Current Level of Function (Summary from OT Evaluation)
Assistive Device History Prior to the onset of the current condition, the patient utilized (List adaptive equipment used): ______________________________________________ Currently, the patient utilizes: _____________________________________________________________________________________________________ Comments: (Address safety and effective use of equipment): ____________________________________________________________________________
Fall History & Risk Assessment Patient has had fall(s). The last fall occurred on (date): ______________________ Location: ____________________________________________ which resulted in (Describe injury or condition): ___________________________________________________________________________________ Patient is at risk for falls due to: Is patient able to call for help?
Loss of balance Yes
Poor postural alignment/control
Difficulty walking
Freezing when walking
No Comments: ________________________________________________________________________
Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or The patient has received ___ PT ___ OT ___ SLP in the last 12 months for the ___ current or a ____ previous condition Describe: __________________________________________________________________________________________________________________ The patient is not currently receiving home health services OT Plan of Treatment
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Revised:
03/2010
Patient’s Last Name
First Name
HICN:
Medical History/Medications (Describe all relevant medical conditions and the date of onset. Include psychosocial diagnosis(es) if present)
Precautions/Contraindications (For a specific activity and/or intensity of rehabilitation services)
Occupational Therapy Plan of Treatment Treatment Plan:
Occupational Therapy ______ days/wk x _______ weeks for a treatment duration of ______ hours per visit
Initial Certification Period:
From:________________ - To: ___________________
Rehabilitation Potential:
Guarded
Fair
Good
Excellent
Long Term Goals (Number Each Goal):
Skilled Intervention to Include: 97535 Self-Care/Home Mngt Training
97532 Cognitive Skills Training
97533 Sensory Integration Training
97110 Therapeutic Exercise
97112 Neuromuscular Re-Education
97140 Manual Therapy
Other: __________________________________________
Additional Recommendations: PT Evaluation Speech/Language Evaluation Social Services Adaptive Equipment: _______________________________________________________________________________________________________ Medical Follow-Up For: _______________________________________________________________________________________________________ Other: ____________________________________________________________________________________________________________________
Professionals Establishing This Plan of Treatment Therapist’s Name & Credentials (Please Print)
Therapist’s Signature
Date
____________________________________________
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’s Name (Please Print)
Physician’s Signature
Date
____________________________________________
X______________________________
_____________
OT Plan of Treatment
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Revised 03/2010
Occupational Therapy Evaluation ”Caring for Your Quality of Life” Patient’s Last Name
First Name
MI
Provider Name
Provider No
Onset Date
LifeCare of Florida
104545
Primary Diagnosis(es)
HICN SOC Date
Treatment Diagnosis(es)
Clinical Evaluation Range of Motion Cervical Spine Lumbar Spine
Grossly WFL or
Impaired (Check All Areas of Impairment)
Left UE Shoulder Elbow Wrist Hand
Right UE Shoulder Elbow Wrist Hand
Left LE Hip Knee Ankle Foot
Right LE Hip Knee Ankle Foot
Left LE Hip Knee Ankle Foot
Right LE Hip Knee Ankle Foot
ROM Measurements:
Muscle Strength Cervical Spine Lumbar Spine
Grossly WFL or
Impaired (Check All Areas of Impairment)
Left UE Shoulder Elbow Wrist Hand
Right UE Shoulder Elbow Wrist Hand
MMT Measurements:
Muscle Tone
Grossly WFL or
Impaired (Describe Area & Level of Impairment Using Modified Ashworth Scale 0-4)
Sensation
Grossly WFL or
Impaired (Describe Below)
Edema
Not Present or
Present (Describe Below)
Pain
Not Present or
Present (Describe using a 0-10 Visual Analog Scale (VAS)
The patient was seen today for an initial therapy evaluation. The Plan of Treatment was developed and skilled therapy will be initiated after the Plan of Treatment has been reviewed and signed by the appropriate physician.
97001 PT Evaluation ________ TIME
__1____ UNITS
97003 OT Evaluation ________ TIME
__1____ UNITS
92610 Evaluation / Swallow ________ TIME
__1____ UNITS
92506 Evaluation / Speech, Language, Voice ________ TIME TOTAL TIME (MIN)
__1____ UNITS TOTAL UNITS
Time Spent for Care:
Time In: ____________________ AM / PM
Time Out: _________________ AM/PM
Patient Certification: I certify that I was seen by the therapist below and agree that the time spent for my care is correct. I understand and agree to the goals and plan of care developed. I certify that I am not receiving home health services at this time. Patient/Authorized Representative (Please Print)
