PT Goals - Certification or Supplemental Orders

Transcription

1 General G01 PT Rehab potential excellent for stated goals C General G02 PT Rehab potential good for stated goals C General G03 PT Rehab potential fair for stated goals C General G04 PT Discharge when goals met or patient no longer meets criteria for services C General G05 PT Discharge to outpatient services when able to attend C General G06 PT Discharge when C General G07 Patient's incision heals without complication by General G08 Patient demonstrates adequate oxygenation as evidenced by A02 C Medication Management G01 Patient verbalizes understanding of medication regimen Medication Management G02 Patient/caregiver demonstrates knowledge of medication dosage, frequency, actions, side effects, and interactions Medication Management G03 Patient adheres to medication/treatment regimen Medication Management G04 Patient/caregiver demonstrates ability to manage anticoagulant therapy safely Medication Management G05 Patient/caregiver demonstrates proper prefill of medication planner Medication Management G06 Patient/caregiver demonstrates independence in management of injection(s) kin G01 Patient/caregiver verbalizes understanding of methods to prevent pressure ulcers kin G02 Patient/caregiver verbalizes methods to prevent skin impairment Pain G01 Patient verbalizes acceptable level of comfort within Pain G02 Patient verbalizes understanding of pain management techniques Therapeutic Ex-Manual G01 Patient/caregiver demonstrates understanding of Home Exercise Program with Therapeutic Ex-Manual G02 Patient demonstrates improved functional mobility by increased ROM of Therapeutic Ex-Manual G03 Patient demonstrates improved functional mobility by increased strength of Therapeutic Ex-Manual G04 Patient demonstrates increased activity/endurance as evidenced by Therapeutic Ex-Manual G05 Patient demonstrated improved balance as evidenced by Therapeutic Ex-Manual G06 Patient demonstrates improved vestibular signs/symptoms as evidenced by Therapeutic Ex-Manual G07 Patient demonstrates improved fluid/edema management as evidenced by Therapeutic Ex-Manual G08 Patient will exhibit decreased edema as evidenced by (measurement in cm) Therapeutic Ex-Manual G09 Patient demonstrates appropriate application of compression garments/wraps Function G01 Patient transfers safely in/out of tub/shower with Function G02 Patient transfers safely on/off toilet with Function G03 Patient transfers safely in/out of bed with Function G04 Patient transfers safely in/out of chair with Function G06 Patient transfers safely on/off the floor with Function G16 Patient transfers safely in/out of car with Function G05 Patient transfers safely in/out of wheelchair with Function G07 Patient ambulates safely with

2 Function G08 Patient ambulates steps/curb safely with Function G17 Patient ambulates ramps safely with Function G09 Patient ambulates uneven surfaces safely with Function G18 Patient ambulates even surfaces safely with Function G10 Patient demonstrates safe bed mobility with Function G11 Patient demonstrates increased balance as evidenced by improved score of (TUG/Tinetti/BERG) Function G12 Patient demonstrates manual wheelchair mobility safely with Function G27 Patient demonstrates powered wheelchair mobility safely with Function G13 Patient/caregiver demonstrates safe use of assistive devices with Function G00 Patient demonstrates adherence with restrictions and precautions (weight bearing/rom) Function G19 Patient/caregiver demonstrates knowledge of fall/safety precautions Function G14 Patient correctly dons/doffs orthotic/prosthetic safely with Function G15 Patient correctly dons/doffs cast/splint safely with Function G20 Patient demonstrates independent dynamic sitting balance with Function G21 Patient demonstrates independent static standing balance with Function G22 Patient demonstrates independent dynamic standing balance with Function G23 Patient demonstrates improved aerobic capacity as evidenced by Function G24 Patient/caregiver verbalize understanding of perceptual deficits and effect on safety Function G25 Patient/caregiver verbalize understanding of visual deficits and effect on safety Function G26 Patient/caregiver verbalize understanding of sensory deficits and effect on safety Function G28 Patient/caregiver verbalize understanding of joint protection and injury prevention Function G29 Patient verbalizes understanding of disease process Function G30 Patient/caregiver verbalize understanding of contracture prevention Function G31 Patient will have decreased spasticity/tone as evidenced by Function G32 Patient will have increased tone as evidenced by Cardiovascular CHF G01R Patient/caregiver demonstrates knowledge of cardiovascular disease management/complications and understands when to report variances Cardiovascular CHF G02 Patient maintains stable cardiovascular status at baseline within parameters Cardiovascular CHF G03 Patient has reduced episodes of chest discomfort Cardiovascular CHF G04 Patient has reduced episodes of shortness of breath Cardiovascular CHF G05 Patient/caregiver verbalizes signs/symptoms of cardiac disease Cardiovascular CHF G06 Patient verbalizes methods to decrease edema Cardiovascular CHF G07 Patient will monitor and record weight daily and report if outside of ordered parameters Cardiovascular CHF G08 Patient is compliant with Oxygen use and safety precautions Cardiovascular CHF G09 Patients PT/INR levels will remain within therapeutic range Cardiovascular CHF G10 Patient/cargiver demonstrates understanding of proper use of cardiac medications and side effects

