Plan of Treatment Provider No Onset SOC Clinical Interview The Interview was completed with: Patient Spouse Caregiver Other: Patient Age: Years Mental Status: Alert Oriented x Impaired: Living Situation The patient resides in a: Home Apt/Condo ILF ALF or Other: Accessibility: Level Ramped Steps: To Enter In Home Concerns: The patient lives: Alone or with Spouse Family Caregiver (Hours/Days) Other: Who currently helps with ADLs? Reason for Referral/Symptom Onset Medical History/Medications Additional Complexities that Impact Care Assistive Device History Prior to the onset of the current condition, Patient utilized: (List equipment used): Currently Patient utilizes: Comments (Address safety and effective use of equipment): Fall History & Risk Assessment Patient has had falls. The last fall occurred on (date): Location: which resulted in (Describe injury or condition): Patient is at risk for falls due to: Loss of balance Poor postural alignment/control Difficulty walking Freezing when walking Is patient able to call for help? Yes No Comments: Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or, Patient has received PT OT SLP in the last 12 months for the current or a previous condition Describe: Patient is not currently receiving home health services PT Plan of Treatment Page 1 of 2 Revised: 01/2013
Plan of Treatment Page 2 Impact on Function Prior Level of Function Independent Required Assistance (Describe) Current Level of Function (Summary from PT Evaluation) Applicable G- Code with Severity Modifier (Impairment) Priority G- Code Functional Area Admission Goal Ranking Code Impairment Level Code Impairment Level (0-100%) (0-100%) Mobility: Walking & Moving Around G8978 G8979 Changing & Maintaining Body Position G8981 G8982 Carrying, Moving & ling Objects G8984 G8985 Self Care G8987 G8988 Other Primary Functional Limitation G8990 G8991 Other Subsequent Functional Limitation G8993 G8994 Instructions: Rank in order of priority from 1-6 with only ONE primary limitation which will be the billable code. Document N/A if appropriate. Plan of Care Recommended # of Visits for Skilled POC: Visits Frequency: /week Duration: hours/visit Certification Period: Start: End: _ (Max 90 days) Rehabilitation Potential: Excellent Good Fair Guarded Poor Long Term Goals: (Number each goal) Skilled Intervention to Include 97110 Therapeutic Exercise 97112 Neuromuscular Re- Education 97116 Gait Training 97140 Manual Therapy 97542 Wheelchair Training 97761 Prosthetic Training Other: Additional Recommendations OT Evaluation SLP Evaluation Social Services Adaptive Equipment: _ Medical Follow- Up For: Other: Therapist Name & Credentials (Please Print) Professionals Establishing This Plan of Care Therapist Signature Physician Name (Please Print) X As of the date of this evaluation, I certify the pertinent medical history and the need for skilled services that have been completed in consultation with the evaluating therapist under this plan. Physician Signature X PT Plan of Treatment Page 2 of 2 Revised: 01/2013
MI HICN Provider No Onset SOC Clinical Evaluation Range of Motion Grossly WFL or Impaired (Check all Areas of Impairment) Cervical Spine Lumbar Spine Left UE Right UE Left LE ROM Measurements Right LE Muscle Strength Grossly WFL or Impaired (Check all Areas of Impairment) Cervical Spine Lumbar Spine Left UE Right UE Left LE MMT Measurements Right LE Muscle Tone Grossly WFL or Impaired (Describe Area & Level of Impairment Using Modified Ashworth Scale 0-4) Sensation Grossly WFL or Impaired (Describe) Edema Not Present Present (Describe) Pain Not Present Present (Describe using 0-10 Visual Analog Scale) Endurance Good Fair Poor (Describe Activity Tolerance in minutes or activity before rest is required) Other Pertinent Clinical Findings PT Initial Evaluation Page 1 of 2 Revised: 01/2013
Functional Scoring Guidelines (FIM Score) 7=Independent 6=Modified Independent 5=Supervision 4=Min Assist (25%) 3=Mod Assist (50%) 2=Max Assist (75%) 1=Total Assist (76% or >) Mobility Assessment Test(s) Administered Clinical Assessment Tinetti Gait/Balance Assessment Other: Test Results: Score: Interpretation: Gait Pattern WFL or Impaired (Describe) Ambulation FIM Prior LOF FIM Eval LOF Assessment Notes FIM Goal LOF Household Uneven Surface Outdoors/Community Stairs Global FIM Score Total Mobility Impairment Level PLOF CLOF Goal LOF Changing & Maintaining Body Position Test(s) Administered Clinical Assessment BERG Balance Scale Other: Test Results: Score: Interpretation: Postural Evaluation WFL or Affects Function (Describe) Transfers FIM Prior LOF FIM Eval LOF Assessment Notes FIM Goal LOF Bed/Chair Chair/Stand Toilet Tub/Shower Car Balance Sitting Unsupported Standing Unsupported Dynamic Balance Challenged Balance Global FIM Score Total Body Position Impairment Level PLOF CLOF Goal LOF Supplemental Functional Assessment Findings PT Initial Evaluation Page 2 of 2 Revised: 01/2013
Evaluation Encounter Note Provider No Onset SOC Billing & Coding Services Rendered Intake Evaluation Skilled Therapy Intake Information Summary 97001 PT Evaluation 97110 Therapeutic Exercise 97112 Neuromuscular Re- Education 97116 Gait Training 97140 Manual Therapy 97542 Wheelchair Training Total Time (Minutes) Total Units Plan: As per Plan of Treatment Time Spent for Care: Time In: AM/PM Time Out: AM/PM Patient Certification I certify that I was seen today by the therapist named below and that the time spent for my care is correct. I understand and agree to the plan of care recommended. I certify that I am not receiving home health services at this time Patient/Authorized Representative (Please Print) Patient/Authorized Signature X Therapist Name & Credentials (Please Print) Provider Certification Therapist Signature X PT Evaluation Encounter Note Revised: 03/2013