Seating Benefits Assessment

Transcription

1 Seating Benefits Assessment Alberta Aids to Daily Living Program The information on this form is being collected and used by Alberta Health pursuant to sections 20, 21 and 22 of the Health Information Act, sections 33 and 34 of the Freedom of Information and Protection of Privacy Act (FOIP) and the Alberta Aids to Daily Living and Extended Health Benefits Regulations for the purpose of obtaining an AADL benefit. If you have any questions about the collection of this information, you can contact the Alberta Aids to Daily Living Program at 10 th Floor Milner Building, Street NW, Edmonton, Alberta T5J 0Z2; Telephone: , Fax: Seating Benefits Assessment form MUST be completed for all authorization for AADL seating benefits. Must be attached to Only submit page 1-5. Pages 6-8 are instructions. Complete all fields. Indicate N/A if not applicable to the client. Incomplete assessment forms will be returned. A) Client Information Name: Personal Health Care Number: B) Medical History Diagnosis/condition: Assessment Date: (dd-mm-yyyy) DOB: (dd-mm-yyyy) Does the client have any short term medical conditions that will affect this assessment? No Stable Progressive Yes, explain: What are the client s expectations from the seating assessment and seating equipment? C) Functional Status Wheelchair: AADL funded Privately funded Manual Power Tilt-in-space Recline Make/Model/Size: Wheelchair use: Independent Assisted Dependent Consecutive hours used per day: Comments: Transfers: Ambulation status: Mobility aids: Other adaptive equipment/technology: Activities of daily living: Independent Assisted Dependent Considerations: 1 of 5

2 D) Environmental Considerations Client s residence: Work/school: E) Skin Integrity Significant risk factors and strategies: Braden (or equivalent): Skin integrity during assessment: Intact Previous ulcers Red area Open area Scar tissue Comments: F) Other Considerations Cognitive status: Hearing/vision: Respiratory status: Pain: Other: G) Posture/MAT Assessment Sitting balance/stability: Level of Sitting Scale: Spasticity: Other postural consideration: Page 2 of 5

3 Posture/ROM in Supine Fixed/ Flexible Posture/ROM in Sitting Fixed/ Flexible Tilt: Tilt: Obliquity: Obliquity: Pelvis Kyphosis: Lordosis: Scoliosis: Kyphosis: Lordosis: Scoliosis: Trunk Flex: Abd: Add: Int. Rot.: Flex: Abd Add: Int. Rot.: Hips Ext. Rot.: Ext. Rot.: Upper Extremities Shoulders Head/ Neck Lower Extremities Page 3 of 5

4 H) Measurements A Shoulder width B Chest width C Chest depth D Hip width E Between knees F Top of head G Occiput H Top of shoulder I J Acromion process Inferior angle of scapula or axilla K Seat to elbow Left Right L Iliac crest M Sacrum to popliteal fossa N Knee to heel O Foot length Degree of Hip Flexion Height: Weight: Other measurements or postural assessment information: Page 4 of 5

5 I) Seating Summary (attach additional pages if more space is required) Team Occupational Therapist: Physical Therapist: Members Seating Technician: Other: Client-centered SMART functional goals: Seating Equipment Clinical Justification Seating Needs Level: Level A Basic Level B Specialized Level C Complex J) Authorizer Information Name: Signature: Seating Team: (if required) K) Client Acknowledgment Authorizer #: By signing below, the client (or caregiver) acknowledges that: He/she has participated in the seating assessment and agrees with the seating summary goals and equipment recommendations. Agrees to take care of the equipment provided. Understands the limits of AADL funding for seating equipment. Name: Signature: Date: Provide a copy of this page to the client/caregiver. Page 5 of 5