3 Cardiovascular CHF G11 Patient is compliant with low sodium heart healthy diet Cardiovascular CHF G12 Patient is compliant with fluid restrictions and intake monitoring Cardiovascular CHF G13 Patient's surgical wound heals without signs/symptoms of infection/complication by Cardiovascular CHF G14 Patient/caregiver demonstrates ability to manage anticoagulant therapy safely Cardiovascular CHF G15 Patient/caregiver demonstrates proper prefill of medication planner Cardiovascular CHF G16 Patient will verbalize benefits of smoking cessation Cardiovascular CHF G17 Patient demonstrates adherence with restrictions and precautions (weight bearing/rom) Cardiovascular CHF G18 Patient transfers safely in/out of tub/shower with Cardiovascular CHF G19 Patient transfers safely on/off toilet with Cardiovascular CHF G20 Patient transfers safely in/out of bed with Cardiovascular CHF G21 Patient transfers safely in/out of chair with Cardiovascular CHF G22 Patient transfers safely in/out of wheelchair with Cardiovascular CHF G23 Patient transfers safely on/off the floor with Cardiovascular CHF G24 Patient transfers safely in/out of car with Cardiovascular CHF G25 Patient ambulates safely with Cardiovascular CHF G26 Patient ambulates steps/curb safely with Cardiovascular CHF G27 Patient ambulates ramps safely with Cardiovascular CHF G28 Patient ambulates uneven surfaces safely with Cardiovascular CHF G29 Patient ambulates even surfaces safely with Cardiovascular CHF G30 Patient demonstrates safe bed mobility with Cardiovascular CHF G31 Patient demonstrates increased balance as evidenced by improved score of (TUG/Tinetti/BERG) Cardiovascular CHF G32 Patient demonstrates manual wheelchair mobility safely with Cardiovascular CHF G33 Patient demonstrates powered wheelchair mobility safely with Cardiovascular CHF G34 Patient/caregiver demonstrates safe use of assistive devices with Cardiovascular CHF G35 Patient correctly dons/doffs orthotic/prosthetic safely with Cardiovascular CHF G36 Patient correctly dons/doffs cast/splint safely with Cardiovascular CHF G37 Patient demonstrates independent static sitting balance with Cardiovascular CHF G38 Patient demonstrates independent dynamic sitting balance with Cardiovascular CHF G39 Patient demonstrates independent static standing balance with Cardiovascular CHF G40 Patient demonstrates independent dynamic standing balance with Cardiovascular CHF G41 Patient demonstrates improved aerobic capacity as evidenced by Cardiovascular CHF G42 Patient demonstrates proficiency in use of HELP system afety G01 Patient/caregiver demonstrates safe, effective use of equipment afety G02 Patient/caregiver demonstrates knowledge of fall/safety precautions afety G03 Caregiver demonstrates proper body mechanics related to patient care afety G06 Patient maintains level of mobility and participation in ADLs within the limits of disease process

