Initial Assessment Date: Re-Assessment Date: Re-Assessment Date: Follow-Up Discharge Date: Risk Assessment Risk Assessment Risk Assessment Risk Assessment BP SpO2 BP SpO2 BP SpO2 BP SpO2 HR Edema HR Edema HR Edema HR Edema Breath sounds Breath sounds Breath sounds Breath sounds Pulses Pulses Pulses Pulses/Edema Medical History CABG Stent COPD CAD MI Nitroglycerin CHF EF ICD / Pacemaker Clinic: Hypertension Hyperlipidemia Diabetes FBS HbA1c Other Med Hx: BP: SPO2: HR: Pain-Site Scale (1-10) Exercising ADL difficulty 1 2 3 4 5 Dyspnea MMRC scale BODE scale FVC FEV1 Productive cough O2 Use Tobacco use/second hand smoke Quit date Type/how much Risk Stratification Risk Stratification Risk Stratification Low [6-18 sessions] Low [6-18 sessions] Low [6-18 sessions] Mod [12-24 sessions] Mod [12-24 sessions] Mod [12-24 sessions] High [18-36 sessions] High [18-36 sessions] High [18-36 sessions] F771-092J (rev 3/2011) 1
Initial Assessment Re-Assessment Re-Assessment Follow-Up Discharge Exercise Exercise Exercise Exercise 6MWT Ft walked Max HR 6MWT Ft walked Max HR Low SPO2 O2 use Low SPO2 O2 use Max BP RPE (1-10) Max BP RPE (1-10) Ex Prescription Ex Prescription Ex Prescription Ex Prescription Mode (A, N, B, AB, E, R, T, S, DB) Mode (A, N, B, AB, E, R, T, S, DB) Mode (A, N, B, AB, E, R, T, S, DB) Mode (TM, N, B, AB, E, R, W, DB) Weights (1A 1B 2 3 4 5 6F 6B 7 8) Weights (1A 1B 2 3 4 5 6F 6B 7 8) Weights (1A 1B 2 3 4 5 6F 6B 7 8) Weights (1A 1B 2 3 4 5 6F 6B 7 8) Frequency (M, T, W, T, F, S, S) Frequency (M, T, W, T, F, S, S) Frequency (M, T, W, T, F, S, S) Frequency (M, T, W, T, F, S, S) Duration Duration Duration Duration Intensity Intensity Intensity Intensity 30-day Progress 30-day Progress 30-day Progress Progression Start home exercise Aerobic: Home exercise Aerobic: Home exercise Aerobic: Home exercise Aerobic: Resistance Packet: Resistance Packet: Resistance Packet: Resistance Packet: Specific Modality: Specific Modality: Specific Modality: Specific Modality: Fall Risk Recent fall, dizziness, foot numbness, assist device, vision disturbance Tinetti Fall Risk Recent fall, dizziness, foot numbness, assist device, vision disturbance Tinetti F771-092J (rev 3/2011) 2
Initial Assessment Re-Assessment Re-Assessment Follow-Up/Discharge Nutrition Nutrition Nutrition Nutrition Motivation to change [1 2 3 4 5] Motivation to change [1 2 3 4 5] Motivation to change [1 2 3 4 5] Motivation to change [1 2 3 4 5] Weight Management Weight Management Weight Management Weight Management Ht Wt BMI Waist RYP Score RYP Score Set Goal Wt Progress Goal Wt Progress Goal Wt Referral to weight management prg Weekly RYP assessment: Weekly RYP assessment: Weekly RYP assessment: Weekly RYP assessment: Target goal HbA1c <7 FBS <120 BMI <25 or >21 Waist <40 in M/<35in F LDL < 80 cardiac patients F771-092J (rev 3/2011) 3
Initial Assessment Re-Assessment Re-Assessment Follow-Up/Discharge Learning barriers Family support Family support Family support Family support Tobacco cessation: Tobacco Tobacco Tobacco Quit date: Cessation goals: Cessation goals: Cessation goals: Class Log : Individual needs assessed Class Log: taught Individual needs assessed Class Log: taught Individual needs assessed Class Log: taught Individual needs assessed Pulmonary Equipment/Skills Target goal Target goal Target goal Oxygen: Flow rate / delivery / pulse Nebulizer: Meds/ cleaning/ use correctly Mechanics: PLB / ABD / RR PEP / IMT: MDI technique: Spacer: F771-092J (rev 3/2011) 4
