NSAID / Analgesic
None Ibuprofen 600mg TID × 2wk Ibuprofen 800mg TID × 2wk Naproxen 500mg BID × 2wk Meloxicam 15mg QD × 4wk Diclofenac 75mg BID × 2wk Acetaminophen 500mg TID PRN
Muscle Relaxant
None Cyclobenzaprine 10mg QHS × 2wk Cyclobenzaprine 5mg TID × 2wk Methocarbamol 500mg TID × 2wk Baclofen 10mg TID × 2wk Tizanidine 4mg TID × 2wk Carisoprodol 350mg TID × 1wk
Topical
None Voltaren Gel 1% BID Lidocaine Patch 5% × 12hrs/day Biofreeze PRN Cyclobenzaprine Cream 2% PRN

OTC Instructions HOME CARE

Ice 20 min QID × 3 days Heat after 72 hrs Activity modification — no heavy lifting Soft collar PRN (cervical) Lumbar support belt PRN Avoid prolonged sitting >30 min

Work & Activity Restrictions POC

Lifting Restriction
No lifting restriction <10 lbs (light duty) <20 lbs No lifting of any weight Sedentary work only No work at this time
Additional Restrictions
No bending/stooping No twisting No overhead reaching No driving No prolonged standing (>30 min) No prolonged sitting (>30 min) No repetitive bending Limited walking Use assistive device (cane/walker) No return to work at this time
Provider Portal doxy.me/renuviamd — Copy Link
Telehealth
Doxy.me — Provider portal loads right here. Copy Link auto-checks in patients by name.
Zoom — Opens in a separate window.
HIPAA-compliant · No downloads for patients · Embedded SDK
⚠

COMPLIANCE AUDIT WARNING

Generation halted to prevent billing errors. Please fix the following:

    PI Notes™ — Medical Report

    📂 Patient Database

    ⚙ Settings

    Stored locally in your browser. Appears on all generated reports.