4 afety G07 Patient/caregiver demonstrate safe mobility and transfer techniques Joint Hip G01 Patient transfers safely in/out of tub/shower with Joint Hip G02 Patient transfers safely on/off toilet with Joint Hip G03 Patient transfers safely in/out of bed with Joint Hip G04 Patient transfers safely in/out of chair with Joint Hip G05 Patient transfers safely on/off the floor with Joint Hip G06 Patient transfers safely in/out of car with Joint Hip G07 Patient transfers safely in/out of wheelchair with Joint Hip G08 Patient ambulates safely with Joint Hip G09 Patient ambulates steps/curb safely with Joint Hip G10 Patient ambulates ramps safely with Joint Hip G11 Patient ambulates uneven surfaces safely with Joint Hip G12 Patient ambulates even surfaces safely with Joint Hip G13 Patient demonstrates safe bed mobility with Joint Hip G14 Patient demonstrates increased balance as evidenced by improved score of (TUG/Tinetti/BERG) Joint Hip G15 Patient demonstrates manual wheelchair mobility safely with Joint Hip G16 Patient demonstrates powered wheelchair mobility safely with Joint Hip G17 Patient/caregiver demonstrates safe use of assistive devices with Joint Hip G18 Patient/caregiver demonstrates safe, effective use of equipment Joint Hip G19 Patient demonstrates adherence with restrictions and precautions (weight bearing/rom) Joint Hip G20 Patient/caregiver demonstrates knowledge of fall/safety precautions Joint Hip G21 Caregiver demonstrates proper body mechanics related to patient care Joint Hip G22 Patient maintains level of mobility and participation in ADLs within the limits of disease process Joint Hip G23 Patient/caregiver demonstrate safe mobility and transfer techniques Joint Hip G24 Patient's surgical incision heals without signs/symptoms of infection/complication by Joint Hip G25 Patient verbalizes acceptable level of comfort within Joint Hip G26 Patient verbalizes understanding of pain management techniques Joint Hip G27 Patient/caregiver demonstrates understanding of Home Exercise Program with Joint Hip G28 Patient demonstrates improved functional mobility by increased ROM of Joint Hip G29 Patient demonstrates improved functional mobility by increased strength of Joint Hip G30 Patient demonstrates increased activity/endurance as evidenced by Joint Hip G31 Patient demonstrated improved balance as evidenced by Joint Hip G32 Patient/caregiver demonstrates home/fire/oxygen safety techniques Joint Hip G33 Patient/caregiver verbalizes plan for evacuation in the event of an emergency Joint Hip G34 Patient/caregiver verbalizes/demonstrates proper hand washing technique Joint Hip G35 Patient verbalizes understanding of medication regimen

