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Joey is given a prescription from the physician for prescriptions for cyclobenzaprine (Flexeril) 10 mg tid for 3 days only, and celecoxib (Celebrex) 100 mg/day for 3 months.
He is also told to use heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds (4.5 kg). Joey is also instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles.
The physician also gives him a written letter to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds (4.5 kg) for 3 months. He is instructed to contact his primary care provider if the pain gets worse.
Use the following documentation tool to document all your care for this patient
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