Patient Name (Last Name, First Name) & MRN: Mileage: Gender: Agency Name/Branch: DOB: / / BP: (Prior) Position Side Heart Rate: Respirations:
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1 Clinician: Mileage: Gender: Agency Name/Branch: M F Time In: Time Out: DOB: HCPCS Select the home health service type that reflects the primary reason for this visit: (G0152) Services Performed by a qualified occupational therapist (G0158) Services performed by a qualified occupational therapist assistant (G0160) Establishment or delivery of a safe and effective occupational therapy maintenance program Select the location where home health services were provided: (Q5001) Care provided in patient's home/residence (Q5002) Care provided in assisted living facility (Q5009) Care provided in place not otherwise specified (NO) Health Status Medical Diagnosis: OT Diagnosis: Homebound? O Yes O No Residual Weakness Needs assistance for all activities Requires max assistance / taxing effort to leave home Other: Unable to safely leave home unattended Severe SOB or SOB upon exertion Confusion, unsafe to go out of home alone Vital Signs BP: (Prior) Position Side Heart Rate: Respirations: Prior / Lying Sitting Standing Left Right Prior Prior O 2 Saturation: Room Air / Rate 2.5 Ipm 6.0 Ipm 12.0 Ipm Route Prior Room Air 3.0 Ipm 7.0 Ipm 13.0 Ipm via NC 0.5 Ipm 3.5 Ipm 8.0 Ipm 14.0 Ipm via Mask 1.0 Ipm 4.0 Ipm 9.0 Ipm 15.0 Ipm via Trach 1.5 Ipm 4.5 Ipm 10.0 Ipm 2.0 Ipm 5.0 Ipm 11.0 Ipm Other: see BP: (During) Position Side Heart Rate: Respirations: During / Lying Sitting Standing Left Right During During via Other: see Kinnser Software 2016 OT Visit Page 1 of 9
2 O 2 Saturation: Room Air / Rate 2.5 Ipm 6.0 Ipm 12.0 Ipm Route During Room Air 3.0 Ipm 7.0 Ipm 13.0 Ipm via NC 0.5 Ipm 3.5 Ipm 8.0 Ipm 14.0 Ipm via Mask 1.0 Ipm 4.0 Ipm 9.0 Ipm 15.0 Ipm via Trach 1.5 Ipm 4.5 Ipm 10.0 Ipm 2.0 Ipm 5.0 Ipm 11.0 Ipm Other: see BP: (Post) Position Side Heart Rate: Respirations: Post / Lying Sitting Standing Left Right Post Post O 2 Saturation: Room Air / Rate 2.5 Ipm 6.0 Ipm 12.0 Ipm Route via Other: see Post Room Air 3.0 Ipm 7.0 Ipm 13.0 Ipm via NC Mid-Treatment Vital Changes: : 0.5 Ipm 3.5 Ipm 8.0 Ipm 14.0 Ipm via Mask 1.0 Ipm 4.0 Ipm 9.0 Ipm 15.0 Ipm via Trach 1.5 Ipm 4.5 Ipm 10.0 Ipm 2.0 Ipm 5.0 Ipm 11.0 Ipm Other: see via Other: see Current Treatment Plan Evaluation Evaluation clinician: Treatment Plan: Subjective Evaluation Subjective Evaluation and Observations Kinnser Software 2016 OT Visit Page 2 of 9
3 Pain Assessment No Pain Reported at Visit Pre-Therapy 0 None High Location: Intensity: Medium 7 9 Primary Site: Post-Therapy 0 None High Intensity: Medium 7 9 Pre-Therapy 0 None High Location: Intensity: Medium 7 9 Secondary Site: Post-Therapy 0 None High Intensity: Medium 7 9 Increased by: Relieved by: Interferes with: Objective Evaluation and Training / Interventions Independence scale key: hover over term for definition Dep Max Assist Mod Assist Min Assist CGA SBA Supervision Mod Indep Indep Balance Training Able to assume / midline orientation Training / Intervention Sitting Static: Good Fair Supported Poor Other (See ) Unsupported Dynamic: Good Fair Supported Poor Standing Static: Good Fair Other (See ) Unsupported Poor Other (See ) Dynamic: Good Fair Poor Other (See ) Assistive Device: With Without Assistive Device: With Without Kinnser Software 2016 OT Visit Page 3 of 9
4 Verbal Cues: Tactile Cues: Deficits Due To / : Bed Mobility Training Assist Level Training / Intervention Rolling L R Assistive Device Supine - Sit Sit - Supine Deficits Due To / : Transfer Training Assist Level Assistive Device Training / Intervention Sit - Stand Stand - Sit Bed - Chair Chair - Bed Toilet or BSC Shower Tub Car / Van Deficits Due To / : Motor Coordination Training Kinnser Software 2016 OT Visit Page 4 of 9
5 Prior to Injury Dominance Right handed Left handed Fine Motor Training / Intervention Gross Motor WNL Deficits Due To / : Impaired Self Care Skills Training Toileting / Hygiene Oral Hygiene Grooming Shaving Bathing Dressing: Upper Body Lower Body Manipulation of Fasteners Socks & Shoes Feeding Swallowing Deficits Due To / : Assist Level Assistive Device Training / Intervention Instrumental ADL Training Assist Level Assistive Device Training / Intervention Light Housekeep Light Meal Prep Clothing Care Kinnser Software 2016 OT Visit Page 5 of 9
6 Use of Telephone Manage Money Manage Medication Home Safety Awareness Deficits Due To / : Cognitive Status / Perception Training Training / Intervention Memory: Short Term Memory: Long Term Safety Awareness Judgment Visual Comprehension Auditory Comprehension Stereognosis Spatial Awareness Ability to Express Needs Attention Span Deficits Due To / : Kinnser Software 2016 OT Visit Page 6 of 9
7 Fall Risk and Functional Testing and Related Testing Previous Follow Up Result Test 1 Test 2 Test 3 Follow Up Testing and Training Training Exercises Therapeutic Exercises ROM Active Active / Assistance Resistive, w/weights Stretching Other Exercise Description(s) Teaching Home Exercise Program Safe Transfer Safety Technique Activities of Daily Living Verbalized Understanding Demonstrated Understanding Correct Use of Adaptive Equipment Correct Use of Assistive Device(s) Required Further Teaching: Title(s) of Teaching Tool(s) Used / Given: Patient Caregiver Kinnser Software 2016 OT Visit Page 7 of 9
8 Assessment Current Treatment Goals Evaluation Treatment Goals: Evaluation clinician: Progress to Goals Progress to goals indicated by: Needs continued skilled OT to address: Progress delayed due to: Other: Additional Narrative Summary Functional Limitations Decreased ROM / Strength Impaired Balance / Gait Increased Pain Decreased Endurance Decreased Transfer Ability Decreased Bed Mobility Decreased Self-Care Poor Safety Awareness : Kinnser Software 2016 OT Visit Page 8 of 9
9 Plan Skilled progress for next visit: Physician contacted to review / update orders Discharge Planning Written notice of discharge provided to patient Care Coordination Conference with: PT PTA OT COTA ST SN Aide Supervisor Other Names: Regarding : Signature and Title: Kinnser Software 2016 OT Visit Page 9 of 9
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Medical Center ADignity Health Member Francisco, ca direct stmarysniedicalcenter.org PATIENT INFORMATION PACKET FOR
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