5 Joint Hip G36 Patient/caregiver demonstrates knowledge of medication dosage, frequency, actions, side effects, and interactions Joint Hip G37 Patient adheres to medication/treatment regimen Joint Hip G38 Patient/caregiver demonstrates ability to manage anticoagulant therapy safely Joint Hip G39 Patient/caregiver demonstrates proper prefill of medication planner Joint Hip G40 Patient/caregiver demonstrates independence in management of injection(s) Joint Hip G41 Patient demonstrates independent static sitting balance with Joint Hip G42 Patient demonstrates independent dynamic sitting balance with Joint Hip G43 Patient demonstrates independent static standing balance with Joint Hip G44 Patient demonstrates independent dynamic standing balance with Joint Hip G45 Patient demonstrates improved aerobic capacity as evidenced by Joint Hip G46 Patient correctly dons/doffs orthotic/prosthetic safely with Joint Hip G47 Patient verbalizes anterior/posterior total hip precautions Joint Knee G01 Patient transfers safely in/out of tub/shower with Joint Knee G02 Patient transfers safely on/off toilet with Joint Knee G03 Patient transfers safely in/out of bed with Joint Knee G04 Patient transfers safely in/out of chair with Joint Knee G05 Patient transfers safely on/off the floor with Joint Knee G06 Patient transfers safely in/out of car with Joint Knee G07 Patient transfers safely in/out of wheelchair with Joint Knee G08 Patient ambulates safely with Joint Knee G09 Patient ambulates steps/curb safely with Joint Knee G10 Patient ambulates ramps safely with Joint Knee G11 Patient ambulates uneven surfaces safely with Joint Knee G12 Patient ambulates even surfaces safely with Joint Knee G13 Patient demonstrates safe bed mobility with Joint Knee G14 Patient demonstrates increased balance as evidenced by improved score of (TUG/Tinetti/BERG) Joint Knee G15 Patient demonstrates manual wheelchair mobility safely with Joint Knee G16 Patient demonstrates powered wheelchair mobility safely with Joint Knee G17 Patient/caregiver demonstrates safe use of assistive devices with Joint Knee G18 Patient/caregiver demonstrates safe, effective use of equipment Joint Knee G19 Patient demonstrates adherence with restrictions and precautions (weight bearing/rom) Joint Knee G20 Patient/caregiver demonstrates knowledge of fall/safety precautions Joint Knee G21 Caregiver demonstrates proper body mechanics related to patient care Joint Knee G22 Patient maintains level of mobility and participation in ADLs within the limits of disease process Joint Knee G23 Patient/caregiver demonstrate safe mobility and transfer techniques

6 Joint Knee G24 Patient's surgical incision heals without signs/symptoms of infection/complication by Joint Knee G25 Patient verbalizes acceptable level of comfort within Joint Knee G26 Patient verbalizes understanding of pain management techniques Joint Knee G27 Patient/caregiver demonstrates understanding of Home Exercise Program with Joint Knee G28 Patient demonstrates improved functional mobility by increased ROM of Joint Knee G29 Patient demonstrates improved functional mobility by increased strength of Joint Knee G30 Patient demonstrates increased activity/endurance as evidenced by Joint Knee G31 Patient demonstrated improved balance as evidenced by Joint Knee G32 Patient/caregiver demonstrates home/fire/oxygen safety techniques Joint Knee G33 Patient/caregiver verbalizes plan for evacuation in the event of an emergency Joint Knee G34 Patient/caregiver verbalizes/demonstrates proper hand washing technique Joint Knee G35 Patient verbalizes understanding of medication regimen Joint Knee G36 Patient/caregiver demonstrates knowledge of medication dosage, frequency, actions, side effects, and interactions Joint Knee G37 Patient adheres to medication/treatment regimen Joint Knee G38 Patient/caregiver demonstrates ability to manage anticoagulant therapy safely Joint Knee G39 Patient/caregiver demonstrates proper prefill of medication planner Joint Knee G40 Patient/caregiver demonstrates independence in management of injection(s) Joint Knee G41 Patient demonstrates independent static sitting balance with Joint Knee G42 Patient demonstrates independent dynamic sitting balance with Joint Knee G43 Patient demonstrates independent static standing balance with Joint Knee G44 Patient demonstrates independent dynamic standing balance with Joint Knee G45 Patient demonstrates improved aerobic capacity as evidenced by Joint Knee G46 Patient correctly dons/doffs orthotic/prosthetic safely with Joint Knee G47 Patient/caregiver demonstrates appropriate application and use of CPM Joint houlder G01 Patient transfers safely in/out of tub/shower with Joint houlder G02 Patient transfers safely on/off toilet with Joint houlder G03 Patient transfers safely in/out of bed with Joint houlder G04 Patient transfers safely in/out of chair with Joint houlder G05 Patient transfers safely on/off the floor with Joint houlder G06 Patient transfers safely in/out of car with Joint houlder G07 Patient transfers safely in/out of wheelchair with Joint houlder G08 Patient ambulates safely with Joint houlder G09 Patient ambulates steps/curb safely with Joint houlder G10 Patient ambulates ramps safely with Joint houlder G11 Patient ambulates uneven surfaces safely with