Initial Assessment Re-Assessment Re-Assessment Follow-Up/Discharge Psychosocial Psychosocial Psychosocial Psychosocial SF-36 MCS Score SF-36 MCS Score Psychotropic medications : Mental illness Dx: No S/S of depression, anxiety or suicide If MCS <42, then monitor and re-test when no S/S of depression, anxiety, suicide or other mental dysfunction. Stress management class for SF-36 MCS <42 with minimal or no S/S If MCS < 42, re-test: If MCS <42 and S/S persist after 30-45 days notify physician and document plan of action: Triggers/ Coping strategies identified in class: If MCS < 42, re-test: If MCS <42 and S/S persist after 30-45 days notify physician and document plan of action: Note patient progress in stress management: MCS final score: Physician referral for MCS <42 with S/S of depression, anxiety or confusion 1) Recognize triggers that evoke stress 2) Identify new coping strategies 3) Utilize medical director to refer patient to health professional as appropriate F771-092J (rev 3/2011) 5
Initial Assessment Re-Assessment Re-Assessment Follow-Up/Discharge Functioning Functioning Functioning Functioning Strength: Sit-to-stand Arm curls Abdominal Aerobic: Flexibility: Chair Sit-and-reach Arm reach ADLs: Deficits: Gait / Balance: 1-legged stand (20sec) Tinetti (24) Functional reach (8 inches) F771-092J (rev 3/2011) 6
Initial Assessment Re-Assessment Re-Assessment Follow-Up/Discharge Summary review with patient: Summary review with patient: Summary review with patient: Summary review with patient: Exercise: Exercise: Exercise: Exercise: Nutrition: Nutrition: Nutrition: Nutrition: / Psychosocial: / Psychosocial: / Psychosocial: / Psychosocial: Rhythm: Rhythm: Rhythm: Rhythm: Patient issues: Patient issues: Patient issues: Patient issues: Patient Patient Patient Staff Staff Staff No changes proceed with Rehab No changes proceed with Rehab No changes proceed with Rehab No changes proceed with Rehab Please add the following Please add the following Please add the following Please add the following Physician Physician Physician Physician F771-092J (rev 3/2011) 7
Key for Individual Treatment Plan AB = arm bike HR = heart rate S= Steps: BMI = basic metabolic index LDL = low density lipids 1A = Triceps pull down BP = blood pressure MET = metabolic expenditure 1B = Biceps curl B = bike N = NuStep 2 = Lat pull down CAD = coronary artery disease R = rower 3 = Knee flexion CHF = congestive heart disease RYP = rate your plate-nutrition survey tool 4 = Knee extension DB = Dual Bike SF-36 = health survey tool 5 = Chest press E = elliptical SPO2 = saturation peripheral oxygen 6F = Front Butterfly FBS = fasting blood sugar S/S = signs and symptoms 6B = Back Butterfly FVC = forced vital capacity 6MWT = six minute walk test 7 = Leg press FEV1% = forced expiratory volume in one second TM = treadmill 8 = Military press Ft = feet Cardiac Risk Stratification Pulmonary Risk Stratification Low [6-18 sessions] Low [6-18 sessions] BMI < 25 BP < 120/80 Bode 0-2 RYP > 54 Medical Hx Medical Hx Non-smoker Exercise most days a week Mod [12-24 sessions] Mod [12-24 sessions] BMI < 29 BP 139/89 Bode 3-6 RYP 39-54 Medical Hx Medical Hx Quit tobacco 6 months ago Exercise 2-3 days a week High [18-36 sessions] High [18-36 sessions] BMI > 30 BP > 140/90 Bode 7-10 RYP <39 Medical Hx Medical Hx Currently using tobacco Exercise < 2 days per week F771-092J (rev 3/2011) 8
Medications Allergies: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Medication Amount (mg) Times Per Day Reason For Taking F771-092J (rev 3/2011) 9
MMRC Dyspnea Scale BODE Index and Stratification Score Grade 0 Not troubled with breathlessness except with strenuous exercise Grade 1 Troubled by shortness of breath when hurrying on the level or walking up a slight hill Grade 2 Walks slower than people of the same age on the level because if breathlessness or has to stop for breath when walking at own pace on the level Grade 3 Stops for breath after walking about 100 yards or after a few minutes on the level Grade 4 Too breathless to leave the house or breathless when dressing or dressing or undressing 0 1 2 3 FEV1% >65 50-64 36-49 <35 6MWT >1148 820-1145 492-816 <488 (ft) MMRC- 0-1 2 3 4 Dyspnea BMI >21 <21 Totals Quartile Q1 (0-2) Q2 (3-4) Q3 (5-6) Q4 (7-10) Low Risk (0-2) Moderate Risk (3-6) High Risk (7-10) F771-092J (rev 3/2011) 10