OT Routine Visit Note Page 1
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1 OT Routine Visit Note Page 1 Vital Signs Temperature: Apical: Pulse Radial: Resp: Lung Sounds: (L) / min Sitting Standing Lying (L) B/P (R) Pain Pain Type: Aching Dull Aching Constant Nagging Burning Gnawing Location: Annoying Throbbing Stabbing Prickling Shooting Electric No Pain Reported Patients acceptable level of pain: Patients present level of pain: (R) Pulse Ox: Patient unable to stand PT INR sec Body Circumference: Weight: Pounds Left Right Arm: Height: Inches Thigh: Telehealth Monitoring Non Verbal Pain Assessment: Not Reported/Observed Facial Grimaces Onset: Restlessness Guarding Rigidity Moaning Crying What makes the pain better? Blood Sugar Blood Glucose Check Performed: Result: Hours mg/dl What makes pain worse? FSBS: Range Relief with Medications: Oxygen Oxygen By L/Min for shortness of breath. History of pain management: Allergies Regimen Current Pain Control Regimen/ Effectiveness of pain control regimen: Repositioning Heat Ice Medication Rest/Relaxation Massage Diversion Care plan reflects pain interventions/goals
2 OT Routine Visit Note Page 2 Episode Date: OT Visit Note Visit Goals Assessed/No Problem Assess ADLs: Teach ADLs: IADLs: IADLs: Functional mobility: Functional mobility: Transfers: Safe transfers: ROM: Body mechanics: Strength: Therapeutic exercise: Shortness of breath: Energy conservation principles: Dyspnea on exertion: Breathing Techniques: Compliance with oxygen therapy & safety: Signs/symptoms of heart failure: Effectiveness of oxygen therapy: Compliance/effectiveness of medication protocol: Importance of prescribed oxygen therapy to prevent heart failure symptoms: Agency Care guidelines & seeking appropriate medical attention: Understanding prescribed diet: Understanding of Agency Care Guidelines: Understanding of patient/caregiver of Disease Management principles: Understanding of importance of rest periods: Effectiveness of telehealth program to prevent unnecessary rehospitalizations: Medication 'Teach Back': High risk medication purpose & side effects: Disease Process 'Teach Back': Importance of follow-up with physician appointments: Importance of discharge planning in maintaining long term functioning: Patient/caregiver coping: Patient/caregiver verbalizes understanding of the following: Disease process:
3 OT Routine Visit Note Page 3 Episode Date: Assessed Continued Progress towards goals/discharge planning process: Plan for next visit: Teach Continued Agency Care Guidelines & when to seek medical help: Medication protocol: High risk medications Diet: Oxygen therapy usage and purpose: Home safety principles: : Perform (Clinician to add below per patient plan of care) ADL training: IADL training: Functional mobility: Safe transfers: Home exercise program: Patient/caregiver demonstrates exercise program:
4 OT Routine Visit Note Page 4 Process Measures Heart failure symptoms identified and addressed timely; MD notified Diabetic foot care; patient/caregiver education implemented Fall prevention implemented Depression prevention implemented Pain prevention implemented Patient/caregiver educated on "high risk meds" Potential medication issues identified; MD contacted Pressure ulcer prevention implemented Pressure ulcer treatment implemented using moist wound healing principles Assess/Teach/Perform for Comorbidities/Additional Diagnosis Comorbidities do not exist
5 OT Routine Visit Note Page 5 If wound has been resolved, use these check boxes to indicate. Wound 1 Resolved Wound 2 Resolved Wound 3 Resolved Location: 1) 2) Origin of Wound: Pressure Vascular Incontinence Pressure Vascular Incontinence Pressure Vascular Surgical Surgical Surgical 3) Incontinence Stage of Wound: Size: Drainage: Drainage Amount: Surrounding Tissue: Odor: Procedure: Patient's Tolerance: S/S of Infection: Pressure Relieving Device(s): Instructions Given: Stage 1 Stage 3 N/A Stage 1 Stage 3 N/A Stage 1 Stage 3 N/A Stage 2 Stage 4 Stage 2 Stage 4 Stage 2 Width Width Width Depth Undermining/Tunneling Depth Undermining/Tunneling Stage 4 Length Length Length Serous Depth Undermining/Tunneling at O'clock at O'clock at Green Yellow/Tan Green Yellow/Tan Green Thin Minimum Moderate Copious Minimum Moderate Copious Minimum Pink Yellow Pink Yellow Pink Yellow Pink Yellow Pink Yellow Thick Purulent Serous Thin Wound Bed Wound Bed Wound Bed Thick Purulent Serous Describe Cleanse With: Rinsed With: Filled With: Covered With: Secured With: Tech: Sterile Well - No Complaint Not Well - Complaint : Patient Clean Describe Cleanse With: Rinsed With: Filled With: Covered With: Secured With: Tech: Sterile Well - No Complaint Not Well - Complaint : Patient Clean Thin Describe Cleanse With: Rinsed With: Filled With: Covered With: Secured With: Tech: Sterile : Patient Yellow/Tan Thick Moderate Well - No Complaint Not Well - Complaint Clean O'clock Purulent Copious ness Hot To Touch ness Hot To Touch ness Hot To Touch Pain Elev. Temp Pain Elev. Temp Pain Elev. Temp None None Odor None Concerning: Serosanguineous Concerning: Serosanguineous Caregiver Concerning: Serosanguineous Pink Caregiver Yellow
6 OT Routine Visit Note Page 6 THERAPY ASSESSMENT SUMMARY GOALS:
7 O T R o u t i n e V i s i t N o t e P a g e 7 HOMEBOUND STATUS Residual weakness Dependent upon adaptive device(s) Confusion, unable to go out of home alone Medical Restrictions Unable to safely leave home unassisted Severe SOB, SOB upon exertion Needs assistance for all activities Requires assistance to ambulate PROGRESS TOWARD THERAPY GOALS PLAN FOR NEXT VISIT DISCHARGE PLANNING CARE COORDINATION (OTHER CARE PROVIDERS) Visit Date Time In Time not recorded on Visit Note End Visit Date Time Out Visit Duration:
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