7 Joint houlder G12 Patient ambulates even surfaces safely with Joint houlder G13 Patient demonstrates safe bed mobility with Joint houlder G14 Patient demonstrates increased balance as evidenced by improved score of (TUG/Tinetti/BERG) Joint houlder G15 Patient demonstrates manual wheelchair mobility safely with Joint houlder G16 Patient demonstrates powered wheelchair mobility safely with Joint houlder G17 Patient/caregiver demonstrates safe use of assistive devices with Joint houlder G18 Patient/caregiver demonstrates safe, effective use of equipment Joint houlder G19 Patient demonstrates adherence with restrictions and precautions (weight bearing/rom) Joint houlder G20 Patient/caregiver demonstrates knowledge of fall/safety precautions Joint houlder G21 Caregiver demonstrates proper body mechanics related to patient care Joint houlder G22 Patient maintains level of mobility and participation in ADLs within the limits of disease process Joint houlder G23 Patient/caregiver demonstrate safe mobility and transfer techniques Joint houlder G24 Patient's surgical incision heals without signs/symptoms of infection/complication by Joint houlder G25 Patient verbalizes acceptable level of comfort within Joint houlder G26 Patient verbalizes understanding of pain management techniques Joint houlder G27 Patient/caregiver demonstrates understanding of Home Exercise Program with Joint houlder G28 Patient demonstrates improved functional mobility by increased ROM of Joint houlder G29 Patient demonstrates improved functional mobility by increased strength of Joint houlder G30 Patient demonstrates increased activity/endurance as evidenced by Joint houlder G31 Patient demonstrated improved balance as evidenced by Joint houlder G32 Patient/caregiver demonstrates home/fire/oxygen safety techniques Joint houlder G33 Patient/caregiver verbalizes plan for evacuation in the event of an emergency Joint houlder G34 Patient/caregiver verbalizes/demonstrates proper hand washing technique Joint houlder G35 Patient verbalizes understanding of medication regimen Joint houlder G36 Patient/caregiver demonstrates knowledge of medication dosage, frequency, actions, side effects, and interactions Joint houlder G37 Patient adheres to medication/treatment regimen Joint houlder G38 Patient/caregiver demonstrates ability to manage anticoagulant therapy safely Joint houlder G39 Patient/caregiver demonstrates proper prefill of medication planner Joint houlder G40 Patient/caregiver demonstrates independence in management of injection(s) Joint houlder G41 Patient demonstrates independent static sitting balance with Joint houlder G42 Patient demonstrates independent dynamic sitting balance with Joint houlder G43 Patient demonstrates independent static standing balance with Joint houlder G44 Patient demonstrates independent dynamic standing balance with Joint houlder G45 Patient demonstrates improved aerobic capacity as evidenced by Joint houlder G46 Patient correctly dons/doffs orthotic/prosthetic safely with

8 Joint houlder G47 Patient/caregiver demonstrates appropriate application and use of CPM Joint houlder G48 Patient performs feeding with Joint houlder G49 Patient performs simple grooming/hygiene with Joint houlder G50 Patient performs oral care with Joint houlder G51 Patient performs toileting hygiene with Joint houlder G52 Patient performs clothing management for toileting with Joint houlder G53 Patient performs upper body dressing with Joint houlder G54 Patient performs lower body dressing with Joint houlder G55 Patient performs sponge bathing in bed with Joint houlder G56 Patient performs sponge bathing in chair with Joint houlder G57 Patient performs showering with Joint houlder G58 Patient performs/participates in meal preparation with Joint houlder G59 Patient performs/participates in laundry with Joint houlder G60 Patient performs/participates in housekeeping with Joint houlder G61 Patient demonstrates safe use of adaptive equipment Joint houlder G62 Patient correctly dons/doffs orthotic/prosthetic with